Sonographic Measurements of the Lateral Abdominal Wall Thickness and Asymmetry in Fencing Players / 대한스포츠의학회지

The purpose of this study is to compare the side-to-side thickness and asymmetry in the lateral abdominal (LAM) wall muscle group between fencing players and matched controls. Twenty fencing players (10 males and 10 females) and 20 matched controls participated in this study. The resting thicknesses of the transversus abdominis (TrA), internal oblique (IO), and external oblique (EO) of the LAM on both sides of the abdominal wall were measured in each group using 7.5 MHz linear array ultrasonography. Statistical analysis showed that the asymmetry of the fencers was 15% TrA, 13% IO, and 15% EO, whereas the control group showed 5% TrA, 5% IO, and 6% EO. The LAM was more asymmetric in the fencers than in the controls (p0.05). The thickness of the TrA, IO, and EO of the side-to-side LAM wall was more asymmetric in the fencers than in the controls. This suggests that clinicians may find benefits in providing scientific baseline data on muscle asymmetry when treating and managing fencing athletes.

Analysis on Structural Variation and Disability Index of Spinal-Pelvic in the High School Students with Low Back Pain / 대한스포츠의학회지

The purpose of this study was to evaluate the prevalence rate of low back pain (LBP) in the high school students and to analyze the differences and correlations with the spinal-pelvic structural variations and disability index with LBP. The subjects are 499 high school students (236 males, 263 females: mean age, 16.38 years). They were assessed for LBP with the numerical rating scale (NRS) and for disability with the Korean version Oswestry disability index (KODI). All subjects were to take the plain radiographic examination for spinal-pelvic structural variations including thoracic, lumbar, thoracolumbar Cobb's angle, lumbar lordotic curve, sacral slope, pelvic tilt and pelvic incidence. All subjects were divided into two groups by NRS scores (0, 1=no/minimum pain group [NMP group], 2-10=low back pain group [LBP group]). The prevalence rate of LBP of all subjects was 56.7% (n=283). NRS and total KODI scores were higher in the LBP group (3.38 cm/11.83%) than NMP group (0.07 cm/2.74%) (p0.05). NRS had significantly positive correlation with KODI (p0.05). In conclusion, this study showed high prevalence rate of LBP in the high school students, but did not show significant correlations with the spinal-pelvic structural variations and disability index.

Rehabilitation after Menisectomy in Elite Soccer Players

OBJECTIVE: To evaluate the effect of systemic and appropriate rehabilitation after menisectomy. METHOD: We reviewed the medical records of 13 patients who had been in rehabilitation program after menisectomy. We measured the range of motion of the knee joint, pain intensity by visual analogue scale (VAS) score, the difference of thigh circumference between normal and menisectomied legs, and strength of flexors and extensor of the knee and functional tests before and after rehabilitation. RESULTS: Range of motion, VAS score, thigh circumference, strength of flexors and extensors of the menisectomied knee were significantly different before and after rehabilitation. Knee flexion angle increased from 76.9degrees to 135degrees and knee extension angle increased from -10.8degrees to 0degrees. VAS score decreased from 4.3 to 0.9. The difference of thigh circumference decreased from 2.80 to 0.44 cm. The torque of flexors increased from 82.88 to 120.05 Nm and that of extensors increased from 97.83 to 149.77 Nm at 60 degrees/ sec. Twelve out of 13 players performed functional activities and returned to sports successfully after systemic rehabilitation. The average duration of rehabilitation was 16.6 weeks. CONCLUSION: We suggested that systemic and appropriate rehabilitation after the menisectomy was needed for successful return to sports.

Comparison of Postural Control Measures between Older and Younger Adults Using Balance Master System

OBJECTIVE: Postural control ability is one of determinant factors of falls in older adults. The purpose of this study was to determine if age affected postural control measures in Balance Master system. METHOD: Forty-four healthy adults (22 men, 22 women) were divided into two groups; younger (20 to 29 years) and older (60 to 69 years) groups. All participants were tested by Balance Master system. A total 5 measurements were analyzed to determine the difference between older and younger group. RESULTS: Older adults demonstrated wider area of sway (o) under condition (eye closed on foam surface) in mCTSIB, low directional control (%) in slow front/back rhythmic weight shift, and low on-axis velocity (o/sec) in fast front/back rhythmic weight shift (p<0.05). Right/ Left weight symmetry (%) during sit to stand was significantly higher in older groups (p<0.05). Wider area of turn sway (o) and longer turn time (sec) during step/ quick turn were demonstrated in older groups (p<0.05). CONCLUSION: The results showed that the postural control ability measured by Balance Master system was reduced in the older adults. Further studies should be carried out to correlate this reduction with the falls in healthy elderly.

