O estudo do controle neurofisiológico do movimento tem sido realizado sob várias perspectivas. Experimentos com seres humanos são realizados durante a execução de uma dada tarefa motora e, frequentemente, mediante a aplicação de estímulos externos (elétrico, magnético ou mecânico) ao sistema neuromuscular. Estes experimentos fornecem uma grande quantidade de dados referentes ao funcionamento das redes neuronais e dos atuadores biomecânicos envolvidos nos procedimentos. Entretanto, alguns achados experimentais permanecem incompreensíveis, requerendo a utilização de outros recursos para elucidar quais mecanismos estão por trás dos resultados. Neste sentido, a modelagem matemática e a simulação computacional servem como parte importante destas ferramentas que são imprescindíveis para uma melhor compreensão dos mecanismos neurofisiológicos e biomecânicos por trás do controle do movimento. A presente tese de doutorado teve como objetivo prover um modelo neuromusculoesquelético biologicamente plausível capaz de investigar diferentes mecanismos responsáveis pelo controle do torque gerado na articulação do tornozelo. Este modelo teve como base um modelo neuromuscular previamente proposto, porém, que não incorporava uma série de elementos fundamentais para um estudo mais amplo do sistema motor. O novo modelo proposto contempla modelos de motoneurônios com dendritos ativos, proprioceptores musculares responsáveis pelas vias reflexas de curta e média latência, modelos que representam as características viscoelásticas dos músculos e um modelo biomecânico do ser humano durante a postura ereta quieta. O modelo foi aplicado a diferentes problemas relacionados ao funcionamento do sistema neuromusculoesquelético, que são tipicamente explorados por experimentos com seres humanos, e forneceu bases teóricas importantes para estes achados. / The neurophysiological control of movement has been studied from several standpoints. Human experiments are performed during the execution of a given motor task and, frequently, by applying an external stimulation (electrical, magnetic, or mechanical) to the neuromuscular system. These experiments provide a large amount of data concerning the functioning of the neuronal networks and biomechanical actuators involved in the procedures. Nonetheless, some experimental findings remain puzzling, so that other available resources should be used to clarify what mechanisms are behind these results. In this vein, the mathematical modeling and computer simulations are invaluable tools that may be used to better understand the neurophysiological and biomechanical mechanisms underlying the motor control. The present PhD thesis aimed at providing a biologically plausible neuromusculoskeletal model that was used to study different mechanisms involved in the control of the ankle joint torque. This model was based on a previous neuromuscular model, which did not employ several elements that are fundamental to a comprehensive evaluation of the motor system. The novel proposed model encompasses motor neuron models with active dendrites, muscle proprioceptors responsible for the short- and medium-latency reflex pathways, muscle models with the main viscoelastic features, and a biomechanical model of the human body during upright stance. It was applied to a series of problems frequently related to the functioning of the neuromusculoskeletal system and its main outcomes provided important theoretical bases for a set of experimental findings.

Qualquer tarefa motora ativa se dá pela ativação de uma população de unidades motoras. Porém, devido a diversas dificuldades, tanto técnicas quanto éticas, não é possível medir a entrada sináptica dos motoneurônios em humanos. Por essas razões, o uso de modelos computacionais realistas de um núcleo de motoneurônios e as suas respectivas fibras musculares tem um importante papel no estudo do controle humano dos músculos. Entretanto, tais modelos são complexos e uma análise matemática é difícil. Neste texto é apresentada uma abordagem baseada em identificação de sistemas de um modelo realista de um núcleo de unidades motoras, com o objetivo de obter um modelo mais simples capaz de representar a transdução das entradas do núcleo de unidades motoras na força do músculo associado ao núcleo. A identificação de sistemas foi baseada em um algoritmo de mínimos quadrados ortogonal para achar um modelo NARMAX, sendo que a entrada considerada foi a condutância sináptica excitatória dendrítica total dos motoneurônios e a saída foi a força dos músculos produzida pelo núcleo de unidades motoras. O modelo identificado reproduziu o comportamento médio da saída do modelo computacional realista, mesmo para pares de sinal de entrada-saída não usados durante o processo de identificação do modelo, como sinais de