Introdução: Déficits cognitivos são parte integrante do quadro clinico da esquizofrenia. Vários estudos procuram métodos de treinamento cognitivo (remediação cognitiva) para melhora destes déficits, pouco responsivos ao tratamento medicamentoso. Ensaios clínicos de treinamento de remediação cognitiva utilizam diversas técnicas, com estimulação de vários domínios cognitivos simultaneamente. Muitos deles utilizam a técnica de errorless learning (aprendizagem sem erros). Pesquisas recentes indicam que alguns domínios cognitivos subjacentes à aprendizagem matemática (atenção, função executiva e memória de trabalho) estão também comprometidos na esquizofrenia. Entretanto não foram encontrados estudos de remediação cognitiva focados no treinamento aritmético em portadores de esquizofrenia. O método de cálculos aritméticos proposto pelo método Kumon utiliza técnica de aprendizagem sem erros e é amplamente utilizado como reforço pedagógico. Dois ensaios randomizados de remediação cognitiva através do método de cálculo aritmético Kumon em idosos sadios e em idosos com Alzheimer mostraram melhora de funções cognitivas com esta intervenção. Este estudo avaliou a eficácia do método de cálculos aritméticos Kumon como remediação cognitiva da memória de trabalho, função executiva e atenção na população com esquizofrenia. Método: 51 sujeitos com o diagnóstico de esquizofrenia (DSM-IV), de ambos os gêneros, idade entre 18 e 55 anos, alfabetizados foram incluídos e randomizados para treinamento de cálculos aritméticos pelo método Kumon (grupo experimental) ou atividades de recreação (grupo controle). Os sujeitos fizeram 48 sessões de intervenção ao longo de 6 meses. Os sujeitos foram avaliados através de uma bateria neuropsicológica, o desfecho clínico através da escala Escala de Síndromes Positiva e Negativa (PANSS) e funcionamento pessoal e social através da PSP no inicio da intervenção, após 6 meses (término da intervenção) e após 6 meses sem a intervenção. Resultados: O grupo experimental apresentou tendência de melhora em atenção sustentada (p=0.075), mas sem manutenção dos ganhos após 6 meses sem intervenção. Ambos os grupos apresentaram melhora em atenção seletiva e função executiva após 6 meses sem manutenção dos ganhos após 1 ano, sem diferenças entre os grupos. Não foram encontradas diferenças no funcionamento social entre os dois grupos e ao longo dos 12 meses de acompanhamento. Através da análise fatorial da PANSS utilizando 5 fatores (proposto por Van der Gaag 2006) não houve mudança significativa nos fatores ,,positivo\", ,,negativo\", ,,desorganização\" e ,,estresse emocional\" ao longo do tempo e entre os grupos. Apenas o grupo placebo demonstrou melhora significativa no fator \"excitação\" após 6 meses em comparação com o grupo experimental, que não persistiu após 6 meses sem intervenção. Conclusão: O treino cognitivo aritmético pelo método Kumon tende a melhorar a atenção sustentada após 6 meses, sem impacto na função executiva e na memória de trabalho. Esta tendência não se manteve após 6 meses sem intervenção / Introduction: Cognitive deficits are an integral part of the clinical picture of schizophrenia. Various studies seek cognitive training (cognitive remediation) methods in order to improve those deficits, which are poorly responsive to pharmacological treatment. Clinical trials of cognitive remediation training use a variety of techniques, with the stimulation of several cognitive domains simultaneously. Many of them employ the \"errorless learning\" technique. Recent research indicates that some cognitive domains underlying mathematical learning (attention, executive function and working memory) are also impaired in schizophrenia. However, no cognitive remediation studies were found focusing on arithmetic training in individuals with schizophrenia. The arithmetic calculation method proposed by Kumon employs the errorless learning technique and is widely used for supplemental education. Two randomized trials of cognitive remediation using the arithmetic calculation method Kumon with healthy elderly subjects as well as elderly subjects who had Alzheimer\'s disease showed cognitive function improvement with this intervention. The present study evaluated the effectiveness of the arithmetic calculation of the Kumon method as cognitive remediation for working memory, executive function and attention in a sample with schizophrenia. Method: 51 subjects with a diagnosis of schizophrenia (DSM-IV), male and female, literate, aged between 18-55 years, were included in the trial and randomized to arithmetic calculation training by the Kumon method (experimental group) or recreational activities (control group). The subjects received 48 intervention sessions over the course of 6 months. The subjects were evaluated through a neuropsychological battery; the