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PubMed1999

Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children.

BACKGROUND: Executive function deficits have been reported repeatedly in children with Attention Deficit Hyperactivity Disorder (ADHD). Stimulant medication has been shown to be effective in improving cognitive performance on most executive function tasks, but neuropsychological tests of executive function in this population have yielded inconsistent results. Methodological limitations may explain these inconsistencies. This study aimed to measure executive function in medicated and non-medicated children with ADHD by using a computerized battery, the Cambridge Neuropsychological Test Automated Battery (CANTAB), which is sensitive to executive function deficits in older patients with frontostriatal neurological impairments. METHODS: Executive function was assessed in 30 children with ADHD: 15 were stimulant medication naive and 15 were treated with stimulant medication. These two groups were compared to 15 age, sex and IQ matched controls. RESULTS: The unmedicated children with ADHD displayed specific cognitive impairments on executive function tasks of spatial short-term memory, spatial working memory, set-shifting ability and planning ability. Impairments were also seen on spatial recognition memory and delayed matching to sample, while pattern recognition memory remained intact. The medicated children with ADHD were not impaired on any of the above executive function tasks except for deficits in spatial recognition memory. CONCLUSIONS: ADHD is associated with deficits in executive function. Stimulant medication is associated with better executive function performance. Prospective follow-up studies are required to examine these effects.

Adolescent↗

PubMed1995

Functional performance in people with chronic obstructive pulmonary disease.

The extent to which individuals with a chronic physical illness perform their day-to-day activities and maintain the independence and autonomy they desire is both an indicator of adaptation and an important clinical outcome criterion. Yet the concept of functional performance is not well understood. Studies of people with chronic obstructive pulmonary disease (COPD) have attempted to identify physiologic and psychosocial factors that contribute to functioning in this population. These studies have used a melange of terms, including functional status, functional ability, quality of life, and health status interchangeably. They have also employed a variety of instruments to operationalize functional performance and an assortment of predictors to understand the phenomena. Perhaps as a result of this disarray, no attempt has been made to synthesize the literature for nursing research and practice. The purpose of this paper is to summarize the research on functional performance in people with COPD, indicate areas of understanding and quandary, suggest possible flaws, and propose several new directions for practice and research.

Activities of Daily Living↗

PubMed2003

The relationship between sitting stability and functional performance in patients with paraplegia.

OBJECTIVES: To compare sitting stability between patients with high and low thoracic spinal cord injury (SCI), to determine the factors that can predict sitting stability, and to examine the relationship between sitting stability and functional performance. DESIGN: Cross-sectional assessment was performed on subjects with paraplegia. SETTING: Rehabilitation hospital affiliated with a medical university. PARTICIPANTS: Convenience sample of 30 adults with complete chronic thoracic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Postural sway during quiet sitting over 30 seconds was recorded as static sitting stability, and composite maximal weight-shift during leaning tasks over 30 seconds was measured as dynamic sitting stability; (2) age, body weight, trunk length, trunk strength, postonset duration, injury level, and presence of spasticity were examined as predictive variables for sitting stability; and (3) the time for completion of upper- and lower-body dressing and undressing and transfer was measured as functional performance. RESULTS: A significant difference in composite maximal weight-shift was found between high and low thoracic SCI subjects (t=2.90, P<.01). Injury level and trunk length were 2 important predictive factors for dynamic sitting stability, and they explained 43.5% of the variance. Only the completion time of upper-body dressing and undressing correlated significantly with static (r=.465, P=.01) and dynamic (r=-.377, P<.05) sitting stability. CONCLUSIONS: The subjects with low thoracic SCI showed better dynamic sitting stability than those with high thoracic SCI. Injury level and trunk length, not trunk flexion or extension strength, predicted the outcome of dynamic sitting stability. Measures were not precise enough to predict functional performance from the viewpoint of injury level and sitting stability. The underlying premise that a reduction or increase in trunk strength is indicative of poorer or better sitting stability in SCI individuals is questioned, and implications for problem identification and treatment planning are discussed.

Activities of Daily Living↗

PubMed1998

Reliability and validity of the functional performance inventory in patients with moderate to severe chronic obstructive pulmonary disease.