Forward Head Posture: Relationship between Spinal Alignment Indicies and Myoelectrical Activities of the Paraspinal Muscles

OBJECTIVE: We evaluated the effects of forward head posture on the myoelectrical activities of the paraspinal muscles. METHOD: 15 healthy persons who were pain-free and didn't have the history of neuromuscular disease were participated in this study. Measurements were taken in three different sitting positions (relaxed, erect and forward head posture) with staring forward and arms hanging at the side. Paraspinal myoelectrical activities were measured by surface electrodes in paracervical, paralumbar, sternocleidomastoid (SCM) and levator scapular (LS) muscles. Simultaneously whole spine lateral X-ray including skull was taken. We measured cranio-cervical spinal alignment indicies (craniovertical, craniocervical, cervicohorizontal and upper cervical angles) introduced by Huggare and Gonzalez, lower cervical angle, lumbar lordosis angle and myoelectrical activity of each muscle in three different sitting positions. RESULTS: The analysis of relationship between lumbar lordosis and cranio-cervical spinal alignment index showed significant results. The more the lumbar lordosis increased, the head forward displacement decreased. But, the myoelectrical activities of paraspinal muscles were not influenced by the posture. CONCLUSION: Maintaining lumbar lordosis is very important to correct forward head posture and research for the distraction force loaded to soft tissue of the neck in forward head posture is needed.

Effects of Sitting Balance Using Visuo-perceptual Biofeedback Training in Stroke Patients

OBJECTIVE: This study was aimed to compare the effect of visuo-perceptual biofeedback sitting balance training using Balance Master in stroke patients with that of conventional sitting balance training. METHOD: The subjects were twenty-four stroke patients receiving rehabilitation therapy who could maintain sitting posture independently. These patients were randomly divided into a control and an experimental group. The ability of static postural balance control with the modified Clinical Test Sensory Interaction Balance (mCTSIB) and the weight bearing test was measured before and after the balance training. The ability of dynamic postural balance control was measured with the limit of stability (LOS) test and the rhythmic weight shift test. Motor assessment scale (MAS) and modified Barthel index (MBI) were also checked for measuring the effects. RESULT: There was significant improvement in both abilities of static and dynamic postural balance control in the experimental group that had visuo-perceptual biofeedback training using the Balance Master (p<0.05). MAS and MBI scores after the training showed a bigger increase in the experimental group than in the control group. CONCLUSION: The visuo-perceptual biofeedback sitting balance training using the Balance Master was considered to be more effective than the conventional training in the stroke patients.

Effects of Exercise Therapy on Natural Killer Cell Cytotoxic Activity in Breast Cancer Patients after Curative Surgery

OBJECTIVE: Exercise may contribute to alteration in cancer in many ways. The major cell in cellular immunity to defense against cancer cell is natural killer [NK] cell. So this study is aimed to investigate the effects of exercise on NK cell cytotoxic activity (NKCA) in breast cancer patients who underwent mastectomy. METHOD: Thirty-one breast cancer patients who had undergone curative surgery were randomly assigned to an exercise group (n=16) and a non-exercise group (n=15). Exercise therapy was consisted of aerobic activity such as bicycle ergometer for 30 minutes, twice a day, five times each week for 2 weeks. The venous blood samplings were obtained on postoperative days 1, 7 and 14. NKCA was assayed by cytotoxic response against K562 cells. The venous blood samplings were obtained on postoperative days 1, 7 and 14. NKCA was assayed by cytotoxic response against K562 cells. RESULT: The baseline study did not show any statistical difference between exercise group and non-exercise group. Mean NKCA of day 7 decreased in both groups compared with that at postoperative day 1 (p<0.05). At day 14, the difference of the mean NKCA between two groups was not significant, but the mean NKCA of the exercise group without metastasis demonstrated a significant increase compared with that of the non-exercise group without metastasis (p<0.05). CONCLUSION: This study suggested that early moderate exercise had a beneficial effect on the function of NK cells in early stage of breast cancer patients after curative surgery. A further study will be needed to evaluate long-term effect of exercise on NK cell.

