The disablement process: factors associated with progression of disability and recovery in French elderly people

PURPOSE: To study the factors associated with progression, recovery and death from different grades of disability in elderly people. METHOD: The sample included 3198 participants of the PAQUID ('Personnes Agées QUID') cohort, aged 65 and over and community-dwellers at baseline. Subjects were re-interviewed 1, 3, 5, 8 and 10 years after baseline. A five-state Markov model was used to estimate transition intensities between four grades of disability and toward death. We used a hierarchic scale of disability, which combines basic and instrumental activities of daily living and mobility. Several explanatory variables were investigated: medical, personal and environmental factors. RESULTS: The factors associated with progression and/or no recovery of disability were cardiovascular diseases, stroke and diabetes, low cognition, visual impairment and dyspnoea (for pathologies and impairments), older age, female gender, low educational level (for risk factors), depression (for intra-individual factor) and being married, recent hospitalization and number of drugs (for extra-individual factors). Older age, male gender, tobacco consumption and living in an urban area were associated with mortality. CONCLUSIONS: These findings confirm the independent contribution of each group of variables in the disablement process and stress their different impact on progression of disability or on recovery from different grades of disability.     

First episode of acute low back pain – an exploratory cluster analysis approach for early detection of unfavorable recovery

Purpose: To identify recovery patterns in patients with a first episode of acute low back pain (LBP) and to define risk factors for unfavorable outcome.

Methods: One hundred and eight patients (55 male, 53 female; mean age?=?40.8, SD 14.2 years) rated pain (NRS) and disability [Oswestry Disability Index (ODI)] before the first treatment and 1 week, 1, 3, 6, and 12 months later. Hierarchical cluster analysis identified recovery patterns based on NRS data. Clusters were compared for age, NRS and ODI at baseline, pain reduction in the first week, gender, radicular signs and traumatic onset using one-way ANOVA (post hoc Bonferroni) and χ² tests.

Results: The cluster analysis revealed four clusters: moderate baseline pain/fast recovery; high baseline pain/fast recovery; high baseline pain/persistent mild pain; high baseline pain/persistent high pain. These clusters differed in baseline NRS [F(3,104)?=?39.61, p?F(3,104)?=?12.17, p?F(3,104)?=?11.51, p?χ²(3)?=?9.20, p?=?0.027].

Conclusions: These results suggest that an initial and regularly repeated assessment of pain intensity and functional disability is important. Initial pain intensity does not seem to be a prognostic factor per se, as it did not negatively affect recovery provided that it decreased early in treatment.

• Implications for Rehabilitation

• Prediction of outcome is particularly important in patients with a first episode of acute LBP as one third did not completely recover.

• Pain intensity and functional disability should be initially assessed and regularly repeated in the first phase of treatment.

• High initial pain intensity and disability combined with small pain reduction during the first week might predict unfavorable outcome and require adequate treatment.

     

Book review

Purpose.?To investigate the relationship between duration and intensity of physical activity and disability 10 years later, and to investigate the possible effect of selective mortality.

Method.?Longitudinal data of 560 men aged 70?–?89 years, without disability at baseline from the Finland, Italy and The Netherlands Elderly (FINE) Study was used. Physical activity in 1990 was based on activities like walking, bicycling and gardening. Disability severity (three categories) in 1990 and 2000 was based on instrumental activities, mobility and basic activities of daily living.

Results.?Men in the highest tertile of total physical activity had a lower risk of disability than men in the lowest tertile (odds ratio (OR) 0.46; 95% confidence interval (CI): 0.26?–?0.84). This was due to duration of physical activity (OR highest tertile 0.42; 95% CI: 0.23?–?0.78 compared to the lowest tertile). Intensity of physical activity was not associated with disability. Addition of deceased men as fourth category leaded to weaker associations between physical activity and disability (OR highest tertile 0.67; 95% CI: 0.44?–?1.02).

Conclusions.?Even in old age among relatively healthy men, a physically active lifestyle was inversely related to disability. To prevent disability duration of physical activity seems to be more important than intensity.     

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: A pilot study

Purpose. Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD).

Method. Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis.

Results. Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04).

Conclusions. Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.     

The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: Results from the UCLA Neck Pain Study

Purpose. The purpose of this study is to estimate the associations of psychosocial factors with pain and disability outcomes among neck-pain patients enrolled in a randomized clinical trial of chiropractic treatments.