The Functional Performance inventory (FPI) is a new instrument designed to measure functional status in terms of activities that people perform on a daily basis. Psychometric characteristics were examined by a survey of 45 men and 27 women with chronic obstructive pulmonary disease (COPD). Internal consistency reliability was high and no ceiling and floor effects were observed for the Total FPI. Concurrent validity was demonstrated by correlations with the Total Sickness Impact Profile (r = -.59). Construct validity was supported by correlations with the Medical Outcomes Study Short Form-36, Physical Functioning (r = .69), the Physical Activity Scale for the Elderly (r = .62) and American Thoracic Society-Division of Lung Disease Breathlessness scale (r = -.62). The Total FPI is a reliable and valid measure of functional performance in persons with COPD.

Activities of Daily Living↗

PubMed2005

A cetylated fatty acid topical cream with menthol reduces pain and improves functional performance in individuals with arthritis.

This investigation was an extension of a previous study conducted in our laboratory in which we showed that 1 month of treatment with a topical cream (Celadrin) consisting of cetylated fatty acids was effective for reducing pain and improving functional performance in individuals with osteoarthritis (OA) of the knee (Kraemer et al., Journal of Rheumatology, 2004). We wanted to verify that the addition of menthol to the compound would produce a similar percentage of improvement in therapeutic effects. We used a single treatment group with a pre-post experimental design to examine % treatment changes. Individuals diagnosed with OA of the knee (N = 10; age, 66.4 +/- 11.5 years) and severe pain (e.g., OA, rheumatoid arthritis) of the elbow (N = 8; age, 59.1 +/- 18.2 years) and wrist (N = 10; age, 60.3 +/- 16.8 years) were tested for pain and functional performance before and after 1 week of treatment with a topical cream consisting of cetylated fatty acids and menthol applied twice per day. In individuals with knee OA, significant improvements in stair-climbing ability (about 12%), "up-and-go" performance (about 12%), balance and strength (about 16.5%), and range of motion (about 3.5%) were observed, as were reductions in pain. In individuals with severe pain of the elbow and wrist, significant improvements in dynamic (about 22 and 24.5%, respectively) and isometric (about 33 and 42%, respectively) local muscular endurance were observed, as was a reduction in pain. Neither group demonstrated significant changes in maximal grip strength or maximal force production. One week of treatment with a topical cream consisting of cetylated fatty acids and menthol was similarly effective for reducing pain and improving functional performance in individuals with arthritis of the knee, elbow, and wrist. The % changes were consistent with our prior work on the compound without menthol. Further work is needed to determine the impact of menthol in such a cream. Nevertheless, our data support the use of a topical cream consisting of cetylated fatty acids (with or without menthol) for enhancing the potential for exercise training in this population.

Activities of Daily Living↗

PubMedDate not supplied

Changes in health, functional performance and activity predict changes in self-rated health: a 10-year follow-up study in older people.

The purpose was to examine changes in self-rated health (SRH) in older people and associations between these changes and various self-reported and objectively measured indicators of health status, functional performance and activity at three time-points 5 years apart. Further, our aim was to examine whether SRH takes the form of a continuum. The study group comprised all the baseline 75-year-old inhabitants of the City of Jyväskylä, Finland (N=382). Four groups were formed according to change/stability in SRH: 'good-good', 'good-bad', 'bad-good' and 'bad-bad'. Cross-tabulation and one-way analysis of variance (ANOVA) was used to examine the cross-sectional differences, and GLM Repeated Measures to analyze the differences in changes in the determinants of SRH over time. Stability was more common than change in SRH, although in most participants there was a decline in most of the determinants of SRH. A systematic relation was found between the SRH groups and the indicators of health status, functional performance and physical and social activity, especially over the first 5-year period. A substantial decrease in these indicators was associated with a decline in SRH. Among older people change and stability in SRH over time systematically reflect health status, functional performance, and physical and social activity. The relatively high stability found in SRH indicates that with increasing age older people adapt to their worsening health conditions. SRH seems to form a continuum when a wide range of self-reported and objectively measured indicators on physical, psychological and social components of health are taken into account.

Journal Article↗

PubMed2004

Effect of an exercise program on functional performance of institutionalized elderly.

