Dissertations / Theses on the topic 'Multimodal intervention'

Multiple sclerosis (MS) is a complex, progressive disease of the central nervous system with potential multifactorial etiology. Subjects with MS experience varying symptoms such as fatigue, muscle weakness, gait and balance impairments, etc. With time, intensity of the symptoms progresses, especially if subjects are in the progressive phase of the disease. So far, there is no effective treatment available which can reverse or even stop progression of the symptoms and disability associated with MS. Given the multifactorial nature of MS, use of multiple interventions is recommended for its treatment. As use of multiple pharmacological agents is usually limited due to adverse side effects, non-pharmacological treatments such as diet, exercises and stress management may provide a safer and potentially effective treatment option. The main aim of this study was to investigate the effects of a combination of non-pharmacological treatments on subjects with progressive MS. In this open-label, single arm cohort study, we investigated the effects of a multimodal intervention consisting of modified Paleolithic diet, nutritional supplements, stretching exercises, strengthening exercises with electrical stimulation of trunk and lower limb muscles, meditation and massage on multiple symptoms associated with progressive MS. We investigated the effects on fatigue, quality of life, clinical disability, walking performance and balance of the subjects over a period of 12 months. Twenty subjects (15 female) with progressive MS (18 secondary progressive and 2 primary progressive) and mean Expanded Disability Status scale (EDSS) score of 6.2 (range, 3.5 to 8) participated in the 12-month main phase of the study. In a subset of subjects (8 SPMS, 2 PPMS; EDSS 6.2 + 1.4), effects of the intervention on microstructure of whole brain, corpus callosum and corticospinal tracts using diffusion tensor imaging (DTI), and measures of clinical disability including ambulation, hand function and cognitive functions were also investigated. Adherence and dosage of individual components of the intervention were calculated from subjects' daily logs. All clinical assessments were completed at baseline, 3, 6, 9 and 12 months. MRI data were collected at 1 and 12 months post-intervention on a subset of 10 subjects. Safety analyses were completed based on monthly side effects questionnaires and blood analyses at 1, 3, 6, 9 and 12 months. Overall subjects showed good adherence with this intervention and did not report any serious side effects. Subjects reported significant improvement in perceived fatigue, energy and general health within 3 months from baseline and sustained the improvement until 12 months. Fifty percent of the subjects showed significant and consistent increases in both comfortable (during timed up and go test) and fast (during timed 25 foot walk) walking speeds. Small but significant improvements in the measures of balance such as Berg Balance test and time to stand up from seated position were also observed. Interestingly, subjects with comparatively lower physical impairment at baseline showed higher improvements in fatigue, walking and balance tests compared to the subjects with severe physical impairments at baseline. We observed consistent improvements in the cognitive functions of the subjects and in the white matter integrity of left corticospinal tracts. Clinical disability assessed with EDSS, and DTI metrics of most white matter tracts did not change significantly during the study period. These results show that a multimodal intervention can be safely implemented and sustained by subjects with progressive MS. This intervention decreases perception of fatigue and improves quality of life of these subjects. Furthermore, this intervention has beneficial effects on subject's walking ability, balance and cognitive functions and white matter integrity. Initiating this intervention during early stage of the disease when subjects have only mild to moderate disability seems to be more beneficial. Larger, randomized, controlled trials are needed to establish efficacy of this multimodal intervention on MS and elucidate mechanisms underlying its effects on MS.

Migraine is a disabling neurological disorder with high prevalence, the clinical manifestations of which are highly dependent on stress. The overall theme of the present thesis was to address aspects of stress in migraine. A multimodal behavioral treatment (MBT) program was developed specifically designed for migraine and focusing on stress as a trigger and an intervention was performed using this Internet-administered program. Migraine symptoms were followed via an Internet administered diary and questionnaires were answered at regular intervals during the 11-month study period. The thesis is based on four papers: In Paper I, life events and current stress, personality traits, and gender were studied cross-sectionally in 106 women and 44 men with migraine, who suffered at least two attacks a month at inclusion. Paper II describes a randomized controlled trial of the MBT program performed on 58 women and 25 men recruited from participants of the study described in Paper I. In the MBT study participants were randomized into one control group and two MBT groups, one of which received hand massage as part of the treatment. In Paper III, complete migraine drug use and changes in use and in drug efficacy during the MBT program were studied. In Paper IV, the salivary cortisol levels of MBT participants were evaluated as a biological stress marker. The MBT program proved effective in decreasing migraine headache; it was feasible and there was low attrition. Moreover, MBT resulted in decreased migraine drug use and increased drug efficacy, but had no discernible effects on salivary cortisol profiles. No effect of hand massage on migraine headache frequency was seen. Personality trait profiling revealed high scores for the neuroticism factor. Stress susceptibility was the single most aberrant personality trait and correlated highly with the reported level of current stress and with experienced negative life events. Gender differences included higher scores for women on trait anxiety, negative life events, depressive mood, anxiety, tension type headache, use of triptans, and efficacy of analgesics, whereas men displayed higher use of analgesics. In conclusion, the efficacy and low attrition associated with the present MBT program appears promising and timely with regard to the development of better and more accessible migraine treatment. Stress susceptibility, gender, negative life events and psychosomatic comorbidity are important factors to consider in relation to the care of persons with migraine.

Thesis (Ph. D.)--West Virginia University, 2009.<br>Title from document title page. Document formatted into pages; contains ix, 177 p. : ill. (some col.). Includes abstract. Includes bibliographical references.

Bakgrund: Långvarig smärta är ett stort folkhälsoproblem som innebär stora kostnader för samhället och självklart också stort lidande för individen. Multimodal smärtrehabilitering (MMR) innebär att olika yrkeskategorier arbetar gemensamt kring dessa patienter. Forskningen visar måttligt till starkt vetenskapligt stöd för MMR vid komplex smärtproblematik. Det finns kunskapsluckor kring vilken typ av fysioterapeutiska interventioner som används vid multimodal smärtrehabilitering. Syfte: Syftet med studien var att kartlägga fysioterapeuternas arbete inom ramen för multimodal smärtrehabilitering i primärvården. Metod: Enkätstudie av tvärsnittstyp med kvantitativ ansats baserad på en egenkonstruerad webbenkät. Populationen utgjordes av fysioterapeuter anslutna till Nationella Registret över Smärtrehabilitering (NRS) primärvård och resultatet bygger på de 23 fysioterapeuter som valde att svara på webbenkäten. Resultat: Resultaten baseras på svar från 71 % av de NRS-anslutna klinikerna. Sammanfattning av resultaten visade framför allt att råd/undervisning samt olika former av fysisk träning utgjorde grunden i fysioterapeutens arbete inom MMR-team i primärvården. Det framkommer att så gott som alla patienter träffade fysioterapeut under behandlingsperioden. Det var en klar övervikt mot gruppbehandling eller en kombination av grupp och individuell behandling gällande de fysioterapeutiska interventionerna. Behandlingsperioderna var för det mesta fyra till elva veckor där patienten träffade fysioterapeut oftast varje vecka eller flera gånger/vecka. I primärvårdens MMR-team var fysioterapeut, arbetsterapeut, KBT terapeut, läkare och rehabkoordinator de vanligast förekommande yrkeskategorierna i teamen. Slutsats: Fysioterapeuten har en central roll i primärvårdens MMR-team och använder sig primärt av evidensbaserade, aktiva interventioner.<br>Background: Chronic pain is a major public health problem which involves high costs for society and, of course, also great suffering for the individual. Multimodal rehabilitation (MMR) means that different occupational categories work together around these patients. Research shows moderately to strong scientific evidence for MMR in complex pain problems. There are a lack of evidence about which type of physiotherapeutic interventions that are used in multimodal pain rehabilitation. Aim: The aim was to study which physiotherapy interventions that are used in multimodal primary healthcare rehabilitation in Sweden. Method: Cross-sectional survey with quantitative approach based on a self-designed web questionnaire. The population consisted of physiotherapists working in clinics reporting to the Swedish Quality Registry for Pain Rehabilitation (SQRP) in primary care and the result is based on the 23 physiotherapists who responded to the web questionnaire. Results: The results are based on 71% of the NRS-affiliated clinics. Counseling/teaching and various forms of physical training formed the basis of the physiotherapist's work in MMR teams in primary care. Almost all patients meet physiotherapists during the treatment period. Group treatment or a combination of group and individual treatment were most common. The treatment periods were mostly between four to eleven weeks where the patient met a physiotherapist most often weekly or several times a week. In the primary care MMR-team, the physiotherapist, occupational therapist, KBT therapist, physician and rehab coordinator were the most common occupational categories. Conclusion: Physiotherapists have a central role in the MMR-teams in primary care, they primarily use evidence-based, active interventions.