Methods. Neck-pain patients were randomized to one of 8 modes of chiropractic treatment. Health status and psychosocial variables were measured at baseline. Changes in neck pain severity and disability from baseline to 6 months were the primary outcome variables. Multivariable regression models were used to estimate effects of psychosocial variables adjusted for potential confounders.

Results. Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.

Conclusions. We found some evidence that certain coping strategies and types of social support are associated with pain and disability outcomes in this population of largely subacute and chronic neck-pain patients.     

The progression of disability among older adults in Mexico

Purpose: This paper seeks to document the progression of disability in a developing country and to examine gender differences in this process.

Methods: The data come from the Mexican Health and Aging Study (MHAS), a nationally representative sample of older adults. An ordinal logistic regression (n?=?3283) is used to measure the progression of disability that considers: (1) no disability, (2) mobility problems, (3) mobility problems with IADLs limitations, (4) mobility problems with ADLs limitations, (5) combinations of the latter three and (6) death.

Results: Approximately 43% of the sample remained in the same level of disability after 2 years. The patterns of progression with two disabilities differ for men and women.

Conclusions: Our model reflects the importance of separating ADLs and IADLs in the study of disability progression in Mexico. Varying risk profiles and cultural differences might influence the divergent disability paths followed by each gender.

• Implications for Rehabilitation

• The disablement process involving transitions from mobility impairments to IADL and ADL limitations seen in developed countries differs for older adults in Mexico.

• Cultural differences may influence the progression from non-disabled to becoming disabled in different ways for females in developing countries like Mexico.

• One-fifth of individuals showed greater function and independence over time, suggesting that the disablement process is reversible. This finding highlights the need to focus on improving mobility, ADL, and IADL skills to facilitate successful aging.

• Although disability is often conceptualised as a combination of ADL and IADL limitations, gender differences seen in Mexico indicate the need to separate ADL and IADL when developing approaches to prevent or ameliorate disability.

     

“When I was no longer able to see and walk,that is when I was affected most”: experiences of disability in people living with HIV in South Africa

Abstract

Purpose: HIV-related disability is an emerging issue in countries where HIV is endemic. This study aimed to understand experiences of disability in patients living with HIV in South Africa using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework. Methods: In-depth interviews were conducted with 19 HIV-positive people receiving ART through a public hospital in KwaZulu-Natal. Data were analyzed using collaborative qualitative content analysis. Results: Participants described a variety of impairments related to mental, sensory, neuromusculoskeletal, skin, cardiovascular, digestive or reproductive systems. A tenuous relationship was evident between HIV and mental health impairments and the experience of other disabilities. Impairments affected participants’ activity levels, especially mobility, domestic life, self-care and ability to work. Activity limitations affecting livelihood were often of more concern to participants than the impairments. Furthermore, women and men appeared to experience disability related to activities relevant to gendered norms in their cultural context. Conclusions: More understanding of the intersections among HIV, disability, gender and livelihood is needed. To respond to the increased need to manage disability within HIV care in Africa, HIV programs should include rehabilitative approaches, address concerns related to livelihoods in households with disability and consider gender differences in the experience of disability.

• Implications for Rehabilitation

• HIV, its opportunistic infections and the treatments associated to them are related to health conditions and impairments that have the potential to develop into disability. Rehabilitation professionals in HIV endemic countries have therefore a larger and changing number of people living with HIV and need to consider the impact of the disease on the rehabilitation process.

• Mental health issues and disability might be interrelated and affect antiretroviral treatment (ART) adherence. Hence, rehabilitation has to use a holistic approach and integrate different therapy approaches (e.g. physiotherapy and mental health).

• The experience of living with HIV and developing disability has unreflected gender dynamics that need to be considered in rehabilitative care. Hence, the rehabilitation process has to consider the cultural realities and gendered experience of the condition.

• The study highlights the interrelationship between disability levels, the influence of environmental and social factors, and the changing experience related to gender. Hence, rehabilitation professionals in resource-poor settings have to go beyond the clinical response and therapy approaches in order to improve the activity and participation of people with disabilities and those living with HIV in their homes and communities. Community or home-based care might be avenues to further explore.

     

A prospective study examining balance confidence among individuals with lower limb amputation

Purpose:?In this study we assessed whether balance confidence scores changed over a 2-year follow up period, and identified predictors of balance confidence and predictors of change in balance confidence among lower limb amputees.

Method:?A prospective follow-up survey of 245 community living adults with unilateral below and above knee lower limb amputation who used their prosthetic limb daily was conducted. Balance confidence, assessed using the 16-item Activity-specific Balance Confidence (ABC) Scale, socio-demographic, health and amputation related variables were collected at baseline and 2 years later.