This study determined the effectiveness of a 6-month program of regular exercises for the improvement of functional performance of the elderly living in a nursing home. The 40 subjects aged 60 to 99 who took part in this trial were assigned either to a comparative group or an exercise group. The following variables were measured: functional performance with the use of an obstacle course, a lower-limb function test, and a 6-minute walk test (gait velocity); isometric strength of the knee extensors; proprioception of the lower limbs; mental status through the Mini-Mental State Examination (MMSE); and depression symptoms with the use of the Geriatric Depression Scale (GDS). In the exercise group, 19 subjects completed the program and attended an average of 32 (68%) sessions. At the end of the trial, the exercise subjects showed significant performance improvement in quantitative and qualitative obstacle course scores, lower-limb function test, gait velocity test, knee extensors strength, and the GDS, while the nonexercise subjects showed significant decrease in qualitative obstacle course score, lower-limb function, gait velocity, MMSE, and the GDS.

Affect↗

PubMed2005

Testing functional performance in people with Parkinson disease.

BACKGROUND AND PURPOSE: Although the Unified Parkinson's Disease Rating Scale (UPDRS) is the most common performance measure for people with Parkinson disease (PD), the Berg Balance Scale (BBS), Forward Functional Reach Test (FFR), Backward Functional Reach Test (BFR), Timed "Up & Go" Test (TUG), and gait speed may be used to quantify some aspects of functional performance not measured by the UPDRS. The purpose of this study was to describe the relationship among a set of tests of balance, walking performance, and mobility in people with PD. SUBJECTS: Twenty-five community-dwelling adults (11 female, 14 male) with a diagnosis of PD were recruited from PD support groups in southeastern Wisconsin and consented to participate in the study. The mean age of the participants was 76 years (SD=7). The average Hoehn and Yahr Stage Scale score was 2. METHODS: Functional abilities of each subject were assessed with the UPDRS, BBS, FFR, BFR, TUG, and gait speed. Spearman and Pearson correlations were performed. RESULTS: The UPDRS total score was correlated with the BBS (r=-.64, P<.001), FFR (r=-.52, P<.05), and TUG (r=.50, P<.05) measurements. The BBS is the only test of functional performance where scores correlate with all other functional tests and the UPDRS. DISCUSSION AND CONCLUSIONS: The UPDRS total score may not reflect a comprehensive measure of mobility in people with PD. Because the BBS scores correlate both with UPDRS scores and with scores of all other tests of functional performance, the BBS appears to be a good overall measure of function in this population.

Aged↗

PubMed2002

Is velocity-specific strength training important in improving functional performance?

A variable considered when designing programs to optimize athletic performance is training velocity. It has been suggested that training at a specific velocity improves strength mainly at that velocity and as velocity deviates from the trained velocity, the less effective training will be. However, the research describing velocity-specific adaptation and the transference of these adaptations to other movement velocities is by no means clear. Compounding the problem in this area is the failure of research to detail the relationship between training velocity and actual movement velocity of a given task or athletic pursuit. In most cases there is a great disparity between training velocity and actual movement velocity. Factors that may better develop and explain velocity-specific adaptation in relation to functional performance are discussed. Developing qualities such as strength, power and rate of force development would appear of greater importance than training at the actual movement velocity of a task. It may be that irrespective of load and limb velocity, the repeated intent to move an isoinertial load as rapidly as possible might be an important stimulus for functional high velocity adaptation. The ability of the nervous system to activate and coordinate agonist, synergist and antagonist activity would seem essential. It was suggested training techniques that simulate the velocity and acceleration profiles associated with the desired functional performance, such as throw or jump training, may optimize functional adaptation. Furthermore combination training that incorporates same session sport specific training with either a heavy load or a mixed training load approach might provide an optimal strategy for promoting intramuscular and intermuscular co-ordination and improving functional performance.

Acceleration↗

PubMed2004

Leg extensor power, cognition, and functional performance in independent and marginally dependent older adults.