La intervención temprana multimodal de fisioterapia se presenta como una intervención preventiva para niños nacidos prematuros y sus padres. Iniciando en la Unidad de Cuidados Intensivos Neonatales y continuando después del alta, hasta los 2 meses de edad corregida del niño, su objetivo es sensibilizar a los padres y proporcionarles estrategias para el cuidado de su hijo, favorecer la interacción entre padres e hijos, así como favorecer el desarrollo del infante y proporcionarle oportunidades de movimiento a través de actividades apropiadas para su desarrollo. Mediante investigaciones de metodología mixta, la presente tesis doctoral aporta nuevas evidencias sobre la intervención temprana de fisioterapia. A través de un ensayo clínico aleatorizado, realizado en el Hospital Sant Joan de Déu de Barcelona, y un estudio cualitativo de entrevistas, que pretende alcanzar un conocimiento más integral sobre la efectividad de la intervención temprana multimodal de fisioterapia.<br>The early multimodal physiotherapy intervention is presented as a preventive intervention for children born prematurely and their parents. The designed intervention starts in the Neonatal Intensive Care Unit and continues after discharge, up to 2 months of corrected age. Its objective is to sensitize parents and provide them with strategies for caring their child, promote interaction between parents and the preterm infant, as well as promoting infant development and providing opportunities for movement through developmentally appropriate activities. Through mixed methodology research, this doctoral thesis provides new evidence of early intervention in physiotherapy. A randomized clinical trial was carried out at the Sant Joan de Déu Children’s Hospital in Barcelona, and a qualitative study with interviews. These studies aim was to achieve a more comprehensive knowledge about the effectiveness of early multimodal physiotherapy intervention.<br>Programa de Doctorat: Cures Integrals i Serveis de Salut

This study examined the efficacy of a multimodal intervention with conduct disordered boys in the middle primary years. The intervention consisted of a behavioural classroom program; a small group, social skills program; and a behavioural parenting program Resource implications of this model were also evaluated. A review of the current literature on conduct disorders showed that these children account for less than 5% of the population, but they have a strong impact on families, teachers, peers, schools and the wider community. About 50% of children with severe, early behavioural problems will continue with these problems, not only throughout their adult lives, but into the next generation. Early intervention appears to offer our best hope of altering this trajectory. Interventions with this population have been largely unsuccessful. At the present time the most promising intervention is behavioural parent training programs. Combining these with child focused social skills programs, and behavioural programs in the school setting, increases their efficacy. This study used a single subject experimental design to examine the effects of this program on four boys with behavioural difficulties. Continuous measures were taken with parent, and teacher daily record charts, and classroom observations. Pre, post and followup measures were taken with the Child Behaviour Checklist. The results of the study were mixed. Some subjects, according to some respondents, improved in home and school behaviours. All three subjects, for whom there was followup data, had improved. The classroom, and parenting programs appeared to be associated with positive changes in child behaviour, the small group was associated with more disruptive behaviour at school.

The study addressed the problem that, although researchers have clearly identified areas of stress for clergy wives and suggested the use of counseling services, they have not identified effective counseling interventions. Clergy wives referred to non-clergy women married to Protestant clergymen. The study included (a) the development of Clergy Wife Wings (CWW), a 5-session psychoeducational group plan for 6 to 10 clergy wives, to alleviate ministry-related stress and (b) the formative evaluation of the plan in its first implementation. Conclusions drawn suggested that CWW showed good potential as an intervention in helping clergy wives to move towards alleviation of stress but needed revisions and additional implementation and evaluation. Recommendations provided a detailed list of specific revisions. CWW had an outcome goal for participants of decreasing ministry-related stress, particularly in three targeted stress domains: role expectations and time demands, clergy family boundary intrusiveness, and lack of social support. As presented in the literature review, the theoretical foundations in stress came from the multimodal-transactional model of stress and its treatment (Palmer, S. & Dryden, W., 1995) and from REBT. The literature review also contained, after a summary of the history of clergy wives, an overview of the plan, with references supporting the components. The plan included pre and post-group testing with two clergy-wife stress assessment instruments -- adaptations of the Clergy Family Life Inventory (Blanton, P., Morris, L, & Anderson, D., 1990) and of the Normative Stress Scale for Clergy Wives (Huebner, 1998). The formative evaluation of the group plan, in its first implementation, identified themes concerning effectiveness, strengths, weaknesses, and suggestions for improvement. These themes emerged from the qualitative analysis of various documents completed by the 9 participants, the group facilitator, and a group observer. Qualitative findings suggested effectiveness of Clergy Wife Wings through themes of participant perceptions and of reported changes in their thinking and behavior related to stress. Quantitative findings, however, from the pre and post-group measures on the clergy-wife stress instruments did not suggest effectiveness, except for a significant decrease in stress related to two of 35 stressor statements. Discussion included possible reasons for the disparity between findings.<br>Ph. D.