clinical outcome was assessed by the Positive and Negative Syndrome Scale (PANSS), and personal and social functioning was evaluated using the Personal and Social Performance (PSP) scale at baseline, at 6 months (discontinuation of interventions) and after 6 months without interventions. Results: The experimental group tended to an improvement in sustained attention (p=0.075), yet this was not maintained after 6 months without interventions. Both groups showed improvements in selective attention and executive function at 6 months, which were not maintained after one year, with no differences between groups. No differences were found in social functioning between the groups and throughout the 12 follow-up months. The factor analysis of the 5-factor PANSS (as proposed by Van der Gaag, 2006) showed no significant change in the factors \"positive\", \"negative\", \"disorganization\" and \"emotional distress\" over time and between groups. Only the placebo group exhibited a significant improvement in the factor \"excitement\" after 6 months compared with the experimental group, which was not maintained after 6 months without interventions. Conclusion: The cognitive arithmetic training by the Kumon method tends to improve sustained attention after 6 months, with no impact on either executive function or working memory. This trend was not sustained after 6 months without interventions

A migrânea está relacionada às disfunções das estruturas da coluna cervical, impulsos aferentes desse local podem ser facilitadores ou mesmo gatilhos da dor. Tratamentos com manipulação cervical isolada e combinada a medicação já foram testados, porém os resultados são conflitantes. O objetivo desse trabalho foi avaliar o efeito adicional da fisioterapia ao tratamento medicamentoso da migrânea na frequência, intensidade e duração da dor de cabeça. Foram inclusas mulheres com migrânea, na faixa etária de 18 e 55 anos, com mínimo de 06 dias de dor por mês, e que apresentasse dor na região craniocervical através do relato. Cinquenta mulheres foram igualmente randomizadas para um dos dois grupos de tratamento, Grupo Fisioterapia (terapia manual + medicação) e Grupo Controle (medicação). O diagnóstico de migrânea foi realizado por uma única neurologista, segundo a Classificação Internacional de Cefaleias. Foram realizadas 12 sessões de terapia manual, duas vezes por semana, durante 50 minutos, por uma única fisioterapeuta. A avaliação, a reavaliação e follow-up foram cegos. Os desfechos primários de frequência, intensidade e duração da dor de cabeça, foram avaliados por meio do diário de dor; e secundários, Limiar de dor por pressão (Algômetro), incapacidade relacionada à cefaleia (Migraine disability assessment program) e a coluna cervical (Neck disability índex), Patient Health Questionnaire eight-item depression scale (PHQ-8), alodinia com Allodynia Sympton Checklist (ASC- /12) e satisfação com Patients Global Impression of Change Scale (PGIC). A análise foi realizada por intenção de tratamento e foi utilizado o Modelo Linear de efeitos mistos e para atribuir relevância clínica o Effect size (ES) e Mínima mudança importante (MID). Não foram observadas diferenças entre os grupos na avaliação inicial. O GF apresentou redução de 37% na frequência de dias de dor de cabeça comparado ao GC que apresentou 22% (p<0.05 e ES 0,4) e (p<0.05 e ES 0,3) respectivamente. Não foram observadas diferenças clínicas significativas entre os grupos na duração e na intensidade da dor de cabeça. Também foi observado aumento significativo (p<0,05) do limiar de dor por pressão, bem como maior satisfação e percepção de mudança da doença ao paciente (p<0,05) no GF em comparação ao GC. Não foram observadas diferenças significativas nos demais parâmetros avaliados. A redução do limiar de dor dos músculos cervicais com o tratamento fisioterapêutico promoveu um efeito benéfico adicional ao medicamentoso, com maior redução da frequência de dias de dor de cabeça e maior satisfação e percepção de melhora dos pacientes. REBEC nº RBR-6kvx74 / Migraine is related to disorders of the cervical spine structures, afferent impulses that location can be facilitators or even triggers pain. Treatments with cervical manipulation alone and combined medication have been tested, but results are conflicting. The aim of this study was to evaluate the additional effect of physical therapy to drug treatment of migraine in frequency, intensity and duration of headache. Women with migraine were included, aged 18 to 55 years, with a minimum of 06 days of pain per month and report of pain in the craniocervical region. Fifty women were equally randomized to one of the two treatment groups, Physiotherapy Group (manual therapy and medication) and control group (medication). The diagnosis of migraine was performed according to the International Classification of headache by a single neurologist. All subjects received similar medications. 