força muscular modulados senoidalmente. Funções de resposta em frequência generalizada do núcleo de motoneurônios foram obtidas do modelo NARMAX, e levaram a que se inferisse que oscilações corticais na banda-beta (20 Hz) podem influenciar no controle da geração de força pela medula espinhal, comportamento do núcleo de motoneurônios até então desconhecido. / Any active motor task is accomplished by the activation of a motor unit population. However, due to many ethical and technical difficulties the synaptic input to the motoneurons cannot be measured in humans. For these reasons realistic computational models of a motoneuron nucleus and the innervated muscle fibers have an important role in the study of the human control of muscles. However such models are complex and their mathematical analysis is difficult. In this text a system identification approach of a realistic motor unit nucleus model is presented with the objective of obtaining a simpler model capable of representing the transduction of the motor unit nucleus inputs into the muscle force signal associated to that nucleus. The system identification was based on an orthogonal least squares algorithm to find a NARMAX model, the input being the net dendritic excitatory synaptic conductance of the motoneurons and the output being the muscle force signal produced by the motor unit nucleus. The identified model output reproduced the mean behavior of the output from the realistic computational model even for input-output signal pairs not used during the identification process, such as sinusoidally modulated output muscle force signals. Generalized frequency response functions of the motoneuron nucleus were obtained from the identified NARMAX model, and led to an inference that cortical oscillations in the beta band (20 Hz) can affect force control by the spinal cord, an unknown motoneuron nucleus behavior until now.

Often neglected in voice study is the understanding that a singer’s instrument lives in his/her body and therefore cannot be packed away like other musical objects. Yoga and mindfulness compliment the belief of a whole body instrument. Data gathered on college campuses report that stress and anxiety are on the rise, thus reinforcing the need for MBSR and yoga as beneficial and proven tools for stress relief. The current state of research in the realm of mental health in colleges merits the study of a cohesive layout of these exercises and their expected outcomes in singing as well as stress management. Therefore, this document will present yoga sequences that align with the core aspects of singing including breath support, fluid vocal production and artistic expression. Exercises founded on principles of mindfulness are provided to bring awareness of mental qualities within a singer. Mental qualities gained from meditation practice include improved self-esteem, lowered anxiety, and increased focus. Yoga sequences will focus on certain areas of the body commonly addressed in voice studies. Collections of yoga asana, or postures, are featured to allow singers to recognize tightness and inefficiencies in their bodies, thus improving vocal function. This guide will combine yoga traditions along with mindfulness research to introduce ancient philosophies to singers and their teachers, resulting in meaningful and productive voice lessons.

Les activités motrices de la vie quotidienne ou sportive se caractérisent par des mouvements de rotations complexes 3D des membres supérieurs pouvant s’effectuer autour d’axes de rotation distincts (i) articulaires (ii) d’inertie ou (iii) passant par le centre de masse du bras, chacun relevant de référentiels distincts. Une étude récente a montré que selon les contraintes de vitesse, un changement d’axe de rotation s’opère dans le cadre de l’exécution d’un mouvement simple de rotation du bras par rapport au tronc (Isableu et al., 2009). Dans ce cadre, l’objectif de la thèse a été de compléter cette première analyse et d’évaluer la robustesse de l’hypothèse selon laquelle les axes autour desquels s’organise le mouvement dépendent de la vitesse du mouvement et des contraintes liées à la tâche en général. L’hypothèse formulée est que l’axe correspondant à l’inertie minimum verra sa variabilité diminuée avec des vitesses qui augmentent par rapport à un axe lié au centre de masse (épaule-centre de masse du membre supérieur) ou géométrique (axe-épaule–coude). Cette étude s’effectue en considérant des mouvements « simples » et plus complexes incluant des gestes sportifs. Ainsi, les études effectuées ont porté sur l’influence des contraintes liées à la tâche et leur incidence sur le choix des axes de rotation. Tout d'abord le rôle de l'instruction initiale est testé. Deuxièmement, la variabilité de l'axe d’inertie minimum est évaluée au cours