Effect of Balance Board Training with Tactile Stimulation on Affected Leg in Hemiplegic Patient

OBJECTIVE: The purpose of this study was to determine the effect of balance board training combined with tactile stimulation on the affected leg of hemiplegic patients in improving the ability of balance control. METHOD: Thirty hemiplegic patients participated. In the study group, two pieces of adhesive tapes were attached on the skin of affected lower leg. And then, they performed balance training on a balance board. The training was performed for 4 weeks. The control group received conventional gait training program for the same period. Subjects in both groups were tested for their balance control abilities using Balance Master before and after the training period. RESULTS: In the study group, there were statistically significant improvements in the abilities of the weight bearing, body sway control, and rhythmic weight shift (p<0.05) after balance board training. After the training, there were statistically significant differences in the abilities of weight bearing and rhythmic weight shift (p<0.05) between the two groups. CONCLUSION: The training with balance board combined with tactile stimulation to the affected leg and foot was proved to be effective for the treatment of balance control abilities in hemiplegic patients.

Clinical Profile of Duchenne Muscular Dystrophy

OBJECTIVE: To evaluate clinical features in general and possible complications in Duchenne muscular dystrophy (DMD) which could be used for comprehensive rehabilitation management. METHOD: One hundred and seventy-two patients with DMD were followed over 3 year period to provide clinical profile causing impairment and disability. We measured height, weight and manual muscle testing (MMT) when the patients visited the hospital. And we could measure pulmonary function, electrocardiogram (EKG), and intelligence quotient (IQ) test in cooporative patients. RESULTS: The median height and weight of DMD boys were normally distributed before age 12, but during the second decade height was markedly reduced, and weight was no longer normally distributed. The MMT measurement showed loss of strength in a fairly linear fashion according to increasing age, and extensor of lower extremities were weaker than flexors showing typical contractures of legs. There was a direct relationship between pulmonary function and MMT scores of upper extremities. There was a high occurrence (40%) of abnormal EKG, but none of the patients had a history of cardiovascular complication. DMD children suffered wide spectrum of psychological disturbance such as somatic complaints, attention and emotional problems in addition to expected psychological problems due to chronic disease and its progression, and 50.9% of them were below average on the IQ test. CONCLUSION: These data on DMD subjects provide clinicians with useful information regarding the prevalence and severity of measurable impairment at different stages of the disease.

Effects of Therapeutic Exercise on Patients with Osteoarthritis of Knee

OBJECTIVE: To investigate the effect of therapeutic exercise on patients with osteoarthritis of knee in view of functional capacity. METHOD: The subjects were 80 patients with osteoarthritis of knee. Patients were randomly allocated to exercise or no exercise (control) group. Osteoarthritis was diagnosed on the base of clinical features, X ray findings. Therapeutic exercise was consisted of quad-setting exercise, isokinetic exercise, squatting exercise. Effects of therapeutic exercise were evaluated by muscle function, functioal performance and degree of pain. RESULTS: In exercise group, muscle function such as torque and endurance of extensor and flexor of knee were increased significantly compaired with control group (p<0.05). Increment was more apparent in extensor. In both group, pain was decreased but more apparent in exercise group (p<0.05). Functional performance was assessed in terms of dependency, difficulty and amount of pain. Exercise group showed improvement of functional performance in walking inside, climbing stairs (p<0.05) but control group did not show improvement. Seventy percent of patients with osteoarthritis of knee showed increment of body weight above 10 kg compaired with their twenties. CONCLUSION: When we manage the osteoarthritis of knee, therapeutic exercise should be included in the treatment regimen as well as physical and medical therapy.

