A Nation-Wide Survey of High School Baseball Coaches' Perceptions Indicates their Arm Care Programs Play a Role in Injury Prevention.

BACKGROUND: Arm care programs consisting of upper extremity strengthening and stretching have been recommended for injury prevention for pitchers of all ages. There has been no investigation into high school baseball coaches' usage and perceptions of arm care programs to mitigate physical impairments associated with injuries in baseball players. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate the current usage of arm care programs by high school baseball coaches. The primary objective was to determine if coaches use group-based or individualized arm care programs. The secondary objective sought to determine if the use of arm care programs is influenced by coaches' age, education, and experience level. Finally, this study explored the potential barriers to arm care implementation and high school baseball coaches' current awareness and beliefs of injury prevention. STUDY DESIGN: Descriptive cross-sectional survey. METHODS: A 29-item online survey was emailed to 18,500 high school baseball coaches throughout the United States. Data were collected for three months, and the response rate was 3.7%. RESULTS: A total of 87.3% (n=571/654) of responding coaches use arm care programs with their players. Of coaches performing arm care, only 18.5% of 571 individualize their arm care exercises based on specific player needs. However, older and more experienced coaches are more likely to individualize their programs. Among the 12.7% (n=83/654) of coaches who do not use arm care programs, the two most commonly cited reasons for not implementing arm care were lack of observed benefit (41%) and insufficient staff (31%). Although 42% of 654 coaches recognized reduced shoulder mobility as a major contributor to injury, risk factors such as throwing with a fatigued arm, previous injury history, and throwing > 8 months per year were not consistently identified as primary risk factors. CONCLUSION: The results of this study suggest that the majority high school baseball coaches implement group-based arm care exercise programs to prevent injury. Lack of confidence in the effectiveness and staffing limitations were major barriers to implementation of arm care programming. However, the responding coaches exhibited inconsistent risk factor awareness and dated injury prevention beliefs. Therefore, better educational collaboration between rehabilitation professionals and high school coaches regarding injury risk factors and preventative strategies is warranted. LEVEL OF EVIDENCE: Level 3.

The spatial structure of Phanerozoic marine animal diversity.

The global fossil record of marine animals has fueled long-standing debates about diversity change through time and the drivers of this change. However, the fossil record is not truly global. It varies considerably in geographic scope and in the sampling of environments among intervals of geological time. We account for this variability using a spatially explicit approach to quantify regional-scale diversity through the Phanerozoic. Among-region variation in diversity is comparable to variation through time, and much of this is explained by environmental factors, particularly the extent of reefs. By contrast, influential hypotheses of diversity change through time, including sustained long-term increases, have little explanatory power. Modeling the spatial structure of the fossil record transforms interpretations of Phanerozoic diversity patterns and their macroevolutionary explanations. This necessitates a refocus of deep-time diversification studies.

Effect of soccer footwear on landing mechanics.

Lower-extremity injury is common in soccer. A number of studies have begun to assess why specific lower-extremity injuries occur. However, currently few studies have examined how footwear affects lower-extremity mechanics. In order to address this question, 14 male (age: 22.1 ± 3.9 years, height: 1.77 ± 0.06 m, and mass: 73.3 ± 11.5 kg) and 14 female (age: 22.8 ± 3.1 years, height: 1.68 ± 0.07 m and mass: 64.4 ± 9.2 kg) competitive soccer players underwent a motion analysis assessment while performing a jump heading task. Each subject performed the task in three different footwear conditions (running shoe, bladed cleat, and turf shoe). Two-way analyses of variance were used to examine statistical differences in landing mechanics between the footwear conditions while controlling for gender differences. These comparisons were made during two different parts (prior to and following) of a soccer-specific jump heading task. A statistically significant interaction for the peak dorsiflexion angle (P = 0.02) and peak knee flexion angle (P = 0.05) was observed. Male soccer players exhibited a degree increase in dorsiflexion in the bladed cleat while female soccer players exhibited a three-degree reduction in peak knee flexion in the bladed cleat condition. Other main effects for gender and footwear were also observed. The results suggest that landing mechanics differ based upon gender, footwear, and the type of landing. Therefore, training interventions aimed at reducing lower-extremity injury should consider utilizing sport-specific footwear when assessing movement patterns.

Using ground reaction force to predict knee kinetic asymmetry following anterior cruciate ligament reconstruction.