12 sessions of manual therapy, twice per week, during for 50 minutes, were done by same physical therapist. The assessment, revaluation and follow-up were blind. The primary endpoints of frequency, intensity and duration of headache were evaluated through diary pain, and secondary endpoints like pain threshold pressure (algometer), headache related disability (Migraine disability assessment program) and cervical spine (Neck disability index), patient Health Questionnaire eight- item depression scale (PHQ-8), with the severity of Allodynia Sympton Checklist (ASC-12) and patients Global Impression of Change Scale to assess satisfaction and perception of patient changes as its disease condition. The analysis was by intention to treat and we used the linear mixed effects model. To assign the clinical relevance Effect size (ES) and Minimum important change (MID) were used. No differences between groups were observed at baseline. The PG showed a 37% reduction in the frequency of headache days compared to GC showed that 22 % (p<0.05 to ES0.4) and (p<0.05 to ES0.3) respectively. No clinically significant differences were observed between groups regarding the duration and intensity of the headache. Significant increase (p<0.05) pain threshold pressure was also observed, as well as greater satisfaction and changing perception of the disease to the patient (p<0.05) in the PG compared with the CG. No significant differences were observed in the other parameters. The reduction of the pain threshold of cervical muscles with physical therapy promoted a beneficial additional effect to medication, with greater reduction in frequency of headache days and greater satisfaction and perceived improvement of patients. REBEC no RBR - 6kvx74

Objetivos: o objetivo do presente estudo é avaliar a resposta molares e não molares a dois protocolos de atenção periodontal na fase de manutenção periódica preventiva (MPP). Métodos: Sessenta e dois pacientes com periodontite moderada ou avançada (idade média 50.97 ± 9.26 anos, 40 mulheres, 24 fumantes) foram tratados de acordo com um protocolo não-cirúrgico. Finalizada a fase terapêutica, os pacientes iniciaram a fase de MPP e foram randomicamente alocados para receber controle supragengival isolado (SPG) ou combinado ao subgengival (SPG+SBG). Exames periodontais, instruções de higiene bucal e as respectivas intervenções experimentais foram realizados em consultas trimestrais. Resultados: não foram observadas diferenças significativas nas variáveis demográficas, número médio de dentes e distribuição média de dentes não-molares/molares e de sítios livres/proximais entre os dois grupos experimentais. Quando do baseline, os dentes molares apresentaram um maior número de sítios positivos para IPV, ISG, SS e maiores valores médios de PS e PI quando comparados aos não-molares (p<0.001). Ao longo da fase de MPP, foi demonstrado que independente da terapia aplicada, tanto para molares e não molares, a resposta para ambos os grupos dentários não foi diferente. Da mesma forma, a perda dentária entre molares e não molares não diferiu ao longo de 24 meses. Conclusões: Molares apresentam semelhante resposta durante a fase de MPP quando comparados a dentes não molares, independente do protocolo de intervenção clínica aportado. / Aim: The objective of the present study was to evaluate the response of molar teeth and non-molar teeth to two periodontal care protocols in the periodic preventive maintenance phase (PMP). METHODS: Sixty-two patients with moderate or advanced periodontitis (mean age 50.97 ± 9.26 years, 40 women, 24 smokers) were treated according to a non-surgical protocol. After the therapeutic phase, the patients started the PMP and were randomly assigned to receive supragingival (SPG) or combined subgengival (SPG + SBG) control. Periodontal examinations, oral hygiene instructions and the respective experimental interventions were performed in quarterly consultations. Results: There were no significant differences in demographic variables, mean number of teeth and mean distribution of non-molar / molar teeth and free / proximal sites between the two experimental groups. At the baseline, molar teeth had a higher number of positive sites for VPI, GBI, BOP and higher mean values of PPD and CAL when compared to non-molars (p <0.001). Throughout the MPP phase, it was demonstrated that regardless of the applied therapy, for both molars and non-molars, the response for both dental groups was not different. Likewise, tooth loss between molars and non-molars did not differ over 24 months. Conclusions: Molars presented a similar response during the PMP when compared to non-molar teeth, independent of the protocol of clinical intervention provided.