Results:?ABC scores were similar at baseline (mean?= 67.6; SD?=?25.7) and follow up (mean?=?68.0; SD?=?25.8). Lower balance confidence scores at follow up were predicted by older age, being female, use of a mobility device, poor perceived health, increased symptoms of depression, having to concentrate while walking, and fear of falling (all p?<?0.05). Predictors of change in balance confidence included gender and perceived health (all p?<?0.05).

Conclusion:?Balance confidence appears to be a persistent problem in the amputee population. Health professionals are encouraged to consider balance confidence as a potentially important variable that may influence function in this clinically unique group of individuals. The identified predictor variables may be useful to clinicians in targeting individuals who require attention to improve balance confidence.     

Disqualified for disability pension – a case/referent study

Objectives:?To analyse medical and other determinants for decisions about rejection or acceptance of applications for disability pension.

Methods:?A register-based retrospective case-control study was carried out in the area of a county in mid-Sweden. Cases were all individuals rejected a full disability pension 1999?–?2000, in all 99 cases. Controls were every tenth person granted a full disability pension during the same period, 198 individuals. Determinants were recorded from the protocols at the Social Insurance Office.

Results:?Unemployment (OR?=?7.1, CI?=?3.1?–?16.4), living in the main municipality, (OR?=?2.8, CI?=?1.4?–?5.8) and age below 50 years (OR?=?0.4, CI?=?0.2?–?0.8) were determinants for rejection of disability pension. Medical status, as described in the Social Insurance act, had no association with the outcome.

Conclusions:?There appear to be variations in praxis of rejection of applicants between Social Insurance boards in different geographical areas due to reasons other than medical. Socio-economic situation of the applicant may have an influence. Established criteria for determining work ability are needed.     

Do the self-concept and quality of life decrease in CP patients? Focussing on the predictors of self-concept and quality of life

Purpose.?To find out if the quality of life (QOL) and self-concept of the children with cerebral palsy (CP) was different from that of children without disability, to investigate predictive variables that could affect self-concept and QOL.

Methods.?A total of 40 children with CP and 46 age-matched peers were included. The baseline characteristics including sex, type of CP, the level of disability according to Gross Motor Function Classification System (GMFCS) were recorded. Education levels of both children and parents, demographic features of parents, features of living area, usage of devices and associated impairments were filled out. Self-concept was measured using Piers–Harris Self-concept (PH) Scale. Quality of life was measured by Pediatric Quality of Life Inventory 4.0 (PedsQL). The physical and psychosocial health subscale scores of PedsQL (P-PedsQL and PS-PedsQL) were recorded.

Results.?Significant differences in mean scores favouring the control group were found for PH scale, PedsQL scale (p?<?0.001). P-PedsQL and PS-PedsQL of the CP group were lower than the control group (p?<?0.001). PS-PedsQL report was significant predictor of self-concept. The presence of incontinence and GMFCS level were significant predictors of PedsQL and PPedsQL, respectively.

Conclusion.?Self-concept and QOL of the CP children were lower than the children without CP. Presence of incontinence, self-concept rating and GMFCS level were important to predict domains of QOL.     

The use of electronic assistive technology for social networking by people with disability living in shared supported accommodation

Abstract

Background: This study aimed to examine use of electronic assistive technology for social networking by people with disability living in shared supported accommodation (SSA), and compare participants’ Electronic Social Networking (ESN) integration with Australian ESN normative data.

Method: Telephone surveys and the ESN subscale of the Community Integration Questionnaire-Revised (CIQ-R) were administered with SSA managers. Surveys gathered demographic data, and data on Internet access, technology use and ESN integration, of 91 people with disability who were identified technology users and living in SSA. Participant ESN data were then matched with existing CIQ-R ESN normative data (N?=?359). Relative risk of reduced ESN integration was calculated.

Results: This study identified that, despite access to mainstream technologies, people with disability living in SSA experience low ESN integration, and use ESN for social contact less than other Australians. This group were 210% more likely to report reduced ESN integration than the matched normative sample when key demographic variables were held constant.

Conclusions: Factors related to disability, including high care and support needs and greater time spent completing essential activities of daily living (such as personal care), may explain the low electronic social networking integration for people with disability living in SSA identified in this study. Further research that examines factors that influence ESN access and use following disability is necessary to inform practice to bridge the digital divide that exists between this group and other Australians.     

