Objective: This dissertation includes three projects that study care environments and apathy in dementia as well as measures of activity. Project 1 developed the Person-Environment Apathy Rating (PEAR) scale to measure environmental stimulation and apathy, and tested its psychometrics. Project 2 examined the association between care environments and apathy in persons with dementia. Project 3 tested the accuracy of ActiGraph and activPALTM activity monitors in measuring weight-bearing activities among persons with previous diabetic foot ulcers. Methods: The PEAR consists of environment (PEAR-Environment) and apathy (PEAR-Apathy) subscales. The validity and reliability of the PEAR was examined through video observation of 24 participants. Project 2 selected 40 participants with dementia in order to examine the association between apathy and environmental stimulation, ambiance, crowding, staff familiarity, and light and sound. Study procedures involved video observation and data extraction. Project 3 enrolled 31 participants to test the accuracy of ActiGraph and activPALTM in measuring number of steps taken and duration of walking, standing, sitting, and lying. Results: The PEAR-Environment subscale had significant but fair correlation with the Crowding Index (Ρ=.27, p<.01), suggesting fair validity. The PEAR-Apathy highly correlated with the Passivity in Dementia Scale (ρ=.81) and Neuropsychiatry Inventory (NPI)-Apathy subscale (ρ=.266), and moderately correlated with the NPI-Depression subscale (ρ=.46), indicating good convergent validity and moderate discriminate validity. The PEAR also demonstrated good internal consistency (Cronbach's Α= .84 -.85) and moderate to good inter-rater (Weighted Kappa=.47-.94) and intra-rater (Weighted Kappa=.47-.94) reliability. Project 2 revealed that stimulation clarity and strength were significantly associated with a low apathy level (p<.001). An increase of 1 point on stimulation clarity and strength corresponded to a decrease on apathy score of 1.3 and 1.9 points, respectively. Project 3 revealed that ActiGraph had widely varied accuracy in measuring duration of standing, walking, sitting, and lying (0-100%) and in measuring number of steps taken (43-81%). In contrast, activPALTM showed consistently high accuracy in measuring duration of standing, walking, sitting, and lying (97-100%) and in measuring number of steps of taken (91-99%). Discussion: The PEAR is a valid and reliable measure of care environment and apathy in long-term care residents with dementia. Care environments that contain clear and sufficiently strong environmental stimulation are significantly associated with lower apathy levels, providing a foundation for interventions targeting apathy. ActivPALTM is a valid tool to measure weight-bearing activity in persons with diabetes in order to examine the role of weight-bearing activity in foot ulceration. This monitor may also be useful as a supplemental measure for apathy in persons with dementia.

Mathematical modeling and realistic human simulation of human jogging motion is a very challenging problem. Majority of the current literature is focused on studying walking or running. This work is aimed at bridging the gap in literature due to the lack of research work in three main areas: (1) simulations and experiments on running at speeds lower than 3 m/s, (2) Kinetics of fore-foot strike pattern in jogging and running and (3) the existence of a double support phase in running at slower speeds and its effects. Formulations to simulate natural human jogging are studied and developed. The digital human model used for this work includes 55 degrees of freedom, 6 for global translation and rotation and 49 for the revolute joints to represent the kinematics of the body. Predictive Dynamics methodology is used for dynamic analysis where the problem is formulated as a nonlinear optimization problem. Both, displacement and forces are considered as unknowns and identified by solving the optimization problem. The equations of motion are satisfied by applying them as equality constraints in the formulation. Kinematics analysis of the mechanical system is performed using the Denavit-Haretneberg (DH) method. The zero moment point (ZMP) condition is satisfied during the ground contact phase to achieve dynamic stability. The joint angle profiles are discretized using B-spline interpolation method. The joint torque squared, also termed dynamic effort, and the difference between predicted motion and motion capture data are used as performance measures and minimized in the optimization formulation. The formulation also includes a set of constraints to simulate natural jogging motion. Two formulations are discussed for jogging on a straight path: (1) one-step jogging formulation and (2) one-stride jogging formulation. The one-stride formulation is discussed for clock-wise and counter clock-wise jogging along a curved path. Cause and effect is shown by obtaining simulation results for different loading conditions. The proposed formulation provides realistic human jogging motion and is very robust.