<p>ART, Aggression Replacement Training är en multimodal behandlingsmetod som bygger på tre samverkande komponenter. Dessa är: Interpersonell färdighetsträning där sociala färdigheter tränas, ilskekontrollträning som lär individen att handskas med sin ilska samt moralträningen som ska höja det moraliska resonerandet. 1987 började ART att användas på ungdomsvårdsskolor i USA, metoden har spridit sig och idag används ART inte enbart inom den institutionella vården utan allt mer i skolans värld.</p><p>Syftet med uppsatsen är att undersöka vilket eller vilka teoretiska perspektiv på inlärning som metoden stödjer sig på och hur väl dessa stämmer överens med skolans styrdokument (Lpo 94). Studien är baserad på en kvalitativ textanalys av ART Aggression Replacement Training A Comprehensive Intervention for Youth, en bok av grundarna till metoden, samt skolans styrdokument (Lpo 94).</p><p>Reultatet visar att ART vilar på flera olika teorier om inlärning, och att olika teorier finns representerade inom de olika komponenterna. I förhållande till Lpo 94 visar de delar jag analyserar på en överensstämmelse, även om någon punkt kan tolkas annorlunda.</p>

Relatório do Projeto de Investigação apresentado para cumprimento dos requisitos necessários à obtenção do grau de Mestre em Fisioterapia, área de especialização em Fisioterapia em Condições Músculo- Esqueléticas<br>Revisão da literatura: A Dor Lombar Crónica (DLC) constitui um importante problema de saúde, com consequências a nível social como económico. A intervenção dos fisioterapeutas na DLC apresenta uma enorme variabilidade, podendo tal acontecer devido à falta de evidência de boa qualidade que suporte a efetividade ou a relação custo – efetividade (RCE) das intervenções. Entre modalidades mais frequentemente utilizadas estão os agentes físicos e modalidades mecânicas, a terapia manual e o exercício terapêutico. O objetivo principal deste estudo foi verificar qual de duas intervenções multimodais apresenta uma melhor efetividade, na diminuição da intensidade da dor, da incapacidade funcional e no aumento da qualidade de vida em utentes com DLC. Foi também realizada uma análise da RCE na perspectiva do utente, utilizando como referência a mudança clinicamente importante nas variáveis de resultados. Métodos/Desenho: Foi estruturado um estudo de série de casos, que estabeleceu a comparação entre duas intervenções multimodais: agentes físicos/modalidades mecânicas e terapia manual (AF+TM) e, agentes físicos/modalidades mecânicas, terapia manual e exercício terapêutico (AF+TM+EXE). A amostra foi constituída por 20 indivíduos cm DLC. Como principais variáveis de resultados utilizou-se a intensidade da dor (Escala Visual Análoga) e a incapacidade funcional (Quebec Back Pain Disability Scale), e como secundários, a qualidade de vida (EuroQuol-5D) e a perceção global de melhoria reportada pelo utente (Pacient Global Impression Change), sendo realizadas 4 avaliações: antes da intervenção, 3, 6 e 12 semanas após o início da mesma. Resultados: Foram encontradas melhorias significativas às 12 semanas para a redução da incapacidade funcional na intervenção AF+TM e na redução da intensidade da dor e aumento da qualidade de vida na intervenção AF+TM+EXE. A comparação entre intervenções, não revelou diferenças significativas. Na RCE a intervenção AF+TM apresentou melhores resultados excepto quando são considerados apenas os custos directos: a intervenção AF+TM+EXE, apresenta uma melhor RCE na intensidade da dor. Conclusões: Os resultados mostram que apesar de não existirem diferenças significativas entre as intervenções a AF+TM apresenta uma melhor RCE no geral. Estes resultados devem ser analisados com cuidado devido às limitações deste estudo, sendo necessárias mais investigações sobre este tema.<br>Abstract: Background: The Chronic Low Back Pain (CLBP) is a major health problem, with a large social and economic impact. The intervention of physiotherapists in the CLBP presents an enormous variability. This may happen due to the lack of good quality evidence to support the effectiveness or cost - effectiveness (CER) of the interventions. Among the most frequently used modalities are physical agents and mechanical modalities, manual therapy and therapeutic exercise. The main objective of this study was to verify which of the multimodal interventions proposed has a better effectiveness in the reduction of pain intensity, functional disability and increased quality of life for users with CLBP. Will also be performed an analysis of the CER of the patient perspective. Methods / Design: A Case Series study design was used to establish comparison between two interventions: physical agents/modalities mechanical and manual therapy (AF + TM) and physical agents/mechanical modalities, manual therapy and therapeutic exercise (AF + TM+EXE). The sample included 20 subjects with CLPB As a result we main variables pain intensity (visual analog scale) and functional disability (Quebec Back Pain Disability Scale), and the secondary, the quality of life (EuroQuol-5D) and improving the perception experienced by the patient (Patient global Impression Change), being performed 4 evaluations: before the intervention, 3, 6 and 12 weeks after the beginning of the intervention. Results: Significant improvement at 12 weeks in reducing functional disability were found in AF+TM intervention and reduction of pain intensity and improved quality of life in AF+TM+EXE intervention. Comparison between interventions, revealed no significant differences. CEA in the AF + TM intervention showed better results unless when we consider only direct costs: AF + TM + EXE intervention, presents a better CEA in pain intensity. Conclusions: The results indicate that although there are no significant differences between interventions, AF+TM provides a better CER in the general. These results should be analyzed with caution due to the limitations of this study. Further research on this topic is needed.

A partir d’une intervention auprès de médecins du travail, cette thèse explore les conditions de développement des sentiments au travail. Elle stabilise une conceptualisation de l’affectivité distinguant affect, émotion et sentiment qui pose des rapports entre l’affect lié aux conflits de l’activité (conflits liés à la conception de l’activité comme triade vivante sujet/objet/autrui et conflits liés aux rapports entre le déjà vécu et le vivant) et les sentiments et émotions qui en sont les instruments de réalisation. Le sentiment est défini comme l’instrument de réalisation de l’affect détaché de l’événement affectif et relié à l’activité de pensée. Une analyse multimodale de nos matériaux s’attache à repérer des indices de l’affect dans trois modalités étudiées (regard, voix, mot) et des indices de développement de la pensée (développement des significations des mots et des objets de discours). Nous concluons que l’intervention en clinique de l’activité par l’exposition de l’activité qu’elle autorise et la production de débats sur les critères du travail bien fait qu’elle organise peut provoquer des affects et contribuer au développement du sentiment du travail bien fait<br>Based on an intervention with occupational health physicians, this thesis explores the developmental conditions of sentiments at work. The thesis seek to stabilize a conceptualisation of affectivity distinguishing affect, emotion and sentiment, and lays the relationships between affect, which is related to conflicts of activity (conflicts related to activity as a living triad subject/object/others and conflicts related to relationships between the « already lived » and the « living »), and sentiments and emotions, which constitute its instruments of realization. Sentiment is defined as instrument of affect realization, detached of affective event, and related to thinking activity.Multimodal analysis of research materials allows the identification of affect indices, based on three studied modalities (gaze, voice, word), and development of thinking indices (development of signification of word, and discourse objects).We conclude that intervention in clinic of activity, by exposing activity and producing disputations on quality of work criteria, can cause affects and contributes to develop the sentiment of « well-done-work »

Purpose: The objective was to study how sedentary behaviour (SB) and physical activity (PA)change during a 6-months multimodal lifestyle intervention including a Multimodal Lifestyle Intervention, a Multimodal Lifestyle and Medical food intervention and a control subgroup, for people with prodromal Alzheimer's disease (AD). Further, the aim was to explore the predictive value of outcome expectancies and self-efficacy beliefs on level of PA in the two intervention subgroups.  Methods: A secondary analysis of existing data (n=66) from MIND-AD trial with a descriptive evaluation design was conducted. Descriptive and non-parametric statistical analysis were used for between- and within groups analysis. To explore the predictive value of a model with self-efficacy and outcome expectancies at baseline on PA at 6 months, regression analysis was conducted. Effect size was calculated for between-group and withingroup differences. Results: Objectively measured PA increased in the Multimodal Intervention subgroup. SB did not change during the intervention. Outcome expectancies for that impact of exercise is beneficial for health in the long run increased during the intervention. Participants higherinitial outcome expectancies for the impact of exercise would lead to less AD-related difficulties predicted higher PA level at 6 months. Self-efficacy for exercise or outcome expectancies for the impact of exercise on AD-related difficulties did not change during the intervention. Conclusions: PA increased in the Multimodal Intervention subgroup. This difference could not be shown with PA measured by questionnaire which indicates that objective measurements are better suited to measuring PA in people with prodromal AD than subjective measurements. Increased outcome expectancies for that impact of exercise arebeneficial for health in the long run demonstrate the participants strengthened intentions to improve their long-term health. Increasing outcome expectancies to manage AD-related difficulties can be an important part of interventions targeting PA in people with prodromal AD.