Asymmetries in sagittal plane knee kinetics have been identified as a risk factor for anterior cruciate ligament (ACL) re-injury. Clinical tools are needed to identify the asymmetries. This study examined the relationships between knee kinetic asymmetries and ground reaction force (GRF) asymmetries during athletic tasks in adolescent patients following ACL reconstruction (ACL-R). Kinematic and GRF data were collected during a stop-jump task and a side-cutting task for 23 patients. Asymmetry indices between the surgical and non-surgical limbs were calculated for GRF and knee kinetic variables. For the stop-jump task, knee kinetics asymmetry indices were correlated with all GRF asymmetry indices (P < 0.05), except for loading rate. Vertical GRF impulse asymmetry index predicted peak knee moment, average knee moment, and knee work (R(2) ≥ 0.78, P < 0.01) asymmetry indices. For the side-cutting tasks, knee kinetic asymmetry indices were correlated with the peak propulsion vertical GRF and vertical GRF impulse asymmetry indices (P < 0.05). Vertical GRF impulse asymmetry index predicted peak knee moment, average knee moment, and knee work (R(2) ≥ 0.55, P < 0.01) asymmetry indices. The vertical GRF asymmetries may be a viable surrogate for knee kinetic asymmetries and therefore may assist in optimizing rehabilitation outcomes and minimizing re-injury rates.

Field-expedient screening and injury risk algorithm categories as predictors of noncontact lower extremity injury.

In athletics, efficient screening tools are sought to curb the rising number of noncontact injuries and associated health care costs. The authors hypothesized that an injury prediction algorithm that incorporates movement screening performance, demographic information, and injury history can accurately categorize risk of noncontact lower extremity (LE) injury. One hundred eighty-three collegiate athletes were screened during the preseason. The test scores and demographic information were entered into an injury prediction algorithm that weighted the evidence-based risk factors. Athletes were then prospectively followed for noncontact LE injury. Subsequent analysis collapsed the groupings into two risk categories: Low (normal and slight) and High (moderate and substantial). Using these groups and noncontact LE injuries, relative risk (RR), sensitivity, specificity, and likelihood ratios were calculated. Forty-two subjects sustained a noncontact LE injury over the course of the study. Athletes identified as High Risk (n = 63) were at a greater risk of noncontact LE injury (27/63) during the season [RR: 3.4 95% confidence interval 2.0 to 6.0]. These results suggest that an injury prediction algorithm composed of performance on efficient, low-cost, field-ready tests can help identify individuals at elevated risk of noncontact LE injury.

Do different disparity proxies converge on a common signal? Insights from the cranial morphometrics and evolutionary history of Pterosauria (Diapsida: Archosauria).

Disparity, or morphological diversity, is often quantified by evolutionary biologists investigating the macroevolutionary history of clades over geological timescales. Disparity is typically quantified using proxies for morphology, such as measurements, discrete anatomical characters, or geometric morphometrics. If different proxies produce differing results, then the accurate quantification of disparity in deep time may be problematic. However, despite this, few studies have attempted to examine disparity of a single clade using multiple morphological proxies. Here, as a case study for this question, we examine the disparity of the volant Mesozoic fossil reptile clade Pterosauria, an intensively studied group that achieved substantial morphological, ecological and taxonomic diversity during their 145+ million-year evolutionary history. We characterize broadscale patterns of cranial morphological disparity for pterosaurs for the first time using landmark-based geometric morphometrics and make comparisons to calculations of pterosaur disparity based on alternative metrics. Landmark-based disparity calculations suggest that monofenestratan pterosaurs were more diverse cranially than basal non-monofenestratan pterosaurs (at least when the aberrant anurognathids are excluded), and that peak cranial disparity may have occurred in the Early Cretaceous, relatively late in pterosaur evolution. Significantly, our cranial disparity results are broadly congruent with those based on whole skeleton discrete character and limb proportion data sets, indicating that these divergent approaches document a consistent pattern of pterosaur morphological evolution. Therefore, pterosaurs provide an exemplar case demonstrating that different proxies for morphological form can converge on the same disparity signal, which is encouraging because often only one such proxy is available for extinct clades represented by fossils. Furthermore, mapping phylogeny into cranial morphospace demonstrates that pterosaur cranial morphology is significantly correlated with, and potentially constrained by, phylogenetic relationships.