There are no large-scale outcome studies of music therapy in secure hospital settings for people who have committed serious offences. These patients have a right to expect evidence-based multi-disciplinary treatment (Duggan et al. 2006); NICE (2010). Music therapy therefore should take a form which can be integrated into the treatment pathway. A single site implementation of a mixed-methods patient preference randomised controlled trial investigated the clinical effectiveness of a manualised music therapy model called Group Cognitive Analytic Music Therapy (G-CAMT). This context-specific, time limited intervention incorporates theories from Group Analysis (Foulkes 1964) and Cognitive Analytic Therapy (Ryle and Kerr 2003). The central research question was ‘Is G-CAMT feasible and effective for offenders in a secure multi-disciplinary treatment setting?’ The research process followed the Medical Research Council framework for developing and evaluating complex interventions (Campbell et al. 2000, 2007). Twenty patients were recruited; those expressing no preference were randomised to treatment or control arms. The two music therapists and the principal investigator were masked to their allocation status. Those in the treatment arm were allocated to one of two treatment groups of five, each run individually by one of the music therapists. Each group had sixteen ninety minute weekly sessions with followup at eight weeks. Treatment and control groups received standard care. The primary measure was the Person’s Relating to Others Questionnaire (Birtchnell and Evans 2004) Secondary measures were the Basic Empathy Scale (Jolliffe and Farrington 2006a), The Multi-Scale Dissociation Inventory (Briere, 2002) and an observational measure, the Chart of Interpersonal Reactions in Closed Living Environments (Blackburn and Glasgow, 1993). Quantitative data from these measures were examined for associations with qualitative data from semi-structured interviews administered to the music therapists and analyzed using Interpretative Phenomenological Analysis (Smith et.al. 2009) Findings from the results of the primary measure demonstrated statistically significant (Mann Whitney U: p<.05) reductions in favour of the treatment group compared to the control, in intrusive, restrictive and possessive behaviors and helpless or self-denigrating behaviours. There were improvements over time within the treatment group in the domains of sociability and hostility (Friedman Test :p<.04). The use of a manual was shown to help the music therapists manage the risk of violence without constraining their creativity. Two years after the end of the treatment 78% of treatment participants had moved to conditions of lower security over a mean period of 19 months compared with 66% of control subjects over a mean period of 25.5 months. The thesis concludes by situating G-CAMT amongst contemporary music therapy models.