Currently there are nearly 2 million people living with limb loss in the United States [1]. Many of these individuals are either transtibial (below knee) or transfemoral (above knee) amputees and require an ankle-foot prosthesis for basic mobility. While there are an abundance of options available for individuals who require an ankle-foot prosthesis, these options fail to mimic an intact ankle when it comes to key evaluation criteria such as range of motion, push-off force, and roll over shape. The roll over shape is created by plotting the center of pressure during a step in a shank-based coordinate system. To address the need for a prosthesis that effectively replaces the ankle's contribution to an able-bodied gait, a biomimetic approach is taken in the design the Compliant & Articulating Prosthetic Ankle (CAPA) foot. The passive CAPA foot consists of four components connected by torsion springs representing the Phalanges, Metatarsal bones, Talus, and Calcaneus. Biomimetic functionality is exhibited by CAPA foot with regards to the roll over shape and a linear relationship between moment exerted and ankle angle, distinguishing the CAPA foot from other ankle-foot prostheses. A mathematical model of the CAPA foot is created to determine the roll over shape a specific CAPA foot geometry would produce and support eventual customization of the 3D printed components. The mathematical model is used to optimize the design to two distinctly different roll over shapes, one with a rocker radius closer to that of the Talus bone and the other closer to the energetically advantageous value of 0.3 times leg length [2, 3]. Compliant and stiff versions of the two CAPA feet were compared to a conventional Solid Articulating Cushioned Heel (SACH) foot and a passive dynamic response foot (Renegade® AT produced by Freedom Innovations). Ten able bodied subjects walked on the Computer Assisted Rehabilitation Environment normally, and then with a transfemoral prosthetic simulator. The study was separated into two experiments. For the second experiment (subjects 6-10), the versions of the CAPA foot had pretension in the dorsiflexion springs. Overall the ankle angles and sagittal plane ground reaction forces of the CAPA foot better mimicked an intact ankle-foot than the existing passive ankle-foot prostheses. Added pretension increased the sagittal plane ground reaction forces and roll over shape radius of curvature and arc length. Nine out of ten participants preferred the CAPA foot and there was a statistical significant difference (F=14.2, p<0.01) between the difficulty level rating given for trials with the CAPA foot versus the existing ankle-foot prostheses. The mathematical model is found to be capable of accurately predicting experimental roll over shape trends and the concept of roll over shape based design is demonstrated. Successful aspects of the CAPA foot can be applied to other ankle-foot prosthesis. The CAPA foot could provide a passive, cheap, and personalizable ankle-foot prosthesis that improves mobility the quality of life for individual’s lacking an intact ankle.

The objective of this study was to investigate the intra-rater (within day & between days) and inter-rater reliability of foot/ankle water volumetry in healthysubjects.Study design: Repeated measures design with 2 raters.Background: Physiotherapists more often aim to reduce swelling in the acute phase of soft tissue injury. Reduction in swelling will hasten the healing process. Therefore swelling forms an important outcome measure that is worth studying during the healing process to determine the efficacy of the intervention. Though there are different methods available to measure extremity swelling, water displacement method is widely used in physiotherapy studies. Although water volumetry has been used to assess the reduction in swelling over time, there is paucity of reliability studies that have assessed the between-days reliability.Methods: Thirty normal subjects with asymptomatic ankles were measured by 2 raters. Three repeated foot volume measurements were performed by each of the rater using water volumetry during a single test session. The same procedure was repeated approximately at the same time on the 3rd day and 5th day following the 1st measurement day by the same raters on the same subjects. The raters were blinded to each other's measurements. The order for rater's volumetric measurement on each subject on each day was determined by a random chart produced by SPSS. The reliability was measured in terms of systematic bias (Paired t test & Bland & Altman's plot), absolute reliability (Limits of Agreement [LOA] & Standard Error of Measurement [SEM]) and relative reliability (Intraclass Correlation Coefficient [ICC]).Results: There was no systematic bias between any of the trials within day/between days or between raters. The intra-rater reliability within day as calculated by ICC; LOA and SEM were 0.99, ±10ml and ±3.5ml respectively and for between days reliability the values were 0.99 (ICC), ±20ml (LOA) and ±7ml (SEM) and for interrater reliability the values were 0.99 (ICC), ±13ml (LOA) and ±5ml (SEM). The results demonstrated that water volumetry method was highly reliable within day and between days for both the raters; and highly reliable between raters.Conclusion: Water volumetry is a highly reliable method for measuring foot/ankle volume repeatedly on different days. The random error range in milliliters (ml) as estimated by the absolute reliability indices provides the practical use of this method in a clinical/research setting.