Diversity patterns amongst herbivorous dinosaurs and plants during the Cretaceous: implications for hypotheses of dinosaur/angiosperm co-evolution.

Palaeobiologists frequently attempt to identify examples of co-evolutionary interactions over extended geological timescales. These hypotheses are often intuitively appealing, as co-evolution is so prevalent in extant ecosystems, and are easy to formulate; however, they are much more difficult to test than their modern analogues. Among the more intriguing deep time co-evolutionary scenarios are those that relate changes in Cretaceous dinosaur faunas to the primary radiation of flowering plants. Demonstration of temporal congruence between the diversifications of co-evolving groups is necessary to establish whether co-evolution could have occurred in such cases, but is insufficient to prove whether it actually did take place. Diversity patterns do, however, provide a means for falsifying such hypotheses. We have compiled a new database of Cretaceous dinosaur and plant distributions from information in the primary literature. This is used as the basis for plotting taxonomic diversity and occurrence curves for herbivorous dinosaurs (Sauropodomorpha, Stegosauria, Ankylosauria, Ornithopoda, Ceratopsia, Pachycephalosauria and herbivorous theropods) and major groups of plants (angiosperms, Bennettitales, cycads, cycadophytes, conifers, Filicales and Ginkgoales) that co-occur in dinosaur-bearing formations. Pairwise statistical comparisons were made between various floral and faunal groups to test for any significant similarities in the shapes of their diversity curves through time. We show that, with one possible exception, diversity patterns for major groups of herbivorous dinosaurs are not positively correlated with angiosperm diversity. In other words, at the level of major clades, there is no support for any diffuse co-evolutionary relationship between herbivorous dinosaurs and flowering plants. The diversification of Late Cretaceous pachycephalosaurs (excluding the problematic taxon Stenopelix) shows a positive correlation, but this might be spuriously related to poor sampling in the Turonian-Santonian interval. Stegosauria shows a significant negative correlation with flowering plants and a significant positive correlation with the nonflowering cycadophytes (cycads, Bennettitales). This interesting pattern is worthy of further investigation, and it reflects the decline of both stegosaurs and cycadophytes during the Early Cretaceous.

Footwear and running cardio-respiratory responses.

This study compared cardio-respiratory responses during running wearing a motion control shoe (MC) or a cushioning shoe (CU) in a cross-over single blinded design. Fourteen runners (10F/4M, age=27.3+/-5.1 years, body mass=64.1+/-12.2 kg, height=167.8+/-7.5 cm, VO (2)max=52.3+/-8.8 ml/kg/min) completed a 40-min run at approximately 65% VO (2) max under both shoe conditions. Oxygen uptake (mL/kg/min; L/min), minute ventilation (L/min), respiratory exchange ratio, and heart rate were measured at minutes 8-10, 18-20, 28-30 and 38-40 of exercise. Rating of perceived exertion was obtained at minutes 10, 20, 30 and 40. Two (footwear) by four (time) repeated measures ANOVAs showed no differences between footwear conditions in overall oxygen consumption (MC=36.8+/-1.5 vs. CU=35.3+/-1.4 mL/kg/min, p=0.143), minute ventilation (MC=50.4+/-4 vs. CU=48.5+/-3.8, p=0.147), respiratory exchange ratio (MC=0.90+/-0.01 vs. CU=0.89+/-0.01, p=0.331), heart rate (MC=159+/-3 vs. CU=160+/-3, p=0.926), or rate of perceived exertion. The design of motion control footwear does not appear to affect cardio-respiratory or perceived exertion responses during submaximal running. The findings are specific to the shoes tested. Nonetheless, the outcomes suggest that footwear selection to reduce certain overuse injuries does not increase the work of running.

Gait mechanics after ACL reconstruction: implications for the early onset of knee osteoarthritis.