Background: By 2050, it is estimated that 14 million older Americans will live with Alzheimer’s disease (AD), a progressive form of dementia with unknown cause or cure. Persons with AD and related dementias (ADRD) become increasingly dependent on others as they experience cognitive decline, which concomitantly undermines individuals’ functional skills, social initiative, and quality of life. The Alzheimer’s Association advocates for interventions that address cognition, mood, behavior, social engagement, and by extension, quality of life – goals music therapists often address. Although a small but growing body of literature suggests that clinical music therapy may be effective, the evidentiary support for the use and appropriate application of music as a form of treatment with this population is currently limited. Objectives: This thesis consisted of the development of a Clinical Practice Model of music therapy for persons with ADRD. It also examined the effectiveness of a specific, protocol-based music therapy intervention, grounded in this model, relative to a verbal discussion activity. Methods: The Clinical Practice Model is theoretically grounded in the biopsychosocial model of healthcare (Engel, 1980) and Kitwood’s (1997) personhood framework, and I developed it through extensive literature review and expert input. It includes an organizational schema for applying intervention strategies, per six themes: cognition, attention, familiarity, audibility, structure, and autonomy. The initial model predicts that an intervention built upon this schema will influence social-affective responses, quality of life, and in turn, psychosocial symptoms of ADRD. I tested a singing-based music therapy intervention, grounded in this model, through a randomized clinical crossover trial. I compared participants’ responses to music therapy to a non-music verbal discussion activity, and both conditions followed a protocol. Dependent variables included: (1) affective responses (self-reported feelings, observed emotions, and observed mood), (2) social engagement, and (3) observed quality of life. Thirty-two individuals with ADRD (n = 6 men, n = 26 women) ages 65-97 years old (μ̂ = 84.13) participated in this study. I randomly assigned treatment order; each treatment occurred in small-group format, three times per week in the afternoon (25 minutes each session), for two consecutive weeks. A two-week “wash-out” period occurred between conditions. Credentialed music therapists led both study conditions. This study followed recommendations from the National Institutes of Health Behavior Change Consortium (Bellg et al., 2004) to enhance quality assurance in protocol administration and data collection. Results and Significance: I used a linear mixed model approach to analysis. Music therapy exacted a significant, positive effect on self-reported feelings, observed emotions, and constructive engagement, particularly for individuals with moderate dementia. Results also suggested that men’s feelings improved in response to music therapy only, whereas women responded positively to both conditions. Weekly observations failed to indicate a significant change in mood or quality of life across the eight-week study. Based on these findings, I revised the Clinical Practice Model to include wellbeing (an outcome more concordant with psychosocial change in response to music intervention) rather than global quality of life (affected by numerous aspects of the care milieu). In addition to the Clinical Practice Model to the music therapy profession, contributions of this thesis include a rigorous clinical study and practical implications for music therapy practice, including the importance of considering patient characteristics and careful selection and implementation of music in a music therapy intervention.

Master of Science / Haematopoietic stem cell transplantation (HSCT) is a complicated and high-risk procedure used to cure disease or stop the spread of disease in a range of cancers. HSCT carries a high incidence of mortality and is associated with distressing short and long-term side effects. In addition, patients remain at risk of recurrence or mortality years after transplantation. Therefore, patients undergoing HSCT have been found to experience significant emotional and psychosocial distress because of the trauma associated with treatment. The literature suggests that about 50% of HSCT patients will experience clinical levels of distress. Carers and family members play an important role in caring for these ill patients in the short and long-term. Major role changes and financial stressors are experienced in many families, adding to the burden of care. However, very little is known about the rates of psychopathology in carers of HSCT patients. Due to the arduous nature of HSCT, psycho-educational programmes have been developed by major transplant centres and hospitals in order to provide HSCT patients and their families with information on the treatment process, side effects, risks, and long-term outcomes. Research on patient education in oncology has shown that providing patients and carers with information about their illness and treatment reduces anxiety and distress. To date, there have been no empirical evaluations to support the use of education programmes for HSCT patients. While it could be assumed that information would be helpful in reducing anxiety and depression in HSCT as it is in oncology generally, the information provided to these patients is usually more confronting and therefore, may be less reassuring. Thus, it is not known whether providing patients with education about HSCT reduces patient and carer distress or whether it might actually increase adverse outcomes. The aim of the present study was to evaluate the rates and correlates of distress in carers and patients and examine the effect of a psychoeducation programme for patients undergoing HSCT and their carers on knowledge, distress, information satisfaction, social support and caregiver burden. A randomised control trial was conducted to provide empirical data in relation to the latter aim. The following hypotheses were proposed. Firstly, it was hypothesised that patients and carers who received the education programme would have higher levels of knowledge, not evidenced in a group waiting to receive the programme. Secondly, it was hypothesised that the education program would not lead to increased anxiety and depressive symptoms. Thirdly, patients who know more about their condition would be the least distressed. As predicted, this study found high levels of distress, particularly in carers. Higher patient distress was related to having more concern about one’s illness and experiencing more symptoms. Education was effective in increasing patient and carer knowledge. Importantly there were no adverse effects of knowledge and greater patient knowledge following the education program was associated with less distress, although there was no direct effect of education on distress. Future research should aim to identify what aspects of the education program are helpful to patients. Finally, support interventions such as CBT are needed to help patients and carers, in particular, cope with the high levels of distress inherent in the HSCT experience.