The International Society of Physical and Rehabilitation Medicine (ISPRM)

Purpose:?To estimate Disability-Free Life Expectancy (DFLE) among a cohort of 3005 Italians aged 65?–?84 and evaluate geographical differences.

Method:?Sullivan method was used to estimate DFLE based on the Performance Test (PPTs), Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs); furthermore, a hierarchical scale of disability was defined to evaluate the pattern of DFLE and geographical differences.

Results:?Men aged 65?–?69 will live 67% of their remaining life free of PPTs disability, 77% free of IADLs and 83% free of ADLs disability. Women aged 65?–?69 will live 44, 63 and 76%, respectively. In the hierarchical structure, mild DFLE for subjects aged 65?–?69, was of 12.8 years for both sexes; moderate DFLE was of 13.4 and 14.2 years and severe DFLE was of 13.5 and 15.3 years, for men and women, respectively. People living in Central Italy are those with the highest number of years lived free of mild disability; people living in Northern Italy are instead those expected to live more years free of moderate and severe disability.

Conclusions:?The hierarchical approach showed that women tend to live more years with some level of disability than men, although the moderate and severe disability occur almost simultaneously among men.     

Levels of ability and functioning: using the WHODAS II in an Irish context

Purpose:?During pilot implementation of the National Physical and Sensory Disability Database in the Republic of Ireland, data were collected that allowed activity limitations and participation restrictions experienced by adults with physical or sensory disability to be assessed. This research will explore the relationships between socio-demographic variables, causes of disability and the domains of ability and functioning of the WHO Disability Assessment Schedule II (i.e., understanding and communication, getting around, self-care, getting along with people, life activities and participation in society).

Method:?1304 people with a physical/sensory disability, less than 66 years of age and receiving or needing a specialised health and personal social service completed the WHODAS II.

Results:?’Life Activities', ‘Getting around’ and ‘Participation in Society’ were the domains where there was greatest difficulty, as experienced by the complete sample. Females experienced greater difficulty in ‘getting around’ and ‘life activities’ than males. Furthermore, an increase in age was associated with an increase in the difficulty of getting around and undertaking life activities and less difficulty in getting along with people. There was also a significant difference in each domain on diagnostic category. Interestingly, a high level of difficulty in ‘Participation in Society’ was recorded for each of the diagnostic categories.

Conclusions:?Further research is required to explore the variability in levels of ability and functioning. This type of research could also be used as a baseline to measure changes over time. Finally, it is important not to become complacent about the ongoing efforts towards inclusiveness and greater participation.     

Recovery from disability after stroke as a target for a behavioural intervention: Results of a randomized controlled trial

Purpose. Disability following stroke is highly prevalent and is predicted by psychological variables such as control cognitions and emotions, in addition to clinical variables. This study evaluated the effectiveness of a workbook-based intervention, designed to change cognitions about control, in improving outcomes for patients and their carers.

Method. At discharge, stroke patients were randomly allocated (with their carers) to a 5-week intervention (n = 103) or control (normal care: n = 100). The main outcome (at 6 months) was recovery from disability using a performance measure, with distress and satisfaction as additional outcomes.

Results. The intervention group showed significantly better disability recovery, allowing for initial levels of disability, than those in the control group, F(1,201) = 5.61, p = 0.019. Groups did not differ in distress or satisfaction with care for patients or carers. The only psychological process variable improved by the intervention was Confidence in Recovery but this did not mediate the effects on recovery.

Conclusions. A large proportion of intervention participants did not complete the workbook tasks. This was perhaps associated with the fairly low level of personal contact with workbook providers. The modest success of this intervention suggests that it may be possible to develop effective behavioural interventions to enhance recovery from disability in stroke patients.     

The relationship between pain,disability, quality of life and cognitive-behavioural factors in chronic back pain

Purpose: This pilot study systematically examined the correlations between the outcome variables pain intensity, disability and health-related quality of life (HRQOL) and between these outcomes and known psychological risk factors for chronic low back pain (CLBP), such as depression, trait anxiety, avoidance- and endurance-related pain responses at two different assessment points. Method: Data from 52 CLBP inpatients treated in an orthopedic clinic were investigated at two points in time: during the first days after admission and 6 months after the termination of the inpatient treatment. Bivariate relationships between pain intensity, disability, HRQOL and psychological variables were examined with the help of Pearson product moment correlations. Furthermore, the differences that exist between correlations at baseline and follow-up were tested for significance. Results: Significant and large differences were found between the correlations with low correlations at baseline and high correlations at the follow-up. Furthermore, HRQOL showed a positive correlation with endurance-related and a negative correlation with avoidance-related pain responses. Conclusions: Focusing on a systematic comparison of two significant assessment time points in CLBP with an acute exacerbation at baseline, the results of this study underlined the recurrent course of LBP. The results highlight that the assessment time points play an important role in CLBP.

