Research Report
A Prospective Cohort Study on the Effect of
a Balance Training Program, Including Calf
Muscle Strengthening, in Community-Dwelling
Older Adults
Carol A. Maritz, PT, EdD, GCS; Karin Grävare Silbernagel, PT, ATC, PhD
ABSTRACT
Background: Falls are the number 1 cause of injury, fractures,
and death among the older population. In fact, one-third of
adults older than 60 years will experience 1 or more falls
annually. Factors including inactivity and decreased mobility
are associated with overall declines in strength, balance, and
functional mobility in older adults.
Purpose: The purpose of this study was to evaluate the effect
of a balance training program, including calf muscle strength-
ening, in community-dwelling older adults and to evaluate
how calf muscle strength correlates with risk factors for falls.
Methods: Community-dwelling older adults from a local senior
center were invited to participate in a 5-week (10 sessions),
1-on-1, balance training program, which included calf muscle
strengthening. All the participants were evaluated before and
after the intervention. The outcome measures were static bal-
ance, unilateral heel-rise test, Timed Up and Go test (TUG),
the 30-second Chair Stand Test (30-sCST), and the Activity
Balance Confidence Scale.
Results: Twenty-eight participants (6 males and 22 females)
mean (standard deviation) age of 78 years were included in
the study and completed the baseline evaluation. Eight par-
ticipants did not complete the study. Static balance with eyes
closed, heel rise, TUG, 30-sCST, and the Activity Balance
Confidence Scale improved significantly (P < .05) following
treatment compared with the baseline evaluation. The heel-
rise ability correlated significantly (P < .05) with TUG (r =
−0.484 to −0.528) and 30-sCST (r = 0.501-0.595). Sixty-
three percent of the participants performed 10 reps or less
of the unilateral heel rise on the right side and 60% on the
left side. None of the participants who performed 10 reps or
more of the unilateral heel rise had a high risk of falls based
on the TUG.
Conclusions: A balance training program that includes calf
muscle strengthening performed twice a week for 5 weeks
Department of Physical Therapy, Samson College of
Health Sciences, University of the Sciences, Philadelphia,
Pennsylvania.
The authors have no conflicts of interest.
The study was partially funded by the Genesis CARE grant.
Address correspondence to: Carol A. Maritz, PT, EdD,
GCS, Department of Physical Therapy, Samson College of
Health Sciences, University of the Sciences, 600 S 43rd St,
Philadelphia, PA 19104 (c.maritz@usciences.edu).
Marybeth Brown was the Decision Editor.
DOI: 10.1519/JPT.0000000000000059
Journal of GERIATRIC Physical Therapy
Copyright © 2016 The Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-14-00070_LR 125
resulted in significant improvements in calf muscle strength,
functional performance and balance, as well as a significant
improvement in balance confidence. The results from this
study identify the importance unilateral calf muscle strength
has to falls risk among older adults.
Key Words: aging adults, balance training, calf muscle
strength, falls prevention, single-legged heel rise test
(J Geriatr Phys Ther 2016;39:125-131.)
INTRODUCTION
Falls are the number 1 cause of injury, fractures, and
death among the older population.1 In fact, one-third of
adults older than 60 years will experience 1 or more falls
annually.1,2 Although men and women are both at risk for
falls, women are 2 times more likely to sustain hip frac-
tures, whereas men have a higher mortality rate due to fall-
ing.1 The Centers for Disease Control and Prevention have
estimated that by the year 2020, direct and indirect medical
costs related to falls could reach nearly 54 billion dollars.