The increased work of breathing associated with intense cycling has been identified as a factor that may negatively affect cycling performance. The aerodynamic position, abnormal respiratory mechanics either at rest or during exercise, and the development of a tachypnoeic breathing pattern are factors known to increase the work of breathing. Breathing pattern retraining aims to decrease the work of breathing by delaying the onset of dynamic hyperinflation and the recruitment of accessory breathing muscles. To date no studies have investigated the performance, physiological and perceptual consequences of manipulating breathing pattern in trained cyclists. Purpose: The aim of the present study was to investigate the effect of breathing pattern retraining on 20-km time trial performance and respiratory and metabolic measures in competitive cyclists. Method: Twenty-four competitive male cyclists (age 37.7 ± 8.6 years, mean ± SD; peak 4.34 ± 0.47 L·min-1) were match paired on 20-km time trial performance and assigned at random to either an intervention group (breathing pattern retraining; N = 12) or control group (N = 12). 20-km time trial performance, pulmonary function and the physiological and perceptual response during a maximal incremental cycle step test were assessed pre- and post-intervention. The intervention group underwent four weeks of specific breathing pattern retraining using exercises designed to reduce dynamic hyperinflation and optimise respiratory mechanics. The control group attended the laboratory once a week during this period and performed a 10 minute sub-maximal ride wearing a biofeedback breathing harness. The control group was led to believe the purpose for their participation was to investigate the effect that maximal exercise had on breathing pattern, and to test the reliability of the breathing harness. There was no attempt to modify the breathing pattern of the control group. Data were analysed using an MS Excel spreadsheet designed for statistical analysis. The uncertainty in the effect was expressed as 90% confidence limits and a smallest worthwhile effect of 1.0% was assumed. Results: The intervention group showed substantial improvements in 20-km time trial performance (-1.5 ± 1.1%) and incremental power (3.2 ± 3%). Additionally, breathing frequency (-13.2 ± 8.9%; -9.5 ± 8.4%), tidal volume (10.6 ± 8.5%; 9.4 ± 7.6%), inspiratory time (10.1 ± 8%; 9.4 ± 7.7%), breathing RPE (-30 ± 33.9%; -24.7 ± 28.1%) and leg RPE (-27.9 ± 38.5%; -24.7 ± 28.2%) were all positively affected at lactate threshold and lactate turn point. No positive changes were observed in the control group for 20-km time trial performance (0.0 ± 1.0%), incremental power (-1.4 ± 3.5%), breathing frequency (-1.6 ± 8.0%; -2.0 ± 7.9%), tidal volume (0.9 ± 7.2%; 2.9 ± 9.4%), breathing RPE (16.1 ± 50.2%, 24.8 ± 43%) or leg RPE (13.4 ± 39.6%; 19.9 ± 43.2%) . Conclusion: These results provide evidence of the performance enhancing effect of four weeks of breathing pattern retraining in cyclists. Furthermore, they suggest breathing pattern can be retrained to exhibit a controlled pattern, without a tachypnoeic shift, during high intensity cycling. Additionally, these results indicate breathing pattern retraining attenuates the respiratory and peripheral perceived effort during incremental exercise. Key words: Breathing pattern disorders, retraining, blood stealing, cycling, performance, power output, respiratory mechanics, perceived exertion, 20km-TT

Background: Physiological studies have shown that many preterm infants and infants with chronic lung disease may suffer chronic hypoxaemia, which possibly leads to poor growth and development. Anecdotal reports indicate that there is a drive to increase the oxygen saturation target range to a higher level in these infants due primarily to perceived benefits derived from clinical experience and from uncontrolled observational studies of babies discharged on home oxygen. Objective The BOOST (Benefits Of Oxygen Saturation Targeting) trial is the first randomised trial to assess the long-term benefits and harms of two different oxygen saturation target ranges. Methods: BOOST was a multicentre, double blinded, randomised controlled trial that enrolled 358 infants born at less than 30 weeks� gestation who remained oxygen-dependent at 32 weeks postmenstrual age. They were randomly assigned to target either a functional oxygen saturation range of 91-94% (standard or control group) or 95-98% (higher or treatment group). The primary outcomes were growth and neurodevelopmental measures at 12 months corrected age. Secondary outcomes included length of hospital stay, retinopathy of prematurity, health service utilisation, parental stress, and infant temperament. Results: Prognostic baseline characteristics did not differ between the two groups. Mean birth weight and gestational age of enrolled infants was 917g and 26.5 weeks respectively. The rate of antenatal corticosteroid use was 83%.