The Effects of Rehabilitative Training in the Treatment of Patellofemoral Pain Syndrome

OBJECTIVE: Inappropriate neural control of the quadriceps femoris muscle group has been implicated in patellofemoral pain syndrome (PFPS) and the methods of biomechanical assessment of PFPS has been developed recently. The aims of the present investigation were to evaluate the effects of therapeutic exercise in the alleviation of PFPS and to develope objective clinical test for PFPS. METHOD: We investigated the onset time of the isometric contraction of vastus medialis oblique muscle (VMO) and the vastus lateralis muscle (VL) under four different conditions: knee flexion and extension in weight bearing (standing) and non-weight bearing (sitting on chair) situations. For each condition, onset times of EMG activities and onset times for VMO and VL were determined from five trials of isometric contraction. In addition, we compared knee flexor and extensor torques in control group and subjects with PFPS. To evaluate the effects of the exercise we compared the onset time difference (onset time of VL-onset time of VM) and quadriceps muscle torque at pre- and post- exercise in PFPS groups. RESULTS: In PFPS group, onset time of VMO during knee extension was significantly longer than the onset time of VL and the knee extensor torque was considerably weaker in comparison with normal group. Although onset time difference was not changed after exercise program, there were significant increase in knee extensor torque in subjects with PFPS. CONCLUSION: The role of exercise in the rehabilitation of quadriceps functions is to reduce the pain, to strengthen the knee extensor, and further accurate diagnostic tools and methods for the result of therapeutic exercise in PFPS are needed.

Variations and Morphometry of the Carpal Tunnel and Its Related Structures

OBJECTIVE: The purpose of this study was to find out diagnostic clue for the carpal tunnel syndrome. So we investigated the postional relationships between the structures, the degree of entrance of the muscle bellies in the carpal tunnel, the location of flexor retinaculum (FR) and the cross sectional area to the tunnel of the tendons, the median nerve and the soft tissues occupied with the wrist. METHOD: Seventy-seven wrists of Korean adults's cadavers were dissected. Fifty-three wrists were examined by posteroanterior view of X-ray. The area of each structure was measured by image analyzer (Optimas Co. WA). The upper and lower borders the FR were confirmed at the sagittal plane after sagittal section. RESULTS: Frequency of the bellies of FDS, FDP and lumbricalis observed in each finger, the length of these bellies entering into the carpal tunnel were obtained. The cases that the third and fourth FDS were located side by side, the second FDS tendon under the third FDS tendon and the fifth tendon under the fourth FDS tendon were most common. The cases that the median nerve was bordered on the third FDS and the second FDS deep inside of the median nerve were most common. Mean length of the FR was 32.1 mm. The cases that the location of the upper margin of the FR was 10 mm and 15 mm from the end of radius were most common (44%). The cases that the margin of FR was 5 mm and 10 mm from the base of the 3rd metacarpal bone were most common (52%). The cross sectional area ratios to the carpal tunnel of the tendon, median nerve and connective tissues were 30%, 4%, 66% at the level of the pisiform bone, 36%, 4%, 60% at the level of the hook of hamate and 28%, 3%, 67% at the level of the lower margin of the FR, respectively. CONCLUSION: These results could help to understand the etiology of the carpal tunnel syndrome and would be a helpful information to the diagnostic imaging of the carpal tunnel.

Behavioral and Emotional Problems for the Patient with Duchenne Muscular Dystrophy

OBJECTIVE: To identify psychological disturbance occurring in Duchenne Muscular Dystrophy (DMD) children. METHOD: Fifty one DMD children aged from 5 up to 14 years and 51 age matched healthy children were evaluated. Korean child behavioral cheak list (K-CBCL) was used to evaluate psychological problems in DMD and healthy control children. Korean Wechsler Intelligence Scale for children were performed in DMD children to evaluate cognitive function. To evaluate children's functional level, Brooke's scale for upper extremities and Vignos' scale for lower extremities were used. A correlational analysis was performed between age and total IQ score and K-CBCL subscales. RESULTS: K-CBCL profiles of the DMD children and control group revealed that DMD children obtained significantly lower scores on social, school, total social competence scales (P<0.01) and significantly higher scores on withdrawn, somatic complaints, anxious/depressed, immaturity, attention problems, internalizing problem, total behavior problems and emotional ability (P<0.01). Correlations of the age and functional level of the DMD group with each social scale of the CBCL resulted in significant negative relationship on social, school, and total social competence scales (P<0.01) and significant positive relationship on withdrawn, somatic complaints, anxious/depressed, immaturity, internalizing problems and total behavior problems (P<0.01). Correlational analysis of IQ score of the DMD group and each scale of the CBCL revealed no significant relationships except school (P<0.05) and total behavioral problem (P<0.05). CONCLUSION: We concluded that DMD children suffer from wide spectrum of psychological disturbance such as somatic complaints, attention and emotional problems in addition to expected psychological problems due to chronic disease and its progression. Thus, for the successful rehabilitation, these various emotional disturbances need proper treatment.