Röntgenavdelningen har ett blandat flöde av patienter vilket medför att denna är en potentiell smittväg för olika sjukdomar. För att minska risken för smittspridning är det viktigt att de basala hygienrutinerna följs, dock visar studier på att följsamheten till de basala hygienrutinerna är låg. Syfte: Syftet med denna litteraturöversikt var att undersöka hur röntgensjuksköterskans följsamhet till handhygienrutiner kan förbättras. Metod: En integrativ litteraturöversikt där vetenskapliga artiklar har sökts i databaserna PubMed och CINAHL. 15 artiklar har kvalitetsgranskats, kategoriserats, analyserats och slutligen har resultatet sammanställts och en syntes skrivits. Resultat: Olika typer av interventioner, såsom utbildning, information, automatiserade observationssystem och multimodala interventioner kan vara hjälpsamma i arbetet med att förbättra följsamheten till handhygienrutinerna Slutsats: Praktisk och teoretisk utbildning, en engagerad ledning och ett klimat i kombination med god tillgång till handhygienprodukter och påminnelser om att utföra handhygien är viktiga delar i arbetet med att förbättra följsamheten till handhygienrutiner.<br>The radiology department has a mixed flow of patients which means that it has the potential to become a site for infection transmission. In order to reduce the risk of infection spreading it is important that the basic hand hygiene routines are followed. However, studies show that the compliance with the basic hand hygiene routines is low. Aim: The aim was to examine how the radiographer's adherence to hand hygiene practices can be improved. Method: An integrative literature review where scientific articles were searched in the PubMed and CINAHL databases. 15 articles have been quality reviewed, categorized, analyzed and finally the result has been compiled and a synthesis written. Result: Different types of interventions, such as education, information, automated observation systems and multimodal interventions, can be helpful in improving compliance with hand hygiene routines. Conclusion: Practical and theoretical education, dedicated management and a responsible climate combined with good access to hand hygiene products and reminders to perform hand hygiene are important parts of the work to improve compliance with hand hygiene routines.

Syfte Studiens syfte är att undersöka hur samspel och kommunikation med personer med flerfunktionsnedsättning, deras assistenter och vattendansledare under vattendans kan analyseras med multimodal interaktionsanalys, för att genom tolkning av kommunikativa uttryck identifiera upplevelse av interventionen. Ytterligare ett syfte med studien är att identifiera vilka styrkor och svagheter analysmetoden har vid studier av interaktion mellan personer med flerfunktionsnedsättning och deras assistenter. Metod I studien videoinspelades och analyserades interaktion mellan personer med flerfunktionsnedsättning, deras medföljare samt personal som höll i vattendansen. Den metod som användes var multimodal interaktionsanalys, som är en metod där man analyserar interaktion i naturligt förekommande situationer. Analysen utfördes genom observation och transkription av videoinspelad interaktion. Resultat Ett flertal uttryck identifierades med multimodal interaktionsanalys. Dessa uttryck kunde säga något om upplevelsen hos personerna med flerfunktionsnedsättning under vattendansen. De kommunikativa uttrycken analyserades alltid i den kontext där de förekom. Uttrycken betraktades som kontextberoende och inte som isolerade handlingar. De modaliteter som personerna med flerfunktionsnedsättning använde för att kommunicera var bland annat blickar, vokalisationer och ansiktsmimik. Dessa uttryck studerades i termer av vilken mening eller sinnesstämning de tycktes förmedla, hur frekvent de förekom, samt vilken respons de väckte. Tolkning av uttrycken gjordes till stor del genom att studera omgivningens respons. Under arbetets gång identifieras styrkor såväl som svagheter med analysmetoden. Att analysera materialet med någon annan metod än just multimodal interaktionsanalys hade varit svårt, eftersom det i dagsläget finns mycket få alternativa sätt att analysera och transkribera den här typen av komplex interaktion på. Slutsats Genom multimodal interaktionsanalys kunde en varierad bredd av olika kommunikativa uttryck identifieras och tolkas, och författarna fick därmed en bild av hur personerna med flerfunktionsnedsättning och deras medföljare upplevde interventionsmetoden. Överlag förefaller upplevelsen av vattendansen vara positiv för personerna med flerfunktionsnedsättning såväl som för deras medföljare. Multimodal interaktionsanalys lämpade sig väl som analysmetod för att identifiera tecken som kan säga något om personernas med flerfunktionsnedsättnings upplevelse av vattendansen.<br>Aim The aim of this study is to investigate whether interaction between people with multiple disabilities, their assistants and waterdance staff during waterdance can be analysed using multimodal interaction analysis, in order to identify how the people with multiple disabilities experience the intervention. Identification of experience is conducted by recognizing and interpreting communicative actions. Another aim is to identify strengths and weaknesses of the method of analysis in the study of interaction between people with multiple functional impairments and their assistants. Method Interaction between three people with multiple disabilities, their assistants and waterdance staff was video recorded and then analysed. The method used is multimodal interaction analysis, which is a method for analysing naturally occurring interaction. The analysis was performed through observation and transcription of video-recorded interaction. Results Several communicative expressions were identified with multimodal interaction analysis. These expressions could say something about the people with multiple disabilities’ experience of the waterdance. The communicative actions and expressions were analysed in the context in which they occurred. The expressions were regarded as contextually dependent, and not as isolated, independent actions. Modalities that were used for communication were among others: gaze, vocalizations and facial expressions. These communicative actions were studied regarding what meaning or mood they seemed to convey, the frequency with which they occurred in, and in what response they evoked. Interpretation of the expressions was largely conducted by studying the response from people in the environment. Strengths as well as weaknesses were identified regarding the method of analysis. To analyse the material with a method other than multimodal interaction analysis would have been difficult, since other options of methods for analysing and transcribing this complex type of interaction are very limited. Conclusions A variety of communicative expressions were identified through multimodal interaction analysis. Through interpretation of the expressions, the authors were able to better understand how the people with multiple disabilities and their assistants experienced the intervention method. Multimodal interaction analysis is well suited as an analytical method for identifying signs that may tell us something about the experience of waterdance, of the three persons with multiple disabilities.