BACKGROUND: Individuals who sustain a rupture of the anterior cruciate ligament (ACL) are at an increased risk for developing early-onset knee osteoarthritis (OA). The mechanism behind the early onset of the disease is still unknown. Knee OA progression has been previously examined by calculating the internal knee-abduction moment during gait. However, knee-joint moments have not been examined in individuals after ACL reconstruction as a potential mechanism for disease progression in early knee OA. OBJECTIVE: To determine if individuals who have undergone ACL reconstruction exhibit altered gait mechanics that may be associated with knee OA progression. METHODS: In total, 17 people who had previously undergone ACL reconstruction were enrolled in the study. A matched control group was recruited for comparison. All participants underwent gait analysis at an intentional walking speed to examine variables previously associated with knee OA progression, primarily the internal peak knee-abduction moment, during gait. One way ANOVAs were performed to examine differences in gait mechanics between the two groups. All joint moments were calculated as internal moments. RESULTS: The peak knee-abduction moment was increased by 21% in the ACL compared with the control group (p = 0.04). No other differences were seen in frontal plane knee or hip mechanics. CONCLUSION: It seems that individuals who have undergone ACL reconstruction exhibit an increased peak knee-abduction moment that may establish a potential mechanism of the earlier onset of knee OA in this population.

Body size evolution in Mesozoic birds: little evidence for Cope's rule.

Cope's rule, the tendency towards evolutionary increases in body size, is a long-standing macroevolutionary generalization that has the potential to provide insights into directionality in evolution; however, both the definition and identification of Cope's rule are controversial and problematic. A recent study [J. Evol. Biol. 21 (2008) 618] examined body size evolution in Mesozoic birds, and claimed to have identified evidence of Cope's rule occurring as a result of among-lineage species sorting. We here reassess the results of this study, and additionally carry out novel analyses testing for within-lineage patterns in body size evolution in Mesozoic birds. We demonstrate that the nonphylogenetic methods used by this previous study cannot distinguish between among- and within-lineage processes, and that statistical support for their results and conclusions is extremely weak. Our ancestor-descendant within-lineage analyses explicitly incorporate recent phylogenetic hypotheses and find little compelling evidence for Cope's rule. Cope's rule is not supported in Mesozoic birds by the available data, and body size evolution currently provides no insights into avian survivorship through the Cretaceous-Paleogene mass extinction.

Meeting the requirements of importing countries: practice and policy for on-farm approaches to food safety.

In light of the increasing consumer demand for safe, high-quality food and recent public health concerns about food-borne illness, governments and agricultural industries are under pressure to provide comprehensive food safety policies and programmes consistent with international best practice. Countries that export food commodities derived from livestock must meet both the requirements of the importing country and domestic standards. It is internationally accepted that end-product quality control, and similar methods aimed at ensuring food safety, cannot adequately ensure the safety of the final product. To achieve an acceptable level of food safety, governments and the agricultural industry must work collaboratively to provide quality assurance systems, based on sound risk management principles, throughout the food supply chain. Quality assurance systems on livestock farms, as in other parts of the food supply chain, should address food safety using hazard analysis critical control point principles. These systems should target areas including biosecurity, disease monitoring and reporting, feedstuff safety, the safe use of agricultural and veterinary chemicals, the control of potential food-borne pathogens and traceability. They should also be supported by accredited training programmes, which award certification on completion, and auditing programmes to ensure that both local and internationally recognised guidelines and standards continue to be met. This paper discusses the development of policies for on-farm food safety measures and their practical implementation in the context of quality assurance programmes, using the Australian beef industry as a case study.

Nocturnal enuresis: a survey of parental coping strategies at 7 1/2 years.

BACKGROUND: Childhood nocturnal enuresis is a potentially distressing experience. Parents have been found to adopt many approaches designed to help their child become dry at night. This study sought to understand, through a large cohort of children at 7 1/2 years of age, the strategies parents adopt, both during the child's development and currently, to help their child overcome bed-wetting. METHODS: A longitudinal cohort of 13,971 children with expected date of delivery between April 1991-December 1992, in the County of Avon (Bristol) formed the population study group. At 7 1/2 years parents were asked, as part of a regular self-report questionnaire, what methods they had tried or were currently using to help their child stop bed-wetting. Eleven options were supplied. RESULTS: Of 8269 parents responding to the questionnaire, 3376 (40.8%) indicated they had tried at least one of 11 strategies, with restricting night-time fluids and lifting being the predominant methods employed. Amongst strategies employed in the past, lifting and showing displeasure were used significantly more by parents of children with nocturnal enuresis than by those with children dry at 7 1/2 years. However, a greater proportion of parents of dry children encouraged their offspring to toilet more regularly in the daytime than parents of those with nocturnal enuresis or infrequent wetting. In terms of treatment interventions, the enuresis alarm had been employed with 19.2% and medication with 13.1% of those with nocturnal enuresis, although only 31.9% of those with nocturnal enuresis had seen a health worker. The results are discussed in relation to preventative and clinical implications.