BACKGROUND: physical and cognitive function must be integrated and optimised in performance of daily activities. Age-related loss of physical function can result in poor performance of necessary daily activities and possibly lead to increased dependency and a change of living status. OBJECTIVES: (1) to evaluate average differences in physiological, cognitive, and functional performance of older adults from two different levels of independence, (2) to examine contributions of leg power, cognition, and functional performance to level of independence. DESIGN: cross-sectional study of self-reported 'independent' versus 'marginally dependent' older adults. SUBJECTS: 35 older adults (77.2 +/- 6 years) were placed into independent (n = 18) or marginally dependent (n = 17) groups based upon the Medical Outcomes Study SF36 physical function scores (independent: SF36PF > or = 85, marginally dependent: SF36PF < 85) and living status. METHODS: assessment of physical function includes the dependent variable, SF36PF. Assessment of physical, cognitive, and functional performance include the independent variables of leg extensor power, reaction time, processing speed, memory, attention, and functional performance. Functional performance is assessed by the Continuous Scale Physical Functional Performance Test. RESULTS: independent older adults have greater performance on leg power, reaction time, processing speed, memory, and functional performance than marginally dependent older adults. Functional performance is an independent predictor of level of independence. Leg power and cognition were separate small but significant predictors of independence. CONCLUSIONS: independent older adults have greater physiological, cognitive and functional performance than marginally dependent older adults. Individuals with greater functional performance tend to remain independent.

Activities of Daily Living↗

PubMed2005

Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure.

BACKGROUND: Patients with diastolic heart failure (DHF) have significant abnormalities in left ventricular (LV) diastolic function, including slow and delayed relaxation and increased chamber stiffness. Whether and to what extent these abnormalities in diastolic function occur in association with abnormalities in LV systolic performance, function, and contractility has not been investigated thoroughly. METHODS AND RESULTS: The systolic properties of the LV were examined in 75 patients with heart failure and a normal ejection fraction (ie, DHF) and 75 normal control subjects with no evidence of cardiovascular disease. LV systolic properties were assessed with echocardiographic and cardiac catheterization data. Stroke work (an index of LV systolic performance), preload recruitable stroke work and ejection fraction (indices of LV systolic function), systolic stress-shortening relationship, end-systolic pressure-volume relationship, and peak (+)dP/dt (indices of LV contractility) were examined. The systolic properties of the LV were normal in patients with DHF. Stroke work was 8.4+/-2.3 in DHF versus 8.8+/-2.5 kg . cm in controls (P=0.26). Preload recruitable stroke work was 99+/-22 in DHF versus 109+/-18 g/cm2 in controls (P=0.13). The relationship between stroke work and end-diastolic volume was similar in DHF and controls. Peak (+) dP/dt was 1596+/-362 in DHF versus 1664+/-305 mm Hg/s in controls (P=0.54). The end-systolic pressure-volume relationship was increased in DHF. The systolic stress versus endocardial fractional shortening relationship was similar in DHF and controls. CONCLUSIONS: Patients with DHF had normal LV systolic performance, function, and contractility. The pathophysiology of DHF does not appear to be related to significant abnormalities in these systolic properties of the LV.

Adult↗

PubMed1996

Effect of closed chain exercise on quadriceps femoris peak torque and functional performance.

OBJECTIVE: To determine the effect of a 6-week leg press training program on quadriceps femoris peak torque and lower extremity functional performance. DESIGN AND SETTING: A 2 x 3 factorial design. A private university-based outpatient physical therapy clinic was used for testing. The university strength and conditioning center was used for training sessions. SUBJECTS: A volunteer sample of thirty nonathletic, collegeage females participated. All thirty subjects completed the study. MEASUREMENTS: Subjects were randomly assigned to either a control group (G(con)) or an exercise group that performed isotonic unilateral leg presses through either 0 to 60 degrees (G(60)) or 0 to 90 degrees (G(90)) of knee flexion. Subjects trained 3 days/wk for 6 weeks using the DAPRE technique. Pre and post isokinetic testing of the quadriceps femoris at 60 degrees /sec and hop tests for distance and time were measured. RESULTS: Both training groups showed significant pre-post increases (p < .05) for: concentric peak torque, eccentric peak torque, and hop test for distance. G\(60) showed a significant decrease in hop test for time values. Significant increases (p < .05) in eccentric peak torque was seen between training groups and the control group, concentric peak torque was significantly greater only in G(90) as compared to G(con), on. No significant differences were observed between G(60) and G(90) for any of the measured variables. There were no differences between the three groups for any of the functional hop test measurements. CONCLUSIONS: Unilateral leg press exercise performed through 0 to 90 degrees of knee flexion increases concentric and eccentric peak torque while training from 0 to 60 degrees improves eccentric torque. No changes in functional performance as measured by hop tests were seen in any groups. Transference between closed kinetic chain (CKC) exercise and open kinetic chain testing was supported, but not between CKC and functional performance testing.