Early rehabilitation program in postmastectomy patients: a prospective clinical trial

The purpose of this study was to determine whether 20 patients who received an early postmastectomy rehabilitation treatment program showed more improvement in range of shoulder motion and functional activities than 13 patients who received instruction for exercise only. Data were obtained at preoperatively, three days after operation, at discharge and at postdischarge one month for each patient on parameters such as range of motion of the ipsilateral shoulder joint, upper extremity circumferential measurements, as well as 10 elements of shoulder function. Postoperatively, both groups showed an increased range of motion of the shoulder joint and improved functional activities, but the group that received postoperative rehabilitation management had a better range of shoulder motion and less difficulty in five items for functional assessment. This study also showed that an early rehabilitation program did not increase postoperative complications. We concluded that an early rehabilitation program or intensive instruction program only by a well-trained physical therapist or physiatrist was beneficial to postmastectomy patients in regaining the function and range of shoulder motion, and significantly better in a rehabilitation group.

The Effect of Diet, Exercise and Growth Hormone Treatment for Obese Non-Insulin Dependent Diabetes Mellitus(NIDDM)

OBJECTIVE: To investigate whether there is a significant effect of growth hormone(GH) treatment with diet and exercise over the diet and exercise alone in obese non-insulin dependent diabetes mellitus(NIDDM). METHOD: Twenty obese NIDDM adults were studied. We measured the body weight, body composition and exercise capacity before and after 12 weeks of treatment program. The subjects were assigned in a double-blind manner either to the diet, aerobic exercise with placebo treatment group(group A) or to the diet, aerobic exercise with GH treatment group(group B) for twenty-week period. Two groups were compared for the demographic data. RESULTS: After 12-weeks of treatment program, each group showed a significant weight loss (group A: 8.54+/-2.29 kg vs group B: 7.14+/-2.99 kg) than before the treatment, however there was no significant weight loss between two groups. After 12-weeks, the fat fraction of body weight loss was significantly higher in group B than group A(0.80+/-0.40%kg versus 0.55+/-0.30%kg). After 12-weeks, the maximal oxygen consumption was similarly increased in both groups(23.75% in the group A versus 29.2% in the group B). After 12-weeks, the peak torque was similarly increased in both groups(9.7% in the group A versus 17.3% in the group B). After 12-weeks, the endurance was similarly increased in both groups(10.1% in the group A versus 8.1% in the group B). CONCLUSION: Both group A and B showed a significant weight loss and resulted in a comparable gain in the muscle strength, endurance, and maximal oxygen consumption. The addition of GH in a low dose to a the calorie-restricted diet and aerobic exercise resulted in a significant fat loss especially around the visceral area.

Clinical Implications of Inspiratory Muscle Training in Patients with Duchenne Muscular Dystrophy

Respiratory insufficiency is a common cause of morbidity and mortality in patients with Duchenne muscular dystrophy(DMD). In these patients, progressive muscle weakness is a major factor in the development of respiratory insufficiency. Therefore, the physical training program to improve the strength and endurance of respiratory muscle could conceivably improve respiratory function and prevent respiratory complication in patients with DMD. The purpose of this study is to examine the effects of inspiratory muscle training on respiratory function of DMD patients according to functional state. Eighteen DMD patients who were registered at the Muscle clinic of Yong Dong Severance Hospital were assessed for the pulmonary function using the routine pulmonary function test and measurements of maximal static pressures at 6 weeks before the training, at the beginning of training, and after the end of 6 week-training. The first 6 weeks were used as a control period. Inspiratory muscle training consisted of breathing through Threshold inspiratory muscle trainer (IMT) at 30% of patients' maximal inspiratory pressures(MIP) for 15 minutes twice a day and the 'endurance time' was recorded weekly for an assessment of inspiratory muscle endurance. This study showed significant improvement of MIP and endurance time after the training in both ambulatory and wheelchair-bound patients. The amounts of improvement were greater in the patients with a better functional state and greater baseline forced vital capacity. We conclude that, in the early stages of DMD, inspiratory muscle training with pressure threshold device is more useful when the forced vital capacity is well preserved.