Although the cause of falls is often multifactorial, lower
extremity weakness and decreased balance are 2 significant
factors associated with falls in the older population.3,4
Older adults tend to fall while performing mobility tasks
such as walking or moving from sit to stand.5,6 Some older
adults are so fearful of falling that they stop being physi-
cally active whether or not they have actually fallen.7 It is
widely known that this activity limitation is largely due to a
loss of confidence in their ability to perform common func-
tional activities.8 Factors including inactivity and decreased
mobility are associated with overall declines in strength,
balance, and functional capacity in older adults.9-12
The American Geriatric Society and British Geriatric
Society updated their guidelines for treatment to reduce
the risk of falls in 2011.13 Although a multifactorial fall
risk assessment is key to the identification of the indi-
vidual risk factors for falling, exercise programs have been
shown to have significant impact on reducing rate of falls,
improving balance, and decreasing fear of falling.9-12 The
panel recommended that balance, gait, and coordination
training along with resistance training should be part of
each multifactorial intervention, which agrees with current
research studies.7,9-12,14
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 Research Report
The calf muscles (medial and lateral gastrocnemius and
soleus muscles) are important both for stability during
standing and for control and propulsion during walk-
ing.15-18 These muscles are all connected to 1 tendon (the
Achilles tendon) and are the strongest plantar flexors of the
ankle. A study on a group of nursing home residents indi-
cated that residents with a history of falling had approxi-
mately 70% lower strength of the ankle muscles compared
with a control group.16 During reactive stepping the ankle
muscles are activated first before the hip and knee. If ankle
muscle strength is insufficient to control balance, individu-
als adopt hip or stepping strategies. Unfortunately, these
strategies require larger gross movements and displacement
of the center of mass and require higher forces, possibly
leading to further loss of balance and falls.
Another recent study also reported that regular bilat-
eral heel-rise training improved postural control measure-
ments.19 In the clinical setting, bilateral heel-rise training
is utilized but rarely is the older adult population pro-
gressed to perform unilateral heel rise. Unilateral heel-rise
exercise provides a greater load on the calf muscles and is
more challenging on the balance. To date, no studies have
examined the impact of calf strengthening exercises along
with balance training on functional mobility, strength,
and balance in older adults. The purposes of this study
were (1) to evaluate the effect of a balance training pro-
gram, including calf muscle strengthening, on calf muscle
strength, functional mobility, balance, and fear of falling
in community-dwelling older adults; and (2) to evaluate
how calf muscle strength correlates to other falls risk fac-
tors in this group.
We hypothesize that the ability to perform unilateral
heel rise correlates to falls risk, functional performance
tests such as Timed Up and Go (TUG), the 30-second Chair
Rise Test (30-sCST), and balance, and that the addition of
unilateral heel-rise exercise to a general balance exercise
program will cause improvements in calf muscle strength
and endurance, function, balance, and balance confidence.
METHODS
Recruitment
Recruitment of participants took place at a senior center in
Klein Jewish Community Center in Philadelphia. A descrip-
tion of the balance program and information regarding
the study was published in the center’s newsletter for all
members to read. Researchers held an on-site session to
further discuss the balance program and the requirements
of the study. An open question and answer session was
held for participants to inquire more about the study.
The University of the Sciences Institutional Review Board
approved the study.
Study Participants
Twenty-eight community-dwelling older adults (6 males
and 22 females) were recruited from a local senior center.
Inclusion criteria consisted of adults aged 60 years or older
126
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JGPT-D-14-00070_LR 126
and independence with community mobility with or with-
out an assistive device. Participants were excluded if they
were unable to follow directions. Mean age of the partici-
pants was 78.5 years with standard deviation [SD] of 6.2.
Both height (mean 160 cm with SD 9.8) and weight (67 kg
with SD 12.2) were recorded.
Procedure
Prior to beginning the 10 sessions of 1-on-1 balance train-
ing and calf strengthening, all participants completed
pretesting measurements that assessed static and dynamic
balance, calf muscle strength, functional lower extremity
strength and endurance, functional mobility, and fear of
falling. The same measures were completed at the end of
the 10 training sessions. All testing sessions were performed
by the principal investigator and physical therapist students
who underwent 2 formalized training sessions with this
investigator.
Outcome Measures
Balance assessment using the Zeno Electronic Walkway
This system developed by Protokinetics (ZenoMetrics LLC
[Peekskill, NY] and PKMAS software from ProtoKinetics
LLC [Havertown, PA], formerly known as GAITRite®
Msqr)20 consists of 4’ × 4’ mat with 16 pressure sensors
designed to assess static and dynamic balance using tem-
poral and spatial parameters such as velocity and center of
pressure (COP). This system has been shown to have strong
concurrent validity and test-retest reliability.21 The pretest
assessments performed on the Zeno Walkway consisted
of 2 balance activities—(1) static standing with eyes open
in normal stance for 30 seconds, and (2) static standing
with eyes closed in normal stance for 30 seconds. During
the static tests of eyes opened and eyes closed 2 variables
were captured. The COP mean velocity (cm/s) determines
the speed of the sway, during the 30-second collection, and
this data was used for analysis. The COP Y mean velocity
is the speed of the side-to-side sway and the COP X mean
velocity is the speed of the front to back sway, and these
were also used for analysis.