Preventive care for the elderly originated with a study in Great Britain in 1964 that reported a large number of unmet health needs in the elderly and advocated early intervention. Subsequent randomised controlled trials (RCT) used a broad assessment of health including bio-medical, functional, psychological and social /environmental components but inconsistently demonstrated improved outcome for the elderly. 'Health checks' were introduced for all patients in British general practice in 1990. European and American models of care evolved similarly and justify a multidisciplinary team assessment, thorough training of assessment staff and medical supervision of recommendations. Two literature reviews published in 2000 have not reported sound evidence in favour of health assessments. Medicare funding of health assessments for the Australians aged 75 years and over was introduced in November 1999. A protocol for conducting 75+ Health Assessment (75+ HA) was developed and a pilot study was conducted in Yarrawonga in 1995 to initiate Australian research of this model of care. A RCT in the Adelaide Western Division of General Practice tested this model of care. The intervention group (n=50) had two 75+ HA one year apart. The control group (n=50) was left to usual care and had a 75+ HA one year later. Demographic data and the Short Form-36 were used to ensure both groups were comparable. Primary outcome measures did not demonstrate statistically significant reduction in problems nor mortality in the intervention (75+ HA) group compared to the control group. Significant improvements in secondary outcome measures in the intervention group were in self-rated health, depression score and decreased numbers reporting falls. 75+ HAs have been widely taken up by Australian general practitioners. It is no longer possible to conduct a RCT due to the inability to find a legitimate control group. Recommendations arising form this literature review and RCT include; evaluation studies of 75+ HA, concentration on a functional model of health and that nurses or allied health professionals should conduct the assessment in the elderly person's home. A consistent framework for analysis of 75+ HA is proposed. The elderly can be conceived to occupy one of 3 cohorts defined by their function state: No impairment of Activities of Daily Living (ADL), Impairment of Instrumental ADL only or Impairment of Basic ADL. The elderly without ADL impairment have not been demonstrated to benefit from 75+ HA and should be left to access the acute care stream of health services. The most disabled elderly with Basic ADL impairment have not consistently been shown to benefit from 75+ HA probably because they need a more intense level of community care. They should have Care Plans renewed regularly, as tested in the Australian Coordinated Care Trials. The cohort with Instrumental ADL impairment only seems most likely to benefit from annual 75+ HA. An evaluation of screening the elderly for Instrumental and Basic ADL impairment and providing appropriate services for each cohort is recommended. / Thesis (M.D.)--Department of General Practice, 2001.