d'une tâche de précision. Troisièmement, l’hypothèse est testée dans le cadre d’une tâche d’interception qui implique des contraintes de temps. Enfin, nous avons testé le rôle des axes lors de gestes complexes, à grande vitesse, notamment lors de lancer à bras cassé et lors du service au tennis. Les résultats obtenus permettent de discuter l’hypothèse de l’importance de l’axe d’inertie minimum lors de l’exécution de mouvements volontaires du membre supérieur. / Motor activities of daily life or sports are characterized by complex 3D rotational movements of the upper limbs can be done around distinct axes of rotation (i) joint (ii) inertia or (iii) through the center mass of arms, each under separate repositories. A recent study showed that within the constraints of speed, a change of axis of rotation occurs in the context of the implementation of a simple rotation of the arm relative to the trunk (Isableu et al., 2009) . In this context, the aim of the thesis was to complete this first analysis to evaluate the robustness of the assumption that the axes around which organizes the movement depends on the speed of motion and the constraints task in general. The assumption is that the axis corresponding to the minimum inertia reduced variability seen with speeds which increase with respect to a center axis associated with the mass (shoulder mass center of the upper limb) and geometric (pin-shoulder elbow). This study is done by considering "simple" and complex athletic movements including movements. Thus, studies have focused on the influence of the task constraints and their impact on the choice of axes of rotation. Firstly the role of initial instruction is tested. Secondly, the variability of the axis of minimum inertia is estimated in a precise task. Thirdly, the hypothesis is tested in an interception task that involves time constraints. Finally, we tested the role of axes in complex gestures, high speed, especially during launch and broken arm during the tennis serve. The results are used to discuss the hypothesis of the importance of the axis of minimum inertia during the execution of voluntary movements of the upper limb.

Currently a lack of guidelines for Criterion B of the DSM-IV-TR (American Psychiatric Association, 2000) hampers diagnosis of children with developmental coordination disorder (DCD). The Performance of Activities of Daily Living Questionnaire (PADL-Q; Dewey, Larkin & Summers, 2004) is a new parent-reported instrument developed to quantify the level of interference in activities of daily living (ADL) experienced by children with DCD and was tested for its efficacy in addressing Criterion B. Thirty-two children aged between 5 and 10 years comprising two matched groups, 16 with DCD (8 boys and 8 girls) and 16 without DCD (8 boys and 8 girls) participated in the study. The aim of the research was to investigate the ability of the PADL-Q to identify differences between children with and without DCD. A further 5 children, in the same age range, who did not have DCD added data that was used to ascertain relationships between the constituent assessments. All children were tested using the MAND (McCarron, 1982) whilst their parents completed the PADL-Q. A set of Tests of Activities of Daily Living (TADL) tasks were devised for the children to perform that further validated parents ratings of children?s ADL performance. A Group x Gender MANCOVA, controlled for age, of the PADL-Q total scores demonstrated that there was a significant difference between the children with and without DCD (F(3,25) = 9.44, p < .001; Wilks' lambda = 0.47). Follow-up univariate tests showed a Group x Gender interaction and simple main effects of this interaction indicated that the PADL-Q did not discriminate between the DCD and non-DCD boys. The ability of the PADL-Q to identify DCD was explored in the concurrent validity against the MAND when using a diagnostic cut-off point. The PADL-Q demonstrated 100% specificity and positive predictive values but only 19% sensitivity and 62% negative predictive values. There was a moderately strong relationship (r = .71), between the PADL-Q total score, considered a measure of Criterion B, and the MAND, a measure of Criterion A (DSMIV- TR, 2000). A two factor (Group x Gender) ANCOVA, controlled for age, of the TADL items revealed a statistically significant effect for DCD only (F(1,19) = 34.65, p < .001). There was a moderate correlation (r = -.64) between the PADL-Q total score and the TADL tasks, indicating that parent-reports are supported by their child?s performance. The PADL-Q appears to have potential as part of the DCD diagnostic process; however, further refinement on a larger sample is necessary before it can be used as an easily-administered guide to ADL performance levels in children.