Unilateral heel-rise test
The muscular endurance test is a standing heel-rise test.22
The heel-rise test for endurance is performed on 1 leg at a
time with the participant standing on a box with an incline
of 10°. For balance the participants were allowed to place
the hand, at shoulder height, against the wall. The partici-
pant was instructed to go as high as possible on each heel
rise and was asked to perform as many heel rises as pos-
sible. The test was terminated when the patient stopped or
could not perform a proper heel rise. The height of the heel
rise (the distance moved superiorly by the heel in reference
to the box) had to be a minimum of 2 cm to be counted as
1 repetition. One tester was responsible for guarding, and
the other tester was responsible for counting repetitions,
checking for compensatory movements, and make sure
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each heel rise reached the minimum height of 2 cm. The
numbers of heel rises were used for data analysis. This test
has been shown to have good reliability (intraclass correla-
tion coefficient [ICC] = 0.78-0.84).23,24
Timed Up and Go test
The TUG is a standardized outcome measure used to assess
mobility in older adults.25 The test involves timing partici-
pants while they stand from being seated in a chair, stand
up, walk 3 m, turn around, walk back 3 m, and sit down.
This test was performed 3 times after which the average
of the 3 trials (in seconds) was calculated and used for
analysis. Community-dwelling older adults should be able
to perform the TUG in less than 12 seconds.26 According
to Bohannon,27 for individuals between the ages of 70 to
79 years, the mean age of this study’s participants, should
be able to perform the TUG in 9.2 seconds. The TUG was
originally developed as a clinical measure to assess balance
in older adults, and it has shown to have excellent inter-
and intrarater reliability. The ICC has been reported to be
greater than 0.95.28
The 30-second Chair Stand Test
This test provides insight into a person’s lower body
strength and endurance.29 It links strength findings to the
ability to perform everyday tasks such as climbing stairs,
getting in and out of a vehicle or a bathtub.30 To perform
this test, participants were seated in a chair without arm
rests. The height of the seat was 17 inches from the floor.
They were asked to stand up and sit down as many times
as they could in 30 seconds. The number of times that
they could stand up was then recorded. This test has been
shown to have excellent reliability with an ICC of 0.84 for
males and 0.92 for females.29
The Activity Balance Confidence Scale
The Activities-Specific Balance Confidence Scale (ABCS) is
a 16-item self-report survey assessing the confidence par-
ticipants have in their balance during certain activities.31
The participant rates their confidence on a scale of 0% (no
confidence) to 100% (complete confidence) for each item.
Age, as well as education level, is factored into evaluating
the data from the survey. The less confidence individuals
have, the lower their scores will be on the survey, and they
will have a higher risk for falls. The results also show that
a higher percentage is correlated to being a more mobile,
active, and functional person. This tool has excellent
internal consistency with a Cronbach α of 0.95.32
Interventions
The balance training program was designed by a physical
therapist using current evidence-based programs as a guide
to specifically address the balance (specifically the falls
prevention guidelines from the American Geriatric Society/
British Geriatric Society). The 1-on-1 balance training was
conducted twice weekly for 5 weeks. Each session was led
by a physical therapist student and lasted approximately
30 minutes.
Journal of GERIATRIC Physical Therapy
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JGPT-D-14-00070_LR 127
Research Report
The balance program was designed to be performed
in standing and included 3 levels of difficulty (Figure 1).
Level 1 involved various exercises that challenged static
balance both with and without visual input as well as
lower-level dynamic balance activities such as marching
and walking in circles. Standing strengthening exercises
with upper extremity support were also included in level
1. In level 2, participants progressed with level 1 exercises
by increasing intensity and/or duration of the exercises.
Additional static and dynamic balance exercises were
added including a modified Tai Chi movement (parting
wild horse’s mane) to facilitate dynamic weight shifting.
Finally in level 3, participants were asked to perform
multidirectional stepping exercises with decreasing upper
extremity support, increased lower extremity strengthen-
ing, and dual-task walking. The complexity and speed
of the balance exercises were steadily increased over the
course of the 10 sessions.