El TDAH és un trastorn neuroevolutiu de l’atenció i la impulsivitat de naturalesa crònica que afecta un 4% de la població i que freqüentment s’associa amb altres trastorns, com els problemes de conducta i les dificultats en l’aprenentatge. Actualment hi ha base empírica sobre el seu origen genètic i biològic, encara que el seu curs evolutiu i el seu pronòstic estan molt influenciats per factors ambientals. És per això que un abordatge adequat del procés d’avaluació i d’intervenció d’aquest trastorn ha de contemplar de forma primerenca els contextos en què el nen es desenvolupa (escola, família i comunitat) i ha de comptar amb un equip multidisciplinari. En aquesta línia, las modalitats d’intervenció que han evidenciat ser més efectives són les medicacions psicoestimulants, les intervencions psicosocials i els tractaments que combinen ambdues modalitats terapèutiques. L’estimulant més utilitzat per al TDAH, el metilfenidat, és el fàrmac més prescrit en psiquiatria infantil i s’ha constatat la seva efectivitat de forma reiterada. No obstant això, s’ha d’administrar amb cautela perquè presenta limitacions que a vegades no en compensen l’administració, com el efectes no desitjats, el desconeixement sobre els efectes a llarg termini o els escassos estudis sobre eficàcia i seguretat en nens preescolars. Aquests troballes ens fan considerar les intervencions psicosocials, que també són una bona opció terapèutica. Les intervencions psicosocials validades empíricament serveixen d’entrenament a pares i mestres per manejar el trastorn, com també al mateix nen, tot i que en menor mesura, per exercitar les seves habilitats socioemocionals. La finalitat d’aquestes teràpies és que paral•lelament o tres la formació, s’implementen intervencions conductuals, cognitiu-conductuals, escolars i sòcio-emocionals en els contexts naturals del nen. Encara que està provada la eficàcia d’aquestes modalitat d’intervenció de forma aïllada, s’han trobat millores superiors amb els tractaments combinats o multimodals, que cobren un ampli ventall de dificultats i plànols de funcionament, permetent en ocasions reduir la dosi de medicació amb un manteniment dels efectes positius. Però, malauradament, encara s’observa una relativa carència d’estudis que incloguin tractaments combinats per al TDAH infantil, si més no a España. En el millor del casos, les intervencions han estat breus i intensives. Tanmateix, no s’han publicat estudis sobre l’eficàcia d’aquestes intervencions per millorar variables com el clima escolar i familiar d’aquests nens. L’objectiu, doncs, d’aquest projecte és analitzar l’eficàcia relativa i diferencial d’un tractament combinat (medicació estimulant + entrenament a pares i mestres) versus un de farmacològic, durant un curs escolar, per millorar diverses variables relacionades amb el nen hiperactiu, com també amb els seus mestres i pares (símptomes, rendiment acadèmic, clima escolar i familiar, autoeficàcia percebuda i coneixements sobre TDAH).<br>El TDAH es un trastorno neuro-evolutivo de la atención, la actividad y la impulsividad de naturaleza crónica, que afecta a un 4% de la población, asociándose frecuentemente con otros trastornos, como los problemas de conducta y las dificultades de aprendizaje. En la actualidad, hay evidencia empírica sobre su origen genético y biológico, aunque su curso evolutivo y pronóstico están enormemente influidos por factores ambientales. De ahí que un adecuado abordaje del proceso de evaluación e intervención de este trastorno deba contemplar de forma temprana los contextos donde el niño se desenvuelve (escuela, familia y comunidad), contando con un equipo multidisciplinar. En esta línea, las modalidades de intervención que han mostrado ser más efectivas son las medicaciones estimulantes, las intervenciones psicosociales y los tratamientos que combinan ambas opciones terapéuticas. El estimulante más utilizado para el TDAH, el metilfenidato, es el fármaco más prescrito en psiquiatría infantil y se ha constatado reiteradamente su efectividad. Pero se debe administrar con cautela porque presenta limitaciones que en ocasiones no compensan su administración, como sus efectos indeseados; el desconocimiento sobre sus efectos a largo plazo; y los escasos estudios sobre su eficacia y seguridad en niños preescolares. Estos hallazgos nos instan a considerar las intervenciones psicosociales, que son también una buena opción terapéutica. Las intervenciones psicosociales validadas empíricamente son el entrenamiento a padres y a maestros en el manejo del trastorno, y en menor medida el entrenamiento en habilidades socio-emocionales al propio niño. La finalidad de estas terapias es que paralelamente o tras la formación, se implementen intervenciones conductuales, cognitivo-conductuales, escolares y socio-emocionales en los contextos naturales del niño. Sin embargo, a pesar de la eficacia de estas modalidades de intervención de forma aislada, se han mostrado mejoras superiores con los tratamientos combinados o multimodales, que cubren un amplio abanico de dificultades y planos de funcionamiento, permitiendo en ocasiones reducir la dosis de medicación con un mantenimiento de los efectos positivos. Pero desafortunadamente, aún se observa una relativa carencia de estudios que incluyan tratamientos combinados para el TDAH infantil, al menos en España. Y en el mejor de los casos, las intervenciones han sido muy breves e intensivas. Asimismo, no se han publicado estudios sobre la eficacia de estas intervenciones para mejorar variables como el clima escolar y familiar de estos niños. Precisamente, el objetivo de este proyecto es analizar la eficacia relativa y diferencial de un tratamiento combinado (medicación estimulante+entrenamiento a padres y maestros) versus farmacológico, durante un curso escolar, para mejorar diversas variables relacionadas con el niño hiperactivo, sus maestros y sus padres (síntomas, rendimiento académico, clima escolar y familiar, autoeficacia percibida y conocimientos sobre TDAH).<br>ADHD is a neuro-developmental disorder of attention, impulsivity and activity of a chronic nature, affecting 4% of the population, frequently associated with other disorders such as behavioral problems and learning disabilities. Today, there is empirical evidence on genetic and biological origin, although its clinical course and prognosis are greatly influenced by environmental factors. Hence, an adequate management of the process of assessment and intervention for this disorder should contemplate early contexts where the child develops (school, family and community), with a multidisciplinary team. In this stratum, the interventions that have proven most effective are stimulant medications, psychosocial interventions and treatments that combine both options. The stimulant used for ADHD, methylphenidate, is the most prescribed drug in child psychiatry and has been found repeatedly to be effective. But it should be administered with caution, because it has limitations, like its side effects, the lack of long-term effects, and the few studies on efficacy and safety in preschool children. These findings urge us to consider psychosocial interventions, which are also a good option. Empirically valid psychosocial interventions are parent training and teachers in the management of the disorder, and less training in socio-emotional skills the child itself. The purpose of these therapies is that, - parallel or after the training -, behavioral, cognitive-behavioral, and socio-emotional interventions would be implemented in the child's natural settings. However, despite the effectiveness of these modalities of intervention in isolation, greater improvement has been shown with combined or multimodal treatments covering a wide range of problems, allowing sometimes to reduce the dose of medication, with a maintenance of positive effects. But unfortunately there is still a relative lack of studies involving combined treatments for childhood ADHD, at least in Spain. And in most cases, interventions have been very brief and intensive. Also, there are no published studies on the effectiveness of these interventions to improve variables such as school and family environment of these children. The precise purpose of this project is to analyze the relative and differential efficacy of combined treatment (stimulant medication + training for parents and teachers) versus drug, during a school year, in order to improve various variables related to the hyperactive child, their teachers and their parents (symptoms, academic performance, school and family evironment, self-efficacy and knowledge about ADHD).