Quality assurance and meat inspection in Australia.

The aim of meat inspection in Australia is to contribute to the production of safe and wholesome food, comply with the requirements of importing countries, and support national animal health objectives. An analysis of the role of quality assurance (QA) in the meat inspection systems at federally inspected establishments shows that the position of Australia as a leading meat exporter is aided by a co-regulatory, QA-based approach to meat inspection, which is equally applicable to all species at slaughter. Technical developments in meat inspection at the national and international level during the 1990s led to significant enhancements in QA systems. Quality assurance is implemented through nationally uniform documented systems, which are designed to achieve consistent standards of meat safety. These systems are complemented by hazard analysis critical control point-based QA programmes which meet the quality-standards of the International Organization for Standardization. Quality assurance programmes aim for a 'whole of chain' approach, so that the system is implemented 'from the paddock to the plate', or from pre-harvest through to post-harvest, i.e., from on-farm practices to the refrigeration, storage and transportation stages. The QA elements of meat inspection employed in production systems in Australia have significantly contributed to the consistent achievement of meat safety objectives that are appropriate to contemporary risks.

Alarm treatment for childhood nocturnal enuresis: an investigation of within-treatment variables.

OBJECTIVE: The enuresis alarm has been widely advocated as an effective intervention in the treatment of childhood nocturnal enuresis. Although there is a body of evidence concerning which pretreatment variables are related to outcome, there is little evidence relating to influential within-treatment variables. This study sought to examine a series of treatment variables against outcome. MATERIAL AND METHODS: A total of 66 children with severe primary nocturnal enuresis but with no day-time wetting were treated with a body-worn enuresis alarm. Pre- and within-treatment variables were collected. Success was considered to be 14 consecutive dry nights during a 16-week period. RESULTS: A total of 54.5% of children achieved the success criterion, with 12.1% being classed as partial successes. Of the pretreatment variables, only low functional bladder capacity was significantly associated with failure. Inability to be woken by the alarm emerged as the most important within-treatment predictor of failure. CONCLUSIONS: The success of alarm treatment is dependent on the child's ability to be aroused by the alarm. Interestingly, of those who successfully became dry, 72.2% slept throughout the night for >80% of nights that they were dry, suggesting that the mode of action of the enuresis alarm is more complex than was previously thought.

An investigation of the impact of nocturnal enuresis on children's self-concept.

OBJECTIVE: This study sought to evaluate the relationship between the self-esteem and the self-image of children with nocturnal enuresis and to examine these in relation to various aspects of clinical and demographic variables. Previous studies investigating the self-esteem of bedwetting children have had mixed findings. Some studies report that children with nocturnal enuresis have a lower self-esteem than their non-bedwetting peers, but other studies report that children with nocturnal enuresis perceive themselves similarly to non-bedwetting children. However, what have not been studied to date are the self-perceptions of bedwetting children treated in community clinics. MATERIAL AND METHODS: A total of 114 bedwetting children treated in community clinics provided the sample. School nurses conducted a routine first-visit assessment, collected baseline demographic and social information and invited children to complete the Butler Self-Image Profile and the Coopersmith Self-Esteem Inventory. RESULTS: Age and extent of wetting were not significantly related to self-concept measures. Girls had significantly (p = 0.008) higher scores on positive self-image compared with boys. Children with secondary enuresis also scored higher on positive self-image compared with those with primary nocturnal enuresis (p = 0.02). The Butler self-image scores indicated a number of significant links between positive self-image and enuresis variables, whereas the Coopersmith self-esteem scores generally failed to distinguish between the enuresis variables and closely reflected those of the negative self-image scores. CONCLUSIONS: These findings suggest that amongst children with nocturnal enuresis, the most vulnerable in terms of self-image are male, those with primary enuresis and those with a greater number of wet nights a week.

Examination of the structured withdrawal program to prevent relapse of nocturnal enuresis.