Plantar heel pain is a common disorder that can involve considerable pain. Many treatments have been suggested to manage the condition however few have been rigorously evaluated. Two treatments commonly recommended in clinical practice are adhesive taping applied to the foot and calf muscle stretching. The effectiveness of neither treatment is supported by good quality evidence. Aim: To examine the effectiveness of two short-term interventions, low-Dye taping and calf muscle stretching, for the treatment of plantar heel pain. In addition, the effect of the interventions on biomechanical variables was investigated. Design: Four studies were undertaken in the thesis. The first study in the thesis (Chapter 3) investigated the biomechanical effect of low-Dye taping on the lower limb by systematically reviewing appropriate clinical trials. Meta-analyses were undertaken where appropriate. The second study (Chapter 4) was a blinded randomised trial conducted to evaluate the effectiveness of low-Dye taping for the short-term treatment of plantar heel pain. The third study (Chapter 5) investigated the effect of calf muscle stretching on ankle joint range of motion by systematically reviewing appropriate clinical trials. Meta analyses were again undertaken where appropriate. The fourth and final study (Chapter 6) was another blinded randomised trial conducted to evaluate the effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain. Setting: Both randomised trials were conducted at a university-based clinic in Sydney, Australia. Participants In the randomised trials, 184 participants who met the inclusion and exclusion criteria for plantar heel pain were recruited from the local community. In the first trial 92 participants were evaluated over a one-week period and randomly allocated to receive either low-Dye taping or a sham intervention. In the second trial 92 participants were evaluated over a two-week period and randomly allocated to receive either calf muscle stretching or a sham intervention. Outcome measures In the first systematic review, all trials that met the inclusion and exclusion criteria evaluated the effect of low-Dye taping on kinematic, kinetic and electromyographic outcomes. For the second systematic review, all trials that met the inclusion and exclusion criteria examined the effect of calf muscle stretching on the outcome of ankle joint dorsiflexion range of motion. Both randomised trials in this thesis used the Visual Analogue Scale and the Foot Health Status Questionnaire as primary outcomes. In the stretching randomised trial secondary outcomes were also assessed, namely the Foot Posture Index-6 and the Ankle Lunge Test. Results: The first systematic review found that low-Dye taping provides a small, statistically significant increase in navicular height immediately after application (weighted mean difference 5.90mm; 95% confidence interval 0.41 to 11.39; p=0.04)1 indicating a reduction in foot pronation. However, after exercise, taping had no statistically significant effect on navicular height (weighted mean difference 4.70mm; 95% confidence interval –0.61 to 10.01; p=0.08). In addition, taping had no statistically significant effect on maximum rear foot eversion (weighted mean difference –0.59°; 95% confidence interval ����2.53 to 1.35; p=0.55) or total rear foot range of motion while walking (weighted mean difference 2.3°; 95% confidence interval –0.64 to 5.24; p=0.13). The first randomised trial found that low-Dye taping had a significantly greater decrease in ‘first-step’ pain compared to a control group. The estimate of the mean difference between the groups (measured on 100mm Visual Analogue Scale) favoured the taping group (-12.3mm; 95% confidence interval -22.4 to -2.2; p=0.017). There 1 P values are provided to three decimal places except when values were generated using systematic review software, Review Manager 4.2.7, which sometimes only calculates results to two decimal places. were no differences detected in any of the other outcome measures. The taping was associated with mild to moderate short-lived adverse events that could be minimised with the use of hypoallergenic tape and careful application of the tape to reduce tightness. The second systematic review found that calf muscle stretching provides a small, statistically significant increase in ankle joint dorsiflexion. Stretching for ≤15 minutes (in a single session or accumulated over multiple sessions) provides a weighted mean difference of 2.07° (95% confidence interval 0.86 to 3.27; p(less than)0.001). 15 to 30 minutes (accumulated over multiple sessions) increased dorsiflexion by a weighted mean difference of 3.03° (95% confidence interval 0.31 to 5.75; p=0.03), and >30 minutes of stretching (accumulated over multiple sessions) increased dorsiflexion by a weighted mean difference of 2.49° (95% confidence interval 0.16 to 4.82; p=0.04) indicating no further increase in dorsiflexion is achieved by stretching for >30 minutes. The second randomised trial found that calf muscle stretching compared to a control group, had no significant effect on ‘first-step’ pain, foot pain, foot function or general foot health. Stretching was associated with mild to moderate adverse effects that were short-lived once stretching ceased. Conclusion: When used for the treatment of plantar heel pain, low-Dye taping provides a small increase in navicular height, and after one week, produces a small reduction in the ‘first-step’ pain. Calf muscle stretching increases ankle joint dorsiflexion approximately 2 to 3 degrees but has no effect on plantar heel pain after two weeks. It can therefore be concluded that low-Dye taping is effective for the short-term treatment of the ‘first-step’ pain associated with plantar heel pain, but calf muscle stretching is not effective for plantar heel pain. / Doctor of Philosophy (PhD)