Major surgery is followed by a long period of convalescence. However this recovery period is not well defined and tools for its measurement and assessment are lacking. This thesis describes the concept of Post Operative Fatigue as a clinically relevant outcome measure for assessment of convalescence. It will analyse the existing literature and describe a clinically relevant measurement tool for assessment of POF and will provide a clinically appropriate definition for this topic. It will demonstrate that POF is as a result of interaction between psychological and biological variables which are as a direct result of the perioperative care and operation itself. It will also be hypothesised that inflammatory mediators may also play an important role in the development of POF. These mediators stimulate the vagus nerve, which through its central connection leads to behavioural changes in subjects. Chapter 2 will analyse evidence available which may address the numerous factors which contribute to the development of POF. This leads to the introduction of Enhanced Recovery After Surgery (ERAS) care pathways. Chapter 3 will review a prospective study which demonstrates that ERAS is an effective measure to improve outcomes following major colonic surgery. Chapter 4 will utilize a recently validated multi-dimensional measurement tool called the Identity-Consequence Fatigue Scale to measure POF in a group of patients undergoing surgery within a conventional care plan compared to a group within a structured ERAS program. It will be shown that ERAS can lead to detectable changes in POF in patients undergoing major colonic surgery. Lastly, it will be demonstrated through a randomised controlled trial that preoperative dexamethasone suppresses the post operative inflammatory response following surgery. It will be subsequently demonstrated that there is a direct correlation between post operative peritoneal IL-6 and POF and reduction in peritoneal IL-6 levels leads to a detectable reduction in POF. Conclusion: POF should be considered an important outcome measure. POF has a multifactorial aetiology and hence it can be modified by multimodal interventions. Inflammatory mediators also play a role in the development of POF and their influence can be modified by preoperative steroids.

Bakgrund: Långvarig smärta har konsekvenser på såväl individ- som samhällsnivå och är ett stort folkhälsoproblem. Forskning har visat måttligt till starkt vetenskapligt stöd för multimodal rehabilitering (MMR) vid komplex smärtproblematik. Vad fysioterapeuten använder för åtgärder inom MMR och hur samarbetet med andra yrkeskategorier ser ut finns dåligt beskrivet. Syfte: Att kartlägga fysioterapeutens arbete inom ramen för multimodal smärtrehabilitering inom specialistvården (MMR2). Metod: Webbenkätstudie där data samlades in från 71 fysioterapeuter som arbetade på enheter anslutna till Nationella registret över smärtrehabilitering (NRS). Resultat: Fysioterapeuternas arbete bestod framförallt av undervisning/råd och olika former av träning. Strategier för beteendeförändring, övningar i medveten närvaro/kroppsmedvetenhet och hemövningar var andra vanliga åtgärder. Acceptance and Commitment Therapy (ACT) och Kognitiv beteendeterapi (KBT) användes i flera moment av rehabiliteringen på många enheter. Rehabilitering i grupp var vanligast med aktiva åtgärder som till exempel träning. Rehabiliteringsperioden var vanligen 8-11 veckor, under vilken patienten träffade en fysioterapeut flera gånger i veckan. Teamen hade ett tätt samarbete med regelbundna teamträffar, uppföljningar och gemensamma åtgärder. Slutsats: Fysioterapeutens arbete inom MMR2 utgår från ett biopsykosocialt perspektiv där tyngdpunkten ligger i att återställa och/eller förbättra kroppsfunktion. Fysioterapeuterna har bred kompetens och lång erfarenhet vilket möjliggör att deras kunskaper om kroppen och rörelsesystemet kan integreras med åtgärder för beteendeförändring. Tillsammans med övriga yrkeskategorier täcker fysioterapeutens arbete in alla domäner i Klassifikation av funktionstillstånd, funktionshinder och hälsa (ICF). För en ökad förståelse kring vad som styr valet av fysioterapeutiska åtgärder inom MMR2 och hur arbetet med dessa åtgärder ser ut i den kliniska vardagen behövs fortsatt forskning.<br>Background: Chronic pain is a common cause for patients seeking care. The consequences of chronic pain can be seen at both individual and social level. Research has shown moderate to strong scientific support for multimodal rehabilitation (MMR) in complex pain problems. What the physiotherapist uses for interventions within MMR and how the collaboration with other occupational categories works is poorly described. Aim: To study what interventions physiotherapist’s use in multimodal pain rehabilitation in specialist care settings (MMR2) in Sweden. Methods: Web survey study where data was collected from 71 physiotherapists working at units connected to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Results: The most common interventions were teaching/counseling and various forms of exercise. Strategies for behavioral change, mindfulness/body awareness and homework exercises are other commonly used interventions. Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT) were used in several stages of rehabilitation on many units. Rehabilitation in group were the most common form of work and the interventions are primarily patient active as physical activity. The rehabilitation period were usually 8-11 weeks, where the patient saw a physiotherapist several times a week. The teams worked closely with regular team meetings, follow-ups and sometimes joint actions such as patient education and group training. Conclusion: The physiotherapist's work in MMR2 is based on a biopsychosocial perspective where the focus lies in restoring and/or improving body function. Physiotherapists have broad competence and long experience, enabling their knowledge about the body and the movement system to be integrated with behavioral change technics. Together with other occupational categories, the physiotherapist's work covers all domains in the Functional Classification, Disability and Health Classification (ICF). For increased understanding of the choice of physiotherapeutic interventions within MMR2, and how these interverventions works in the clinical setting, further research is needed.

Nell’epoca attuale il settore dei trasporti ha registrato un’importante crescita di mobilità a causa dell’aumento della popolazione e della diffusione della ricchezza, con i conseguenti problemi dovuti a traffico, incidenti, consumi ed inquinamento. Nell’elaborato in esame si propone una soluzione a tali problematiche tramite l’utilizzo della microsimulazione. In particolare si è sperimentata una microsimulazione non, come solitamente avviene, su un nodo o un arco, ma su una vasta area per la quale, di norma, si effettuano, invece, macrosimulazioni: una porzione dell’area metropolitana ad ovest di Bologna. Innanzitutto si è implementata la rete del trasporto multimodale di questa zona in ogni suo dettaglio (semafori, fermate degli autobus, precedenze, attraversamenti pedonali, piste ciclabili, marciapiedi, corsie preferenziali, limiti di velocità, ecc.) sul software SUMOPy, programma open source tutt’ora in via di sviluppo, creato dall’agenzia spaziale tedesca. Successivamente si è composta la domanda tramite rilevamenti in loco e dati di precedenti progetti europei, tra i quali i progetti iTetris e COLOMBO. Si è quindi potuto effettuare la simulazione, la quale ha dato in output risultati non solo riguardanti i flussi (quindi anche densità di veicoli e tempo di waiting), ma anche i consumi e l’inquinamento atmosferico e acustico. Si è anche verificata la bontà della simulazione tramite osservazioni empiriche mediante il confronto con Google Maps e la tipica validazione matematica. Infine si sono rilevate le criticità della zona e si sono proposti interventi migliorativi andando ad intervenire sui cicli semaforici, sul numero delle corsie e sui sensi unici, tenendo conto del fatto che tali interventi potessero essere concretamente realizzabili. Si è sperimentata la versatilità della microsimulazione anche tramite la rappresentazione di scenari particolari, come uno scenario di incidente o l’evento della “Notte bianca” nella zona in esame.