The principal investigator held 2 instructional sessions
for all physical therapist students assisting in the balance
training program. Students were given a copy of the pro-
gram prior to the training session and asked to review
prior to the formal instructional session. Each exercise was
reviewed by the principal investigator to ensure correct
performance as well as how to safely progress participants
through the program.
All participants started at level 1 and progressed through
to level 3. The majority of participants were able to fully
progress from 1 level to the next after 3 sessions. A few
participants required upper extremity support during both
static and dynamic balance activities due to fear.
In addition, the program included heel-rise exercises to
improve calf muscle strength and endurance. If the partici-
pants could perform more than 10 unilateral heel rise, they
were encouraged to perform unilateral heel rises otherwise
they performed bilateral heel rise. The number of repeti-
tions were progressively increased with a goal of perform-
ing 3 sets of 10 to 15 repetitions.
Adherence Monitoring
Researchers completed a treatment log after each ses-
sion. The details of each session, participant’s response,
and explanations for any missed sessions were recorded.
Exercises and the number of repetitions of each exercise
were documented.
Data Analysis
All data were analyzed using the Statistical Package for
Social Science (IBM Corp, Released 2011, IBM SPSS
Statistics for Macintosh, Version 20.0, Armonk, New York).
Descriptive data are reported as mean (SD). The paired test
was used to compare baseline and postintervention data for
all variables except for the ABCS (ordinal data), which was
compared using the Wilcoxon singed-rank test. The cor-
relation between the heel-rise test and TUG and 30-sCST
was evaluated with the Pearson r, and the Spearman rho
was used for the correlation with ABCS. Participants were
classified as high and low risks for falls based on the TUG.
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Figure 1. Balance training program.

Participants who took 12 seconds or more to complete
the TUG were considered as having a high risk for falls.2
Statistical significance was set at P < .006, and a Bonferroni
correction for multiple hypothesis test was used (0.05/8).
was found. One subject did not perform the baseline heel-
rise data due to fear of stepping up onto the testing box.
In static balance measurements, there were signifi-
cant changes in balance with eyes closed but not with
eyes opened (Table 2). Heel rise, TUG, 30-sCST, and

RESULTS Table 1. Pretest Data of the 8 Subjects Lost to Attrition

Of the 20 participants, 18 completed all 10 sessions with
Variable Mean (SD)
the other 2 having completed a total of 9 sessions (mean
of 9.95 sessions). Two participants participated in the Heel-rise right, number 11 (8.7)
pretest only. One subject attended 1 training session, Heel-rise left, number 8 (6.9)
whereas 5 participants attended 6 to 8 sessions. None of TUG, s 10.7 (3)
the 6 participants returned the postintervention evaluation
30-sCST, s 12 (4.5)
(Table 1). It is unclear why participants dropped out of the
study; however, there were no adverse events noted. No ABCS 61 (21)
significant difference (P > .05) between the participants Abbreviations: 30-sCST, the 30-second Chair Stand Test; ABCS, the Activity Balance Confi-
dence Scale; TUG, Timed Up and Go test; SD, standard deviation.
lost to attrition and those who completed the intervention
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Table 2. Comparison Between Baseline and Postintervention for Table 4. Correlations Between Heel-Rise Performance and
Static Balance (n = 20) Mobility Tests Pre/Post Intervention
Pretest Posttest Pre-Post Heel Rise Timed Up and Go 30-S Chair Stand
Variable Mean (SD) Mean (SD) Comparison
Right −0.528a/−0.484b 0.595a/0.580a
Balance eyes open
Left −0.504a/−0.527b 0.505a/0.501b
COP mean velocity 1.57 (0.47) 1.77 (0.76) P = .181
aSignificant at P < .01; bsignificant at P < .05.
COP mean velocity X 1.00 (0.34) 1.14 (0.46) P = .088
COP mean velocity Y 1.02 (0.29) 1.13 (0.56) P = .358
Balance eyes closed functional performance and balance, as well as a significant
COP mean velocity 1.70 (0.87) 2.11 (1.07) P = .033 improvement in balance confidence. None of the partici-
pants who were able to perform 10 or more unilateral heel
COP mean velocity X 1.15 (0.62) 1.51 (0.77) P = .016 rises were at high risks for falls based on the TUG. This
COP mean velocity Y 1.03 (0.51) 1.19 (0.65) P = .136 suggest that unilateral heel-rise ability is of importance for
Abbreviation: COP, center of pressure; SD, standard deviation. function in community-dwelling older adults.