PURPOSE: A variety of treatment options are available for children with nocturnal enuresis. The success of any intervention depends on if the child remains dry once the treatment is withdrawn. All interventions for children with nocturnal enuresis are vulnerable to some degree of relapse. Pharmacological interventions, involving either desmopressin or imipramine, seem particularly susceptible to relapse occurring rapidly once medication is withdrawn. The usual practice is to taper the dose gradually although this is time-consuming and of questionable effectiveness. An alternative approach is to use a time-limited structured withdrawal program, the success of which has been recently documented. We investigated the effectiveness of the structured withdrawal program to understand the variables related to success. MATERIALS AND METHODS: A total of 51 patients 7 to 16 years old were included in the 8-week structured withdrawal program. Patients were 90% dry with medication taken for 4 to 24 months before the program and had experienced 2 unsuccessful withdrawal attempts. Patients were offered the choice of using an enuresis alarm on medication-free nights. Progress was monitored at 2, 5 and 8 weeks, and long-term success was defined as no relapse 6 months after cessation of treatment. RESULTS: At weeks 9 and 10 with complete cessation of medication 74.5% of children remained dry, and success was not related to use of an enuresis alarm. CONCLUSIONS: The structured withdrawal program significantly reduces relapse rates, and offers an alternative and rapid means of successfully withdrawing medication. It is argued that the influential variable concerns the ability of the child to shift attribution for success from an external source (that is medication) to an internal focus (that is changes in themselves).

Impact of nocturnal enuresis on children and young people.

An understanding of the psychological impact of nocturnal enuresis has been consistently hampered by inter-changeability of terminology, varied inclusion criteria, diverse methodologies and equivocal findings. This paper reviews the impact on children and young people by examining both qualitative and quantitative findings. Aspects of functioning that are explored include social adjustment, emotional state, personality, self- concept and behaviour. Generally the findings suggest children do experience bedwetting as distressing but those with mono-symptomatic nocturnal enuresis are no different from the normal population or from matched controls across all aspects of functioning. Those children most vulnerable to psychological distress as a consequence of bedwetting are identified. Interestingly there is consistent evidence for improvement in emotional functioning and self-esteem following treatment although this may not be necessarily due to the treatment itself. Methodological issues are addressed in terms of future research directions.

Genetic and gender influences on nocturnal bladder control--a study of 2900 3-year-old twin pairs.

OBJECTIVE: The present study of over 2900 twin pairs born in England and Wales in 1994 examines the influences of genetics and gender on nocturnal bladder control at 3 years of age. MATERIALS AND METHOD: Parent report data was analysed in terms of means and components of variance, using a sex-limitation model to explore genetic and environmental variation within and between the sexes. RESULTS: Both genetics and gender are seen to influence acquisition: bladder control at 3 years is moderately heritable (24%), and girls show on average slightly increased acquisition compared with boys, even within opposite-sex pairs. The sex-limitation modelling showed an interaction between genetic influence and gender whereby nocturnal bladder control was significantly more heritable in boys (33%) than girls (10%). CONCLUSIONS: Both genetics and gender are important and interacting factors in the aetiology of nocturnal bladder control.

Correlates of work injury frequency and duration among firefighters.

This study examined demographic, personality, and economic incentive correlates of workplace injuries suffered by 171 firefighters over a 12-year period. Results showed that female firefighters experienced more injuries than male firefighters. Several Minnesota Multiphasic Personality Inventory (MMPI) scales (Conversion Hysteria, Psychopathic Deviate, and Social Introversion) were positively related to injury frequency. Regression analyses revealed that age, tenure, gender, marital status, type of injury, and wage variables were significant when predicting the duration of injuries as well as an interaction between marital status and gender. Two MMPI scales (Psychopathic Deviate and Schizophrenia) were also significantly related to injury duration. Indemnity cost estimates were calculated. The results underscore the importance of distinguishing the duration of injury from the occurrence of injury.

Combination therapy for nocturnal enuresis.

Nocturnal enuresis (NE) is a multifactorial condition of childhood affecting both children and their parents. NE may result from a vasopressin deficiency, bladder instability or lack of arousal from sleep to bladder sensations. The development of the three-systems model offers increased understanding of the multifactorial aetiology of NE and may aid the development of a tailored treatment regimen for the individual child. For decades, treatment of NE has focused on pharmacological, behavioural and combination therapies, and many studies provide supporting evidence for each of these treatment approaches. However, many of these studies were performed on unselected patient populations. without assessment of the cause of the patients' enuresis, and therefore both the methodologies and results of these studies are questionable. This paper reviews the efficacy of combined treatment interventions and assesses when such interventions may be of most benefit to the patient.