Journal Article↗

PubMed2006

Muscle strength, functional performance, and self-reported outcomes four years after arthroscopic partial meniscectomy in middle-aged patients.

OBJECTIVE: To examine thigh muscle strength, functional performance, and self-reported outcome in patients with nontraumatic meniscus tears 4 years after operation, and to study the impact of a strength deficit on self-reported outcome and evaluate the feasibility of 3 performance tests in this patient group. METHODS: The study group comprised 45 patients (36% women, mean age 46.7) who had an arthroscopic partial meniscectomy a mean of 4 years (range 1-6 years) previously. Main outcome measures included isokinetic strength of knee extensors and flexors, functional performance (1-leg hop, 1-leg rising, and square-hop tests), and a self-reported questionnaire (Knee Injury and Osteoarthritis Outcome Score). RESULTS: We found lower knee extensor strength and worse 1-leg rising capacity in the operated leg, but no difference between operated and nonoperated leg for knee flexors (P < or = 0.004 and P > 0.3, respectively). Patients with a stronger quadriceps of the operated leg compared with the nonoperated leg had less pain and better function and quality of life (r = 0.4-0.6, P < or = 0.010). We found the 1-leg rising and 1-leg hop tests to be suitable performance tests in middle-aged meniscectomy patients. CONCLUSION: Quadriceps strength is reduced in the meniscectomized leg compared with the nonoperated leg 4 years after surgery. This relative quadriceps weakness significantly affects objective and self-reported knee function, pain, and quality of life, indicating the importance of restoring muscle function after meniscectomy in middle-aged patients.

Adult↗

PubMed1996

Self-report of difficulty in performing functional activities identifies a broad range of disability in old age.

OBJECTIVE: To describe a broad range of physical disability by examining the association between a four-level measure of disability, based on self-report of difficulty in performing functional activities, and previously identified risk factors for disability. DESIGN: Cross-sectional. SETTING: Community-based. PARTICIPANTS: A total of 2373 noninstitutionalized men and women aged 65 and older from the Veneto Region of Italy. MEASUREMENTS: Odds ratios for the association of the four levels of disability (none, mild, moderate, and ADL disability) differentiated by this new measure with known risk factors for physical disability. MAIN RESULTS: This summary measure of physical disability distinguished older persons with disability from the population typically classified as nondisabled. Twenty-one percent of study participants were identified as having Activities of Daily Living (ADL) disability (defined as self-report of difficulty in one or more ADLs), and an additional 40% had mild or moderate disability based on degree of difficulty in Instrumental Activities of Daily Living (IADLs) and physical functional activities. Hip fracture and lower extremity performance were strongly independently associated with each level of disability. The association of a range of established risk factors for disability and health care utilization measures with the levels of disability identified in our study, and the trend toward increasing odds with increasing disability, provide evidence of the construct validity of this measure. CONCLUSIONS: Self-report of difficulty in performing functional activities identifies older persons with physical disability not ascertained by self-report of the need for help, the measure typically used to identify disability in older populations. Further studies should evaluate the potential for self-reported difficulty in functional activities to predict important disability-related outcomes.

Activities of Daily Living↗

PubMed2006

Functional performance of Alzheimer's disease and vascular dementia in southern Taiwan.

This study investigated the functional performance of two major subtypes of dementia, Alzheimer's disease (AD) and vascular dementia (VaD), by the Functional Independence Measure (FIM), and to understand the need for assistance in performing activities of daily living. The subjects comprised 64 AD and 21 VaD patients who were recruited from two epidemiologic studies of dementia with a total of 3,931 community residents aged 65 years and above in southern Taiwan. The results showed that the severity of dementia was similar between the two groups. The mean score for AD was 82.7 and for VaD was 56.5 for total FIM (p < 0.05), 61.6 and 41.7 for the motor dimension (p < 0.05), and 21.1 and 15.7 for the cognitive dimension (p < 0.05). There were significant differences (p < 0.01) between AD and VaD in six FIM items and borderline or marginal significance (p < 0.05) in most of the FIM items. For AD patients, stairs, lower dressing, bathing, and tub/shower transfer were the most difficult items in the motor dimension, and it was memory in the cognitive dimension. For VaD patients, bathing, upper and lower dressing, and grooming were the most difficult items in the motor dimension, and it was problem solving in the cognitive dimension. VaD patients were more dependent on all FIM items and required more assistance than AD patients. The functional performances of dementia patients were significantly associated with dementia severity and subtypes, together accounting for 40% of the variability in total FIM. In conclusion, most dementia patients are dependent in daily activities and different types and severity of dementia lead to different disability profiles; individualized care is, therefore, most appropriate.