The striatum represents the main input nucleus of the basal ganglia, a system of subcortical nuclei critically involved into motor control and motivational processes and altered in several conditions such as Parkinson’s diseases or drug addiction. The projection neurons of the striatum are GABAergic (γ-aminobutyric acid) medium-sized spiny neurons (MSNs), and account for the large majority of striatal neurons, while interneurons represent about 10% of striatal cells. The MSNs are subdivided into two subpopulations that form two main efferent pathways: the striatonigral and striatopallidal neurons. The striatonigral MSNs project to the entopeduncular nucleus (EP) and substancia nigra pars reticulata (SNr) (direct pathway) and co-express dopamine D1 receptors (D1R) and substance P neuropeptide (SP). On the other hand, striatopallidal MSNs project to the lateral globus pallidus (LGP) (indirect pathway) and co-express dopamine D2 receptor (D2R), adenosine A2A receptor (A2AR) and enkephalin (Enk). The D1R striatonigral and D2R striatopallidal MSNs are equal in number and shape and are mosaically distributed through all the striatum. The dorsal striatum is mainly involved in motor control and learning while the ventral striatum is crucial for motivational processes. In view of the still debating respective functions of projection D2R-striatopallidal and D1R-striatonigral neurons and striatal interneurons, both in motor control and learning of skills and habits but also in more cognitive processes such as motivation, we were interested in the development of models allowing the removal of selective striatum neuronal populations in adult animal brain. Because of the mosaical organisation of the striatum, a targeting of specific neuronal type, with techniques such as chemical lesions or surgery, is still impossible. Taking advantage of new transgenic approaches, the goal of the present work was to generate and/or to initiate the characterization of genetic models in which a selective subtype of striatal neuron can be ablated in an inducible way. We used a transgenic approach in which mice express a monkey diphtheria toxin (DT) receptor (DTR) in D2R-striatopallidal or D1R-striatonigral neurons. Local stereotactic injections of DT can then induce selective neuronal ablation in functionally different striatal areas. We first investigated functions of D2R-striatopallidal neurons in motor control and drug reinforcement by their selective ablation in the entire striatum or restricted to the ventral striatum. This DTR strategy produced selective D2R striatopallidal MSN ablation with integrity of the other striatal neurons as well as the striatal dopaminergic function. D2R MSN ablation in the entire striatum induced permanent hyperlocomotion while ventral striatum-restricted ablation increased amphetamine place preference. We next compared respective roles of D2R-striatopallidal and D1R-striatonigral neurons in motor control and skill learning in functionally different striatum subregions. Finally, to target nitrergic interneurons of the striatum, we developed a bacterial artificial chromosome genetic strain in which the cre-recombinase expression is under the control of the neuronal nitric oxide gene promoter. Altogether, those results show that DTR expression and DT local injections is an efficient and flexible strategy to ablate selective striatum neuronal types with spatial resolution. We provide the first direct experimental evidences that D2R striatopallidal neurons inhibit both locomotor and drug-reinforcement processes and that D2R and D1R MSNs in different striatum subregions have distinct functions in motor control and motor skill learning. Those results strongly support a cell-type and topographic functional organization of the striatum and underscore the need for characterization of the specific cellular and molecular modifications that are induced in D2R and D1R MSNs during drug-reinforcement or procedural learning.

Muscle spindles are complex sensory organs that have been strongly implicated in the control and perception of movements. Human muscle spindles in relaxed muscles behave as stretch receptors, responding to the length and velocity of their parent muscles. However, it has been unclear how they discharge during active movements since their discharges are also affected by fusimotor activity and extrafusal contractions. The vast majority of neurophysiological recordings of muscle afferents have been obtained under passive conditions, or active but behaviourally restricted conditions. These restrictions prevent predictions of human muscle afferent activity during purposeful multi-joint movements, naturally occurring during tasks such as hand shaping, grasping or key-pressing. An experimental protocol was therefore developed which allowed recordings of muscle receptor afferent activity using microneurography during unrestrained wrist and digit movements. Along with single afferent discharges, recordings were obtained of electromyographic activity of major forearm muscles and the kinematics of the wrist and digits. This approach allowed investigations of the factors shaping afferent discharge during everyday manual tasks, i.e., block-grasping and pressing sequences of keys, and during active sinusoidal joint movements. The afferents’ ability to encode information concerning the state of the muscle and joint kinematics during these tasks was also assessed. The responses of spindle afferents from load-bearing muscles were approximatelly 90 degrees more phase-advanced than expected on the length of their parent muscles. That is, the discharges of primary muscle spindle afferents were significantly affected by both velocity and acceleration, the discharges of secondary afferents by velocity, and neither afferent type was particularly affected by static muscle length. Accordingly, these afferents failed to encode length, encoded velocity well and acceleration poorly. The representation of muscle length and velocity was, however, significantly improved when the discharge activity of Golgi tendon afferents was taken into consideration along with muscle spindle activity. The discharge of primary afferents during both key-pressing and block-grasping was best correlated to the muscle velocities observed ~100-160 ms in the future. This predictive ability went beyond what could be expected from the spindles’ simultaneous sensitivity to velocity and acceleration, and could thus only be explained by implicating the fusimotor drive. In addition, evidence is presented that the fusimotor control of spindles was contingent on entire movement sequences during the key-pressing task. It is proposed that the phase relationship between the discharge rate of spindle afferents and the length of their parent muscles is load dependent. Moreover, muscle spindles seem to act as forward sensory models of their parent muscle, which makes sensorial feedback control possible despite neural delays.