Merino sheep are the most numerous domestic livestock in Australia and feral goats are wide-spread and locally abundant in many of the regions where sheep are grazed. Foot and mouth disease (FMD) is a disease of ungulates that causes severe economic hardship to countries where outbreaks occur or where it has become endemic. In India, Africa, Greece and recently the United Kingdom and Eire, sheep and goats have been implicated in the spread and maintenance of FMD. In Australia, there are contingency plans (AUSVETPLANS) for dealing with an outbreak of FMD. Included in those plans are strategies for control of the disease in feral ungulates including feral pigs and feral goats. Modelling has provided assistance in developing strategies to combat outbreaks in feral pigs and for controlling outbreaks in domestic livestock. No models have been constructed to aid decisions about controlling FMD in feral goats where they co-occur with merino sheep. In Australia, the greatest densities of free-ranging feral goats and domestic livestock occur in the high rainfall zone (> 500 mm mean annual rainfall) along the eastern tablelands and adjacent slopes of the Great Dividing Range. Previous studies of feral goat biology, population dynamics and behaviour in Australia have concentrated on arid and semi-arid zones or on islands. Interactions between free ranging feral goats and merino sheep have not previously been studied in the high rainfall zone. My study investigated the ecological and behavioural characteristics of feral goats and their interactions with sympatric merino sheep at a high rainfall site in central eastern New South Wales. The population dynamics, biological and behavioural parameters of feral goats and sheep were then used to model FMD in such an environment. Deterministic temporal models and a new spatial stochastic model were used. Of particular interest were the rates of contact within and between subgroups of feral goats (termed herds and mobs), within and between subgroups of merino sheep (termed flocks and mobs), and between subgroups of the two species. Feral goats at the study site were found to be numerous (mean density = 34.94 goats km-2, from aerial surveys), in good condition, fecund and had high adult survival and low annual adult mortality (survival= 0.81�1.00) in the absence of harvesting and hunting. They had an observed instantaneous rate of increase of 0.112 per year. Annual rate of increase was similar to other sites in Australia without sustained harvesting pressure. Home ranges were small for both males (3.754 km², s.e. = 0.232, n = 116 goats) and females (2.369 km², s.e. = 0.088, n = 241 goats). From this and other Australasian studies, an inverse power function was found to be an excellent descriptor of the relationship between mean annual rainfall and female home range size. A resource selection function was fitted in a geographic information system to observational data of feral goats. The habitat selection of feral goats included a preference for wooded vegetation on eastern and north eastern aspects at higher elevations. The resource selection function was also used to set the probabilities of occurrence of feral goats in 1 ha areas of the landscape and these probabilities were used to generate heterogeneity in a spatial model of foot and mouth disease virus (FMDV) transmission. Daily per capita contact rates were estimated from observed contacts in the field where a contact between individuals was recognised when one approached within 1 body length ([approx] 1m) of another. The contacts between feral goats within herds were frequent and occurred at a rate of 6.96 (s.e. = 1.27) goat�goat contacts day-1. Sheep to sheep contacts were slightly less frequent (4.22 sheep�sheep contacts day-1, s.e. = 0.65) but both estimates were most likely negatively biased because of observer errors in estimating the number of individual animals coming in contact with observation subject (focal) animals. Contacts between herds of feral goats were not common and those between adjacent populations were fewer than 1 per year. In sheep, flock to flock contact was largely governed by husbandry practices and occurred at a mean daily rate of 0.0014 flock�flock contacts. Contacts between sheep and feral goats were less frequent but nonetheless common (2.82 goat�sheep contacts day-1, s.e. = 0.40). In feral goats the size of the mob in which focal goats were observed was found to be the most important factor in determining contact rates between individuals and a counter-intuitive inverse relationship was identified. Contacts were heterogeneous and density was not an important determinant of contact rates implying that, because