Implications for Rehabilitation

• Low back pain is a major public health problem with high direct and indirect back-pain-related costs.

• Chronic low back pain is a disabling disease which restricts quality of life.

• Psychological factors may have a larger impact on disability and quality of life than pain itself.

• The recurrent course of low back pain highlights the importance of multidisciplinary pain management even during acute exacerbations of pain.

     

Measuring disability with parsimony: evidence for the utility of a single item

Purpose: To provide evidence for the utility of a single item measure designed to quantify disability in the past 30 days.

Method: Australian data from studies comprising a community-dwelling elderly sample (N?=?328) and a sample of chronic osteoarthritis (OA) patients (N?=?119) are reported. Degree of disability was classified as 0?–?30 days, 0 vs. 1 or more days, and 0?–?9 vs. 10 or more days. Associations between disability and a range of demographic, health-related, and psychological variables were assessed.

Results: Participants with OA reported a significantly higher level of disability than participants from the community sample regardless of how disability was classified. Modest levels of association were noted between the number of disability days (0?–?30) and both health and psychological indices in both samples. The three alternative classifications of disability made little difference to the significance of associations. On balance, the comparison of 0?–?9 vs. 10 or more days appeared the more predictive classification of disability.

Conclusions: The performance of the single item measure of disability was generally very satisfactory. Future investigations into the clinical application of the item across a range of patient groups are encouraged.     

Factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture

Purpose: To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture. Method: Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables. Results: Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes. Conclusions: While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.

• Implications for Rehabilitation

• In almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation.

• Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation.

• A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

     

Identifying factors associated with self-rated health according to age at onset of disability

Purpose: Although later-onset disability has been associated with poor self-rated health (SRH), factors mediating differences in SRH related to age at onset of disability remain unclear. The present study was designed to identify the variables explaining poor SRH in later-onset disability. We examined chronic disease and functional status as alternatives to psychosocial adaptation as explanatory variables. Method: Our data were taken from the seventh National Survey for People with Disabilities among Korean individuals ≥18 years of age (n =5311). Results: Those with later-onset disability (onset ages 20–40, 41–64 and ≥65 years) showed higher age-adjusted odds ratios (ORs) for poor SRH compared with those with earlier-onset disability (onset ages 0–19 years). The ORs for poor SRH in individuals with later-onset disability were not substantially changed after adjusting for confounding variables including alternatives to psychosocial adaptation (chronic diseases and functional status) as explanatory variables. Conclusions: Failure to explain poor SRH in later-onset disability with explanatory variables other than psychosocial adaptation indirectly supports the role of psychosocial adaptation in differences in SRH related to age at onset. Because we could not include appropriate measures of psychosocial adaptation, the use of additional instruments should be considered in future studies.

Implications for Rehabilitation

• Poor health-related quality of life (HRQOL) in later-onset disability is not merely due to more prevalent chronic disease and worse functional status.

• Strategies in helping with psychosocial adaptation after disability may be important to promote HRQOL in people with later-onset disability.

     

Socioeconomic status predicts functional disability in patients participating in a back pain trial

Purpose. To investigate whether socioeconomic status in patients with back pain participating in a randomised controlled trial was predictive of functional disability (Roland Disability Questionnaire, RDQ).

Method. Secondary analysis of data (n = 949) from a national primary care trial of physical treatments for back pain (UKBEAM trial) using multilevel modelling. The three indicators were Townsend scores, educational levels and work status.

Results. All indicators were significant predictors of outcome after adjusting for baseline variables. As Townsend scores increased (indicating greater deprivation) RDQ scores (functional disability related to back pain) increased. Lower levels of educational attainment were associated with higher RDQ scores. Those ‘Not in Work’ reported markedly higher levels of RDQ scores which increased over time. There was no evidence that one particular treatment was more suitable for participants of different socioeconomic status.

Conclusions. The findings from this study add to the body of literature which suggests the importance of socioeconomic factors as an influence on health, including resultant disability related to chronic musculoskeletal conditions such as back pain. Work status was particularly dominant in our findings and may suggest that helping patients with back pain back to work where appropriate, is an especially important part of the management process.