The norm for TUG in individuals between the age of 70
and 79 years has been reported to be within 9.2 seconds.27
ABCS improved significantly following the intervention The participants in this study had a mean age of 78.5 years
(Table 3). and a mean TUG score of greater than 9.2 seconds on the
The heel-rise ability correlated significantly with the 2 pretest. A significant improvement was noted following
functional tests, TUG and 30-sCST (Table 4), but not with the intervention as the mean score moved closer to the
balance confidence (ABCS) or the static balance measures. normative value. This suggests that the training program is
Of the 27 participants who performed the unilateral achieving its goals and is of relevance even though it was
heel rise at baseline, 63% (17 out of 27) of the participants only 5 weeks in duration.
performed 10 reps or less of the unilateral heel rise on the Measuring the number of times an individual can
right side and 60% (16 out of 27) on the left side (Table 5).
move from sit to stand, the 30-sCST, can predict risk of
None of the participants who performed more than 10 reps
falling in higher-risk older adults.29 Those who perform
of the unilateral heel rise had a high risk of falls based on the
the test should be able to achieve more than the cutoff
TUG (Table 5). We also found that the majority of the par-
score for their age group. For women between the ages
ticipants who performed the TUG slower than the average
speed (9.5 seconds) for the age group were not able to per- of 75 and 79 years, they should be able to complete 10
form more than 10 reps of the unilateral heel rise (Table 5). to 15 rises. For men in this same age group, 11 to 17
rises are considered normal. The participants in this
study demonstrated improvement in the number of rises
DISCUSSION from pre- to posttesting. Of interest is that there was a
The findings of this study indicate that community-
significant correlation between the participants’ ability
dwelling older adults’ calf muscle strength, as measured
to perform heel rise and the 30-sCST suggesting that calf
with the unilateral heel-rise test, is considerably less than
what has been described as normal (20-25 repetitions).33
Heel-rise performance also correlated moderately with
functional performance measures such as the TUG and
30-sCST. A balance training program that includes calf Table 5. Comparison Between Performance on TUG and Single-
muscle strengthening performed twice a week for 5 weeks Legged Heel-Rise Ability (Based on the Baseline Evaluation)
resulted in significant improvements in calf muscle strength, Number of Right Leg Heel Rise (n) Left Leg Heel Rise (n)
Subjects in Each
Group ≤10 Reps >10 Reps ≤10 Reps >10 Reps
Table 3. Comparison Between Baseline and Postintervention
TUG high risk
Variable, Pretest Mean Posttest Mean Pre-Post 5 0 5 0
(≥12 s)
n = 19 (SD) (SD) Comparison
TUG low risk
Heel-rise right 9 (8.3) 16 (8.2) P < .001 (<12 s)
12 10 11 11

Heel-rise left 9 (6.3) 17 (8.0) P < .001 TUG slower than

TUG 10.2 (2) 9.5 (1.8) P = .046 age average 13 4 14 3
(≥9.5 s)
30-sCST 10 (3.2) 11.9 (3.4) P = .003
TUG faster than
ABCS 69 (16) 78 (12) P = .003 age average 4 6 2 8
(<9.5 s)
Abbreviations: ABCS, the Activity Balance Confidence Scale; 30-sCST, the 30-Second Chair
Stand Test; TUG, Timed Up and Go test; SD, standard deviation. Abbreviation: TUG, Timed Up and Go test.

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 Research Report
muscle strength is of importance for this functional task.
Part of the improvement seen in 30-sCST can possibly be
attributed to calf muscle strength, but this relationship
needs to be further investigated. At the end of the study
the mean scores were still slightly lower than the age-
related normative values, which may have more to do
with ongoing quadriceps weakness that was not remedi-
ated through this protocol.
Participation in the balance-training program had a posi-
tive effect on their confidence performing normal everyday
activities as shown through a significant increase on the
ABCS. One explanation for the improvement in confidence
may be due to the 1-on-1 nature of the training program.