of the uniformly high densities at the site, saturation had occurred. The temporal models of FMDV transmission showed that the rate of contact within and between species was such that FMD was predicted to spread rapidly throughout an infected herd or flock. Control strategies of intense culling of feral goats at the population level were predicted to allow the disease to persist at low prevalence, with a small peak corresponding to the annual lambing pulse in sheep. However, the same level of control (>90% reduction) at the herd level was predicted to eliminate FMD and allow the safe reintroduction of sheep. Extreme control that left very small groups (<3 individuals) may be counter productive because such small groups are likely to join the reintroduced sheep in an effort by the goats to meet gregarious urges. The spatial model was more reassuring. It predicted that FMD would die out in a mixed sheep and feral goat population in less than 90 days because of the low rate of herd to herd contact and herd to flock contact. For similar environments, the contingency planning consequences are that an outbreak of FMD introduced into feral goats from sympatric sheep is likely to be containable by removing all the sheep, determining the extent and likely range of the feral goats, then removing a substantial proportion of or eradicating each herd. Feral goats, being relatively sedentary, are unlikely to spread to adjacent populations and the disease will die out through lack of contact between herds and populations. Because feral goat home ranges overlap and are centred on one or two small catchments, a containment ring of feral goat control, set to encompass the home range of a target herd and that of adjacent herds, should be adequate to limit spread of FMD.

This thesis is concerned with studying aspects of the ecology of feral pigs in the wet-dry tropics of the Northern Territory. The data are needed for use in the management of feral pigs to reduce their agricultural and potential epidemiological impact. Particular emphasis is placed on collecting data needed for modelling foot-and-mouth disease in feral pigs, estimating agricultural damage caused by pigs and evaluating control techniques. All fieldwork was conducted in the Douglas Daly district of the Northern Territory.

People with diabetes are at a greater risk of burn injuries than those without diabetes. This stems from the epidemiological profiles of the conditions and the effects of morbidities associated with diabetes. Both conditions share some similarities in terms of metabolic alterations and suboptimal immune functions which may result in poor outcomes for patients. For that reason, it is reasonable to deduce that patients with diabetes are a challenging group to manage in burns units. However, this deduction should be taken cautiously because of lack of supporting evidence. Accordingly and after consulting with clinical experts, the research in this portfolio investigated the association between diabetes and burn injuries. In particular, two different aspects of this association were investigated in two individual quantitative and descriptive inquiries. The first was a case note review of patients hospitalised with a principal diagnosis of a foot burn injury in a large tertiary hospital in South Australia from 1999 to 2004. The second study investigated management of diabetes in burns units treating adults. This study is an e-mail survey of clinical leaders of burns units in Australia, New Zealand, Hong Kong and the United Kingdom. The clinical leaders were approached indirectly through key liaison persons in each identified unit. In the first study, outcomes for twelve subjects with and fifty-two without diabetes were described using descriptive and non-parametric statistics. In the second study, descriptive frequencies and content analysis were adopted to analyse twenty-nine responses from seventeen out of thirty burns units which participated in the study. Supporting findings in the literature, the first study showed that burn injuries among subjects with diabetes were mainly resulted from household devices. There were no statistically significant differences between subjects with and without diabetes in terms of size and depth of burn injuries and treatment received. In spite of this, there was a statistically significant association between diabetes and the experience of local post-burn complications and longer duration of hospitalisation. The second study indicated that more than twenty-five percent of the respondents believed that multidisciplinary centres should only occasionally be involved in the process of care. Participants reported that the individual profile of each patient plays a major role in determining the management of diabetes. Additionally, it was found that the insulin sliding scale was commonly used in the management of diabetes in burns units. The association between diabetes and a burn injury is a serious issue in terms of health and cost. This association need be addressed firstly and most importantly at the prevention level; secondly through proper management of both diabetes and burns. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1285462 / Thesis (D.Nurs.)--Population Health and Clinical Practice, 2007.