Stress management interventions (SMIs) are increasingly used by organisations across both private and public settings. Such interventions are employed with the expectation that they will be effective in reducing levels of stress in participants and in turn, will provide a return to the organisation by way of increased productivity through performance improvements of those employees whose stress has been reduced. Despite the increasing popularity of SMIs, there exists a lack of evidence on whether they have any effect on the performance of users, and on the relative effectiveness of the components that often make up SMIs. Although the literature addressing SMIs and their effects is increasing, relatively few studies directly compare different techniques, and even fewer employ randomised controlled designs or follow-up measures. The assumed relationship between the reduction of stress and improvement of managerial performance does not appear to have been tested with a randomised controlled trial. The term “stress” as used in this study specifically denotes the concept of “distress” as defined by Selye (1956; 1987). To support this use of the term, the evolution of current terminology in the field of occupational stress is briefly discussed with specific reference to the development and influence in the wider literature of the Yerkes Dodson Law (Yerkes, 1909). The aims of this thesis were to (1) compare the relative effectiveness of two component techniques often used in SMIs (somatic and cognitive techniques) in the reduction of stress, and (2) to examine the effect of the use of these techniques on the performance of managers in their workplace. Study One was a randomised controlled trial assessing the effect of the use of somatic and cognitive stress management interventions on stress and performance in managers. Participants were 112 corporate managers who were randomly assigned to one of two intervention groups (somatic or cognitive technique training) or to a wait list control group. The intervention groups were trained in their respective techniques over a 4 week period in brief (20-30 minute) face-to-face workshop sessions. Participants were provided with recordings of the techniques to assist practice between training sessions. At baseline, stress was assessed using the Occupational Stress Inventory – Revised Edition (OSI-R, Osipow, 1998), and managerial performance was assessed with the Personal Qualities Competency from the Inventory of Management Competencies (IMC, Saville Holdsworth Ltd., 1993). In the case of the IMC, self, colleague, and subordinate assessments were used. On completion of the 4 week intervention, the OSI-R was readministered, and then at week 12 and week 24, follow-up assessments of stress and managerial performance took place. At the week 12 follow-up, MANOVA for the OSI-R showed no significant difference between the somatic and cognitive interventions in their effect on stress, although both interventions did reduce stress relative to the wait list control group, as measured by the OSI-R. A significant intervention effect was also shown (ηp2 = 0.089, p = 0.002) for the combined intervention groups (cognitive and somatic). MANOVA for the Personal Qualities Competency showed a significant intervention effect for the self (ηp2 = 0.077, p = 0.008) and colleague (ηp2 = 0.064, p = 0.013) assessments, and a no significant effect (ηp2 = 0.032, p = 0.063) for the subordinate assessment at the week 12 follow-up point. Unfortunately, withdrawal and attrition reduced the sample size below that required for analysis at the week 24 follow-up point. Study Two was designed as a follow-up qualitative study that aimed to gather information on participants’ perceptions of the effects of the interventions on their stress and performance, and of their reasons for completion or no completion of the SMI. In this study, 14 participants from Study One took part in semi-structured interviews after the final follow-up assessment (week 24) for that study. The interviews were structured to elicit responses concerning participants’ perceptions of the demands of their workplace and their stress, their experience of using the stress management techniques (including perceived benefits or behavioural changes from that use), their reasons for completion or no completion of the intervention, and their own definitions of stress. Several important findings emerged from this study. First, participants described their workplace as characterised by high pressure and demand with rapid change and a perceived lack of personal control. Second, participants who continued to use the techniques they had learned after the formal intervention was completed did so because they perceived personal benefits in terms of their ability to relax and in terms of their perceptions of workload and demand. For those who did not complete the intervention, the predominant reasons reported for no completion were workplace task demands, lack of top management commitment to an intervention of this nature, and lack of personal gain once the techniques had been learned. In relation to defining stress, participants did not have agreement, but rather reported definitions reflecting a multifaceted complex amalgam of physiological, psychological, and emotional aspects. Research such as this is important in terms of its contribution to the general field of occupational stress and its alleviation. It addresses a long-standing need to assess the relative effectiveness of some of the subcomponents commonly employed as part of more complex multifaceted approaches to SMIs, and the effect of the techniques on both stress and performance. This thesis makes several contributions to existing knowledge. First, this thesis clarifies the origin of the Yerkes Dodson Law and its relevance to current stress management thinking. In management texts distress has come to be regarded as too much stress or pressure. This is coupled with the idea that some stress has a positive impact on performance due to an earlier and erroneous interpretation of the Yerkes Dodson Law. Second, Study One provides evidence of the relative effectiveness of two different SMI components in the reduction of individuals’ occupational stress, as well as evidence for the effectiveness of individual focussed SMIs in the reduction of stress in corporate managers. Third, Study One provides evidence for a positive effect on managers’ performance consequent to their use of stress management techniques. This thesis also sheds light on managers’ definitions of stress, and their reasons for completion or no completion of SMIs. In summary, individual focussed (or secondary) SMIs have the potential to reduce stress and to improve performance in corporate managers as perceived by both the individual and others in the workplace.