This thesis describes a series of experiments in human observers using neurophysiological and behavioural approaches to investigate the effects of varying haptic stimuli, attentional demand and age on motor control and perception during haptic sensing (i.e., using the hand to seek sensory information by touch). In Experiments I-IV, transcranial magnetic stimulation (TMS) was used to explore changes in corticomotor excitability when participants were actively engaged in haptic sensing tasks. These studies showed that corticospinal excitability, as reflected in motor evoked potential (MEP) amplitude, was greatly enhanced when participants were engaged in different forms of haptic sensing. Interestingly, this extra corticomotor facilitation was absent when participants performed finger movements without haptic sensing or when attention was diverted away from haptic input by a concurrent cognitive task (Exp I). This provided strong evidence that the observed corticomotor facilitation was likely central in origin and related to haptic attention. Neuroimaging has shown activation of the parieto-frontal network likely subserves this aspect of haptic perception. Further, this haptic-specific corticomotor facilitation was finely modulated depending on whether participants focused attention on identifying material (texture) as opposed to geometric properties of scanned surfaces (Exp II). With regards to aging effects, haptic-related corticomotor facilitation was associated with higher recognition accuracy in seniors (Exp III). In line with this, seniors exhibited similar levels of haptic-related corticomotor facilitation to young adults when task demands were adjusted for age (Exp IV). Interestingly, both young and senior adults also showed substantial corticomotor facilitation in the ‘resting’ hand when the ipsilateral hand was engaged in haptic sensing (Exp IV). Simply touching the stimulus without being required to identify its properties (no attentional task demands) produced no extra corticomotor facilitation in either hand or age group, attesting again to the specificity of the effects with regards to haptic attention. In Experiments V-VI, the ability to recognise 2-D letters by touch was investigated using kinematic and psychophysical measures. In Experiment V, we characterized how age affected contact forces deployed at the fingertip. This investigation showed that older adults exhibited lower normal force and increased letter-to-letter variability in normal force when compared to young adults. This difference in contact force likely contributed to longer contact times and lower recognition accuracy in older adults, suggesting a central contribution to age-related declines in haptic perception. Consistent with this interpretation, Experiment VI showed that haptic letter recognition in older adults was characterized not only by lower recognition accuracy but also by substantial increases in response times and specific patterns of confusion between letters. All in all, these investigations highlight the critical interaction of central factors such as attentional demand with aging effects on motor and perceptual aspects of haptic sensing. Of particular significance is the clear demonstration that corticomotor excitability is greatly enhanced when a haptic sensing component (i.e., attending to specific haptic features) is added to simple finger movements performed at minimal voluntary effort levels (typically <15 % of the maximal effort). These observations underline the therapeutic potential of active sensory training strategies based on haptic sensing tasks for the re-education of motor and perceptual deficits in hand function (e.g., subsequent to a stroke). The importance of adjusting attentional demands and stimuli is highlighted, particularly with regards to special considerations in the aging population.