Clinical Implications of Pulmonary Function Test and Maximum Static Pressure in Duchenne Muscular Dystrophy

Respiratory failure and pulmonary infection are the major causes of death in the Duchenne muscular dystrophy patients. The purposes of this study are to evaluate pulmonary function of Duchenne muscular dystrophy patients, to verify usefulness of the measurements of maximum static pressures and to define functional classes in Duchenne muscular dystrophy patients. Forty two Duchenne muscular dystrophy patients were assessed for pulmonary function by a routine pulmonary function test and the measurements of maximum static pressures. This study showed significant negative correlations between the subject's functional class and the values of forced vital capacity(FVC), maximum inspiratory and expiratory pressures(MIP and MEP). Significant reduction of maximum static pressures began earlier than FVC in the course of disease. The MEP was as low as 64% of the predicted value before FVC and MIP showed demonstrable decline. A pulmonary care program focusing on maintaining adequate respiratory pressures is suggested to start early for the child with Duchenne muscular dystrophy.

Psychological Investigation in Myofascial Pain Syndrome Patients

The myofascial pain syndrome patients usually have characteristic personalities. The purpose of this study is to investigate the psychological characteristics of myofascial pain syndrome patients. We reviewed medical records of fifty-four patients with myofascial pain syndrome for their Minnesota Multiphasic Personality Inventory, Visual Analogue Scale, and psychological interview notes. On MMPI profile, the patients scored high in hypochondriasis, hysteria and depression scales, which are the triad of neurosis. According to stress factors and occupations, the psychologic responses were different. We have compared the severity of pain according to different life stress and occupations. VAS scores of the student group were higher statistically in the occupation comparison and of the marital problem group were higher in the life stress comparison. It is suggested that psychologic intervention on myofascial pain syndrome patients should be stressed for the management of pain.

Comparison on Treatment Effects of Dextrose Water, Saline, and Lidocaine for Trigger Point Injection

Myofascial trigger point(TP) is characterized as an impaired energy metabolism. We hypothesized that the use of dextrose as an energy supplement for TP injection would be more effective than saline or lidocaine. Sixty four typical myofascial pain patients were treated with TP injections. Among them 23 were injected with 5% dextrose water(D/W Group), 20 with normal saline (N/S Group), and 21 with 0.5% lidocaine (Lidocaine Group). Visual analogue scale(VAS) and pressure threshold algometer(kg/cm2) were used as measuring tools before, immediately after, and 7 days after the injection therapies. Mean VAS scores were 6.78 before, 5.19 immediately after, and 3.39 seven days after the injections, and the treatment effects were greater after the second and third injections. Mean differences of pressure threshold were 0.37 before and immediately after injections, and 0.42 before and 7 days after injections. Significant elevation of threshold was noted after the second and third injections. Mean VAS were not significantly different in three groups before and immediately after injections. But after 7 days, only D/W Group showed significantly lower score of 2.39, compared to 3.85 in N/S Group and 4.05 in Lidocaine Group(P<0.01). Mean pressure threshold before and immediately after injections was not different in each group. After seven days D/W Group also showed significantly higher value of 2.49, compared to 1.91 in N/S Group and 2.07 in Lidocaine Group(P<0.05). We have concluded that 5% dextrose water would be the preferable choice for TP injection.

Effect of Topical Capsaicin in Chronic Low Back and Posterior Neck Pain

The purpose of this study was to evaluate the effectiveness of topically applied capsaicin cream for the treatment of chronic low back and posterior neck pain. Fourty-one patients with chronic low back or posterior neck pain of more than 6 months despite comprehensive management in our rehabilitation department were selected for this study. Of these subjects, a group of 21 patients used capsaicin cream, and the other 21 patients used NSAID gel as a control group. Pain intensities in both groups were measured with the visual analogue scale(VAS) before the treatment, 2 weeks and 5 weeks after the treatment. McGill Pain Questionnaire(MPQ) was used before and 5 weeks after the treatment. According to followed-up VAS, MPQ-number of words chosen, and MPQ-pain rating index, there was an evidence of effective pain relief by capsaicin cream for the low back and posterior neck pain 5 weeks after the treatment. We conclude that continuous use of capsaicin cream for 5 weeks can be beneficial for the chronic pain patients in relieving pain and subsequently helping their rehabilitation process.