Interventional magnetic resonance imaging (MRI) aims at performing minimally invasive percutaneous interventions, such as tumor ablations and biopsies, under MRI guidance. During such interventions, the acquired MR image planes are typically aligned to the surgical instrument (needle) axis and to surrounding anatomical structures of interest in order to efficiently monitor the advancement in real-time of the instrument inside the patient's body. Object tracking inside the MRI is expected to facilitate and accelerate MR-guided interventions by allowing to automatically align the image planes to the surgical instrument. In this PhD thesis, an image-based workflow is proposed and refined for automatic image plane alignment. An automatic tracking workflow was developed, performing detection and tracking of a passive marker directly in clinical real-time images. This tracking workflow is designed for fully automated image plane alignment, with minimization of tracking-dedicated time. Its main drawback is its inherent dependence on the slow clinical MRI update rate. First, the addition of motion estimation and prediction with a Kalman filter was investigated and improved the workflow tracking performance. Second, a complementary optical sensor was used for multi-sensor tracking in order to decouple the tracking update rate from the MR image acquisition rate. Performance of the workflow was evaluated with both computer simulations and experiments using an MR compatible testbed. Results show a high robustness of the multi-sensor tracking approach for dynamic image plane alignment, due to the combination of the individual strengths of each sensor.

Le trouble bipolaire (TB) est une pathologie chronique de l'humeur, caractérisée par des perturbations du fonctionnement émotionnel et cognitif lors des périodes dépressives, maniaques, et intercritiques (euthymiques). L'essor récent des interventions psychosociales spécifiques, telles que la psychoéducation, dans la prise en charge du TB est dû à une efficacité considérable démontrée dans l'optimisation de la réponse et la stabilisation clinique des patients bipolaires (BP). L'objectif de cette thèse a été d'identifier le substrat cérébral, anatomique et fonctionnel, qui sous-tend (i) les troubles cognitifs et émotionnels persistants lors des périodes euthymiques, afin de dégager des marqueurs traits de la maladie ; (ii) l'amélioration symptomatique suite à l'application d'un programme de psychoéducation chez les patients BP. Nos résultats ont montré que le TB se caractérise par une dérégulation de l'activité et de la connectivité des régions préfrontales et limbiques, respectivement impliquées dans le contrôle cognitif et la génération/perception des émotions. Nous avons également mis en évidence, à la fois au repos et lors d'une tâche cognitivo-émotionnelle, une connectivité anormale chez les patients BP entre le « default mode network », qui sous-tend des processus mentaux égocentrés, et le « task positive network », qui est impliqué dans des processus cognitifs exocentrés. Suite à trois mois de psychoéducation, les anomalies d'activation fronto-limbique chez les patients BP étaient atténuées. De plus, la diffusivité au sein du faisceau unciné, qui relie ces régions, était améliorée. En outre, l'atteinte de la structure anatomique des régions fronto-limbiques ainsi que de leurs connexions, constituait un facteur prédictif de la réponse à la psychoéducation. L'ensemble de nos résultats suggèrent que les déficits de régulation émotionnelle et de contrôle attentionnel caractérisant le TB pourraient être modulés par l'amélioration du contrôle cognitif « top-down », induit par la participation à un programme de psychoéducation<br>Bipolar disorder (BD) is a chronic mood disorder characterized by disturbances in emotional and cognitive processing during periods of depression, mania, and intercritical (euthymic) periods. Recently, the management of BD has been expanded by specific psychosocial interventions, such as psychoeducation, which showed high efficacy in improving BD symptoms. The aim of this thesis was to identify the anatomical and functional cerebral substrate related to (i) enduring cognitive and emotional impairments during euthymic periods, in order to identify trait markers of the disease; (ii) symptomatic improvement due to the participation in a psychoeducation program in BP patients. Our results showed that BD is characterized by dysregulation of the activity and the connectivity of prefrontal and limbic regions, responsible for the cognitive control and the generation/perception of emotions respectively. We also highlighted, both at rest and during a cognitive task, an abnormal cerebral connectivity between the “default mode network”, which is involved in egocentric thought processes, and the “task positive network”, which is involved in exocentric cognitive processes. After three months of psychoeducation, BD patients showed significant reduction of fronto-limbic abnormalities and better diffusivity along the uncinate fasciculus, which connects these regions. Furthermore, abnormalities of the anatomical structure of fronto-limbic regions, as well as of their connections, may be a predictor of psychoeducation outcome. We thus suggest that impairment of emotional regulation and attentional control that characterized BD could be modulated by the improvement of the “top-down” cognitive control induced by the participation in a psychoeducational program

Come si evince dal titolo della tesi, la ricerca effettuata dal presente candidato nel corso del dottorato di ricerca ha avuto ad oggetto lo studio della materia relativa ai trasporti nell’ambito di diversi sistemi giuridici europei, con particolare attenzione ai risvolti di carattere pratico che l’interpretazione delle normative uniformi poteva produrre nell’ambito delle diverse giurisdizioni nonché alle diverse impostazioni e alla variegata gamma di soluzioni interpretative che nell’ambito di problemi simili possono essere adottate a seconda che una stessa questione venga discussa in un ordinamento piuttosto che in un altro. Dall’avvento del trasporto marittimo di containers alla necessità di disciplinare l’intera materia attraverso una normativa multimodale il passo è estremamente breve, posto che, proprio in considerazione delle caratteristiche proprie del trasporto containerizzato, gli aventi diritto al carico sono principalmente interessati al completamente del trasferimento door-to-door inteso nella sua globalità, piuttosto che al buon esito del trasporto sulla singola tratta marittima. Il progetto di revisione delle Regole dell’Aja-Visby adottato dall’United Nations Commission on International Trade Law (Uncitral) e il Comité Maritime International (CMI) costituisce per definizione un progetto limitato ad un trasporto multimodale comprendente necessariamente una tratta marittima, ma rappresenta comunque un interessante banco di prova per valutare la funzionalità di strumenti di recente impiego, come ad esempio i cosiddetti e-documents, concetto peraltro già inserito nel progetto UNCITRAL, anche se con scarsi elementi di reale novità rispetto alla tradizionale disciplina relativa ai documenti cartacei. Proprio la parte relativa ai documenti e titoli di viaggio merita particolare attenzione soprattutto in riferimento alle problematiche connesse al traffico containerizzato, con particolare riferimento al concetto di transhipment, e alla conseguente necessità che la polizza garantisca al legittimo portatore una copertura completa sull’intero viaggio della merce, oltre a dargli la possibilità di individuare agevolmente la propria controparte contrattuale, e cioè il vettore.<br>As evident from the title of the dissertation, the research of this student over the phd has been focused on the topic relating to transports in the various juridical systems in Europe, with particular attention to the practical aspects produced by the interpretation of the uniform disciplines in the different jurisdictions, as well as by the various approaches and by the range of interpretative solutions adopted in relation to a similar problem according to the state in which the argument is discussed. From the introduction of the container transport to the necessity to discipline the entire topic through a multimodal discipline the way is short, since due to the characteristics of the container transport, the cargo interests are now interested in a global door-to-door performance rather than in a sea carriage. The project of the revision of the Hague Visby Rules adopted by the United Nations Commission on International Trade Law (Uncitral) and by the Comité Maritime International (CMI) is, literally, a project limited to a multimodal transport in which one of the legs is necessarily a sea transport, but it still represents an interesting test in order to evaluate the instruments recently employed, such as the e-documents, which was already introduced into the UNCITRAL project, even though there are few elements of real practical interest, compared to the traditional discipline of the paper documents. The part relating to the documents and to the titles of carriage deserves particular attention especially with reference to the problems relating to the container transport, with particular reference to the concept of transshipment, and to the necessity for the bill of lading to furnish to the holder a complete cover over the entire voyage of the goods, giving him the possibility to easily spot his counterparty, namely the carrier.