The purpose of this dissertation was to gain insight into spinal sensory regulation during locomotion. To this end, I developed a novel in vitro spinal cord-hindlimb preparation (SCHP) composed of the isolated in vitro neonatal rat spinal cord oriented dorsal-up with intact hindlimbs locomoting on a custom-built treadmill or instrumented force platforms. The SCHP combines the neural and pharmacological accessibility of classic in vitro spinal cord preparations with intact sensory feedback from physiological hindlimb movements. thereby expanding our ability to study spinal sensory function. I then validated the efficacy of the SCHP for studying behaviorally-relevant, sensory-modulated locomotion by showing the impact of sensory feedback on in vitro locomotion. When locomotion was activated by serotonin and N-methyl D-aspartate, the SCHP produced kinematics and muscle activation patterns similar to the intact rat. The mechanosensory environment could significantly alter SCHP kinematics and muscle activitation patterns, showing that sensory feedback regulates in vitro spinal function. I further demonstrated that sensory feedback could reinforce or initiate SCHP locomotion. Using the SCHP custom-designed force platform system, I then investigated how presynaptic inhibition dynamically regulates sensory feedback during locomotion and how hindlimb mechanics influence this regulation. I hypothesized that contralateral limb mechanics would modulate presynaptic inhibition on the ipsilateral limb. My results indicate that contralateral limb stance-phase loading regulates ipsilateral swing-phase sensory inflow. As contralateral stance-phase force increases, contralateral afferents act via a GABAergic pathway to increase ipsilateral presynaptic inhibition, thereby inhibiting sensory feedback entering the spinal cord. Such force-sensitive contralateral presynaptic inhibition may help preserve swing, coordinate the limbs during locomotion, and adjust the sensorimotor strategy for task-specific demands. This work has important implications for sensorimotor rehabilitation. After spinal cord injury, sensory feedback is one of the few remaining inputs available for accessing spinal locomotor circuitry. Therefore, understanding how sensory feedback regulates and reinforces spinally-generated locomotion is vital for designing effective rehabilitation strategies. Further, sensory regulation is degraded by many neural insults, including spinal cord injury, Parkinson's disease, and stroke, resulting in spasticity and impaired locomotor function. This work suggests that contralateral limb loading may be an important variable for restoring appropriate sensory regulation during locomotion.

Chronic neck pain is a widespread problem that causes individual suffering as well as large costs for the society. The knowledge about the pathophysiology is poor and therefore specific diagnosis and causal treatment are rare. Important knowledge for characterization of the disorders has been gained from research on sensorimotor functions in people with neck pain. Moreover, rehabilitation regimes including sensorimotor exercises indicate promising results. The main objectives of this thesis were to extend the knowledge on sensorimotor dysfunctions in chronic neck pain, and to develop a new exercise method for improving sensorimotor functions of the neck. The studies focused on aspects of postural control and movements of the arm and neck. These are vital functions for many activities of daily living. People with chronic (&gt;3 months) neck pain were compared to healthy controls (CON). Neck pain related to trauma was referred to as whiplash associated disorders (WAD), while neck pain without association to trauma was referred to as non-specific (NS). Arm-functioning was assessed in a pointing task. WAD and NS had reduced pointing precision compared to CON. The reduced precision was associated with self-rated difficulties performing neck movements, physical functioning, and in WAD, also pain and balance disturbances. Postural control was assessed in quiet standing on a force platform without vision. The center of pressure signal was decomposed into it’s slow and fast components. WAD and NS were compared to CON. The results revealed an effect of age on the magnitude of the fast sway component, but no effect of group. The magnitude of the slow component was elevated in both WAD and NS. This increase was associated with self-rated balance disturbance, arm-functioning, difficulties to run and sensory alterations in WAD, while in NS, the increase in the slow sway component was associated with concurrent low back pain. Neck movements were assessed in a cervical axial rotation test with maximal speed. In total 8 variables representing basic kinematics, including variables reflecting movement smoothness and conjunct motions were calculated. NS were compared to CON. Linear discriminant modelling indicated Peak Speed and conjunct motions as significant classification variables that together had a sensitivity of 76.3% and specificity of 77.6%. Retest reliability was good for Peak Speed but poor for the measure of conjunct motions. Peak Speed was slower in NS compared to CON, and even slower in a sub-group of NS with concurrent low back pain. Reduced Peak Speed was associated with self-rated difficulties performing neck movements, car driving, running, sleeping disturbances and pain. The clinical applicability of a novel method for neck coordination exercise was assessed in a pilot study on persons with NS. The results supported the applicability and indicated positive effects of the exercise: reduced postural sway in quiet standing and increased smoothness in cervical rotations. Indications on improvement in self-rated disability and fear of movement were seen at six months follow up. In conclusion, sensorimotor functions can be altered in chronic neck pain, particularly in neck disorders with concurrent low back pain and WAD. The discriminative ability and clinical validity displayed in pointing precision, postural sway and cervical axial rotation speed imply that such tests can be valuable tools in the assessment of chronic neck pain patients, and for selecting and evaluating treatment interventions. Indications of improvements seen in the pilot-study support a future RCT.