Activities of Daily Living↗

PubMed1996

Functional performance following an ice immersion to the lower extremity.

Cryotherapy is a widely accepted component of treatment for acute injuries. It has recently re-entered the later stages of rehabilitation as a contributing modality. Cryotherapy's depressive effects on the body's physiological systems have generated concern among many health care practitioners about its effect on motor activity. This study examined the effects of an ice immersion on three functional performance tests: the shuttle run, the 6-m hop test, and the single-leg vertical jump. Twenty volunteers from Division III soccer and football teams who had not sustained an injury to the lower extremity within the past 6 months were randomly assigned to either an experimental or control group. Subjects in the experimental group performed three trials of each functional performance test before and after the application of a 20-minute ice immersion (13 degrees C) to the lower leg. Subjects in the comparison group followed the same procedure except that a 20-minute resting period replaced the cold treatment. A mixed design analysis of variance was used to analyze the data. Vertical jump scores decreased in the experimental group (41.4 +/- 6.8 cm to 39.3 +/- 6.1 cm) but not in the control group (45.2 +/- 5.5 cm to 45.7 +/- 5.9 cm) as a result of the treatment. Shuttle run times decreased in the experimental group (6.5 +/- 0.3 seconds to 6.7 +/- 0.4 seconds) but not in the control group (6.8 +/- 0.4 seconds to 6.8 +/- 0.4 seconds). Six-meter hop test values were not affected. We suggest that clinicians should carefully consider the immediate effects, potentially, of cold on motor activity.

Journal Article↗

PubMed2006

Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke.

OBJECTIVE: To examine the effectiveness of task-oriented progressive resistance strength training on lower extremity strength and functional performance in chronic stroke subjects. DESIGN: Single-blind, randomized controlled trial. SETTING: Medical centre and district hospital. SUBJECTS: Forty-eight subjects at least one year post stroke. INTERVENTIONS: Participants randomly allocated to two groups, control (n-/24) and experimental (n-/24). Subjects in the control group did not receive any rehabilitation training. Subjects in the experimental group were put on a four-week task-oriented progressive resistance strength training. MAIN MEASURES: Lower extremity muscle strength, gait velocity, cadence, stride length, six-minute walk test, step test, and timed up and go test. RESULTS: Muscle strength significantly improved in the experimental group for strong side muscle groups (ranged from 23.9% to 36.5%) and paretic side muscle groups (ranged from 10.1% to 77.9%). In the control group muscle strength changes ranged from 6.7% gain to 11.2% decline. The experimental group showed significant improvement in all selected measures of functional performance except for the step test. In the control group, the number of repetitions of the step test significantly decreased (-20.3%) with no change in other functional tests. There was a significant difference between groups for muscle strength and all functional measures. The strength gain was significantly associated with gain in the functional tests. CONCLUSIONS: The task-oriented progressive resistance strength training programme could improve lower extremity muscle strength in individuals with chronic stroke and could carry over into improvement in functional abilities.

Aged↗

PubMed1981

Functional performance assessment: a program approach.

An interdisciplinary method of functional assessment is presented utilizing the Patient Evaluation Conference System, or PECS (Harvey and Jellinek, 1979), which has been successfully applied to a medical rehabilitation setting to guide treatment and to assess program effectiveness. Our method requires that functional performance items be evaluated in terms of progress using an 8-point, 0 to 7 scale, 0 representing unmeasured or unmeasurable function, and 7 representing fully independent or normal function. Rehabilitation outcomes of 4 or below present varying degrees of dependent function, and outcomes of 5 or more represent degrees of independent function. Data are presented which demonstrate level of gain, goal-setting effectiveness, and degree of independent function.

Computers↗