In this study, a promising new intervention implemented for adults with aphasia due to stroke, Multimodal Communication Treatment, was modified for its use with one child with autism spectrum disorder to identify if the child could learn and communicate new words through learning multiple modalities. Data was collected on the child’s communicative output as well to assess the frequency and types of his communication attempts. The child presented with challenging behaviors throughout the intervention period, and its potential impact on the execution of the intervention was studied. The study found that Multimodal Communication Treatment was not an effective intervention approach for this child. The majority of his output was not communicative in nature and challenging behaviors impacted the effectiveness of implementing the approach. Further research is needed to identify whether Multimodal Communication Treatment could be an effective intervention for children with more communicative intent and increased attention.<br>text

ABSTRACT The purpose of this qualitative inquiry was to describe parents’ experiences of the Brain Balance Program, as revealed in their online writing. This study provides a description of parents’ experiences in a way that highlights what participating in the program was like, asserts their judgements about this program, describes the impact of the program on the parent and child and describes the parents’ motives for doing the program and motives for writing about the experience. Six online documents were chosen that were information rich and showed a maximum variation of viewpoints. The sample of online documents were written by parents and retrieved from online sources in November, 2012. Basic Qualitative Descriptive research (Merriam, 2009) was used to design the study and qualitative content analysis was used to produce the findings. Content analysis is “a research method for the subjective interpretation of the content of text data through systematic classification process of coding and identifying themes or patterns” (Hsieh & Shannon, 2005, p. 1278). The findings provide a thick description of parents’ perspectives on their experience of helping their child through a multimodal program for neurobehavioral disorders. Limitations, implications and areas of future research pertaining to the study are discussed. This study can inform parents’ decision making around interventions and provides support for further research in biomedical and cognitive rehabilitative approaches for neurobehavioral disorders.

Les interventions proactives ou comportementales en classe sont reconnues empiriquement pour leur efficacité à améliorer le comportement ou le rendement scolaire des enfants ayant un TDAH (DuPaul & Eckert, 1997; Hoza, Kaiser, & Hurt, 2008; Pelham & Fabiano, 2008; Zentall, 2005). Or, l’écart entre les interventions probantes et celles retrouvées dans le milieu général de l’éducation souligne l’importance de répliquer les résultats d’études obtenus dans un environnement contrôlé dans un format de livraison réaliste. L’objectif principal de cette thèse est d’élaborer et d’évaluer un programme de consultation individuelle (PCI) fondé sur une démarche de résolution de problème et d’évaluation fonctionnelle, pour soutenir les enseignants du primaire dans la planification et la mise en œuvre cohérente des interventions privilégiées pour aider les enfants ayant un TDAH. D’abord, une recension des principales modalités d’intervention auprès des enfants ayant un TDAH est effectuée afin d’identifier les interventions à inclure lors du développement du programme. Par la suite, des solutions favorisant le transfert des interventions probantes à la classe ordinaire sont détaillées par la proposition du PCI ayant lieu entre un intervenant psychosocial et l’enseignant. Enfin, l’évaluation du PCI auprès de trente-sept paires enfant-enseignant est présentée. Tous les enfants ont un diagnostic de TDAH et prennent une médication (M). Les parents de certains enfants ont participé à un programme d’entraînement aux habiletés parentales (PEHP). L’échantillon final est: M (n = 4), M et PEHP (n = 11), M et PCI (n = 11), M, PEHP et PCI (n = 11). Les résultats confirment l’efficacité du PCI au-delà de M et M + PEHP pour éviter une aggravation des comportements inappropriés et améliorer le rendement scolaire des enfants ayant un TDAH. Par ailleurs, une augmentation de l’utilisation des stratégies efficaces par l’enseignant est observable lorsqu’il a à la fois participé au PCI et reçu une formation continue sur le TDAH en cours d’emploi. Les implications cliniques de l’intervention pour l’enfant ayant un TDAH et son enseignant de classe ordinaire sont discutées.<br>Classroom management interventions, such as behavior and academic strategies, are well-established interventions for improving social behavior and academic skills of children with ADHD (DuPaul & Eckert, 1997; Hoza, Kaiser, & Hurt, 2008; Pelham & Fabiano, 2008; Zentall, 2005). However, bridging the gap between research and practice raises the question of the practicality of interventions. Therefore, results from controlled studies need to be replicated in regular classrooms with a format that takes into account the practicality of the intervention. The aim of this research is to evaluate the effectiveness of a consultation-based program for teachers (CPT), using a problem-solving approach and a functional assessment to support elementary school teachers in the knowledge of the principles, design and implementation of classroom management evidence-based practices for children with ADHD. First, a review of the literature identifying the main interventions for ADHD children is presented. Then, the consultation-based program for regular class teachers involving solutions in the implementation of these evidence-based strategies in the classroom is detailed. Finally, the evaluation of the CPT implemented with thirty-seven child-teacher pairs is presented. All children were diagnosed as ADHD and received a stimulant medication treatment (M). The parents of some of these children had previously participated in a parent-training program (PTP). The final group composition is: M (n = 4); M + PTP (n = 11), M + CPT (n = 11), M + PTP + CPT (n = 11). Findings confirm the effectiveness of the CPT above and beyond M, and M + PTP to prevent the intensification of inappropriate behaviors and to improve academic performance of ADHD children. Results also indicate that teachers who participated in the CPT and had previous continuing education on ADHD showed a significant improvement of their classroom management strategies. Overall findings offer valuable information for discussing clinical implications for the psychosocial treatment of ADHD children.

Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model.<br>Graduate<br>2015-04-24<br>0571<br>0382<br>0384<br>jazkim@uvic.ca

archives@tulane.edu<br>Preeclampsia is a leading cause of maternal and fetal mortality, affecting up to 8% of pregnancies. Clinically, preeclampsia is diagnosed by the new onset of maternal hypertension and proteinuria presenting in the second half of gestation. The etiology of this disease, however, occurs during early development with abnormal vascular remodeling that results in reduced placental perfusion and hypoxia. This abnormal placental function increases the production of soluble antiangiogenic factors which are then released into maternal circulation, creating the systemic endothelial dysfunction associated with maternal symptoms. Despite being a critical indicator of disease progression and therapeutic response, placental function cannot be fully characterized by existing imaging modalities. The objective of this work was to develop multimodal imaging and image processing tools characterize placental function in the reduced uterine perfusion pressure (RUPP) rat model of preeclampsia. We demonstrate spectral photoacoustic (sPA) imaging and contrast-enhanced ultrasound (CEUS) imaging of the longitudinal changes in placental oxygenation, perfusion, and vascular growth in the development of preeclampsia and evaluate the placental response to therapeutic intervention.<br>1<br>Dylan J Lawrence