Past research on the acceleration phase in sprint running has concentrated on the kinematics of sprint blocks set-up and the initial steps after exiting the sprint blocks. In contrast, there has been limited research on the ground reaction forces (GRF) generated during the initial post-block foot contacts. These initial foot contacts in sprinting are important for optimising performance in the initial acceleration phase of sprinting. However, little is known about the GRF elite sprinters generate during the initial foot contacts and how these GRF characteristics relate to performance. It is the anterior-posterior (A-P) GRF that are of most importance as they indicate the sprinter’s motion from the start to the finish line. This thesis investigates the A-P GRF of the first two foot contacts of the sprint start after leaving the blocks. The participants included seventeen male and six female sprinters with a mean age of 22.6 (SD 4.4 years). Seventeen of the sprinters had competed at international/national level competitions and six at recreational/amateur level competitions. The athletes were classified as senior male elite (SME), senior female elite (SFE), junior male elite (JME) and senior male recreational (SMR). The sprinters were instructed to perform block starts at maximal effort to produce the fastest time over 5 metres on a 30 metre indoor laboratory track. Timing gates were used to record 5 metre times and two strain gauge force plates were placed in series to collect GRF data from the first two foot contacts after leaving the starting blocks. From the GRF data, braking time, maximum A-P braking force, A-P braking impulse, propulsive time, maximum A-P propulsive force, A-P propulsive impulse and A-P contact impulse were determined for each trial. The A-P propulsive phase constituted greater than 90% of the total contact time, had approximately twice the magnitude of the maximum force of the braking phase and accounted for more than 95% of the total contact impulse across the four groups of sprinters. The SME group produced a significantly larger A-P propulsive impulse on the first and second steps compared to the SFE (p less than 0.05 and p less than 0.05 respectively), JME (not significant and p less than 0.05 respectively) and SMR (p less than 0.05 and p less than 0.05 respectively) groups. The SME group’s maximum A-P propulsive force was significantly larger on the first and second steps than the SFE (p less than 0.05 and p less than 0.05 respectively), JME (p less than 0.05 and p less than 0.05 respectively) and SMR (p less than 0.05 and p less than 0.05 respectively) groups. The SME group’s propulsive time on the first and second steps was not significantly different compared to the SFE (both not significant) but was significantly shorter compared to the JME (p less than 0.05 and p less than 0.05 respectively) and SMR (p less than 0.05 and p less than 0.05 respectively) groups. The maximum A-P propulsive force correlated strongly with 5 metre time for the first step (rs = -0.670, p less than 0.01), second step (rs = -0.621, p less than 0.01) and the addition of the first and second steps (rs = -0.678, p less than 0.01) across all the sprinters. Whereas, the A-P propulsive impulse correlated strongly with 5 metre time for the first step (rs = -0.525, p less than 0.01), second step (rs = -0.592, p less than 0.01) and the addition of the first and second steps (rs = -0.584, p less than 0.01). Three A-P GRF patterns were observed during the first and second foot contacts of the sprinters examined in this study. A braking-propulsive (B-P) pattern was the most frequently observed followed by a propulsive-braking-propulsive (P-B-P) and a no braking (NB) pattern 82.7%, 15.4% and 1.9% respectively. The P-B-P and NB patterns, which have not been described previously, appeared most frequently in the least experienced sprinters. In the past, some sprinters and their coaches have tried to minimise the braking phase and maximise the propulsive phase of the first two foot contacts after exiting the blocks during sprinting. This study suggests that increasing the maximum propulsive force is the best way to increase performance over the first 5 metres of the acceleration phase. The research also suggests that there will be little benefit gained from trying to increase performance by focusing on the braking phase during these first two steps after exiting the blocks. As such, sprinters and coaches should focus their attention primarily on producing a large A-P propulsive force during the first two steps of a sprint.

<p>This thesis discusses South Scandinavian cup marks in general, and cup marks in Kronobergs County in particular. The question is whether the cup mark phenomena can be viewed as an ordinary family-based cult for a kind of everyday use, or more likely as a community passage ritual. The thesis also suggests that cup marks were made by ritual participants in, or in the process of trying to reach, an altered state of consciousness.</p>