Having the opportunity to have individualized instruction
and attention could have fostered an improved level of
self-efficacy leading to a willingness to try more challeng-
ing exercises. In addition, the ABCS is more closely linked
to physical functioning, which may also explain the results
seen in this study.32
Although the participants did not show any significant
changes in their static standing balance with their eyes
opened, they did with eyes closed. In this study, the par-
ticipants had an increase in the mean COP velocity. One
reason for the increase in mean COP velocity following
the training may have to do with a decrease in muscle
co-contraction and an increase in overall confidence
allowing for more sway. This reduction in co-contraction
of muscles allows the older individual to more readily
respond to changes in COP. In the literature, there are 2
postural movement strategies described for maintaining
balance, the ankle and the hip strategies.34 The improve-
ment in calf muscle strength might have made it easier for
the participants to use the ankle strategy for maintaining
the balance. Of interest is that the mean COP X velocity
that measures the front to back movement improved sig-
nificantly but not the mean COP Y velocity that measured
the side-to-side movement, which again might indicate
that the improvement in calf muscle strength was related
to these changes. Since the calf muscle is important for
propulsion during gait and during reactive stepping the
ankle muscles are recruited first. We propose that future
studies evaluate the correlation between both forward
and backward gait and calf muscle strength instead of just
static balance.
Plantar flexion strength is often measured with the
unilateral heel rise, and performing 20 to 25 repetitions is
considered normal. However, this ability is affected by age,
and it has been reported that in a group of 61- to 80-year-
old individuals the mean is 3 to 4 repetitions.35 Since calf
muscle strength is important for stability during standing
and significant weakness has been reported in nursing
home residents who had a history of falling, it seems of
great importance to encourage calf muscle strengthening in
the older adult. In this study, we were able to significantly
improve the calf muscle strength in just 5 weeks by just
encouraging the participants to perform unilateral heel rise.
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JGPT-D-14-00070_LR 130
Of interest was that many of the participants described
a fear of performing the unilateral heel rise and also had
difficulty performing these during the initial evaluation.
If the change in measured heel-rise ability is solely due to
increased muscle mass is questionable. Other factors such
as improved neuromuscular adaptation and decreased fear
of performing the test might also have been attributing to
the improvement. In summary, unilateral heel-rise exercise
can be recommended as part of a balance exercise program
for older adults.
As described in the literature and supported by the cur-
rent results, it seems that performing 20 to 25 unilateral
heel rises is too high of a level for considering normal
strength in the older population. The question remains,
however, what is normal strength and what should be
considered the minimal safe strength level of the calf
muscles to avoid an increase risk for falls. In this study,
we explored this question. Community-dwelling older
adults who require more than 12 seconds to complete
the TUG said to be at risk for falls.26 In this study, the
heel-rise ability was compared between the participants
with high and low risk for falls, and it was reported that
none of the participants who performed 10 or more heel
rises was in the high risk for falls group. It is not known
that if 10 repetitions for a unilateral heel rise should be
considered the minimal safe level or not, and it needs to be
investigated in future studies. However, we feel it is safe to
say that clinically it should be encouraged to have healthy
older adults strive for being able to perform at least 10
unilateral heel rises.
This study has several limitations that need to be
considered when interpreting the results. This was a
nonrandomized study with a fairly small sample size.
It is therefore not possible to determine how much of
the improvements seen were from the exercise pro-
gram or just as an effect of the testing. However, there
were significant improvements in all the measured
parameters in a short period of time, which can be
considered of great importance for this population.
Further studies are needed to determine whether these
benefits remain long term after ending the intervention
and to see if there are any changes in the occurrence
of falls. This study also included only healthy older
community-dwelling adults, and future studies need
to evaluate the importance of calf muscle strength in
other populations.
CONCLUSIONS
A balance training program that includes calf muscle
strengthening performed twice a week for 5 weeks resulted
in significant improvements in calf muscle strength, func-
tional performance and balance, as well as a significant
improvement in balance confidence. The results from
this study identify the importance unilateral calf muscle
strength has to falls risk among older adults. It is therefore
critical for physical therapist to both test and train their
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10/06/16 4:39 AM

older patients in unilateral heel-rise exercises when screen-
ing and performing falls prevention programs.
ACKNOWLEDGMENTS
We thank the Klein Jewish Community Center for their
partnership in this study. We also thank the students from
the University of the Sciences for assisting with this study.
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