human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE A subset of fibromyalgia ( FM ) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 ( IGF-1 ) axis , as evidence d by low serum levels of IGF-1 and a reduced growth hormone ( GH ) response to physiologic stimuli . There is evidence that pyridostigmine ( PYD ) improves the acute response of GH to exercise in FM patients . The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms . METHODS FM patients were r and omized to 1 of the following 4 groups : PYD plus exercise , PYD plus diet recall but no exercise , placebo plus exercise , and placebo plus diet recall but no exercise . The primary outcome measures were the visual analog scale ( VAS ) score for pain , tender point count , and total myalgic score . Secondary outcome measures were the total score on the Fibromyalgia Impact Question naire ( FIQ ) and FIQ VAS scores for individual symptoms ( fatigue , poor sleep , stiffness , and anxiety ) , as well as quality of life ( QOL ) and physical fitness ( lower body strength/endurance , upper and lower body flexibility , balance , and time on the treadmill ) . RESULTS A total of 165 FM patients completed baseline measurements ; 154 ( 93.3 % ) completed the study . The combination of PYD and exercise did not improve pain scores .  PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups . Compared with the nonexercise groups , the 2 exercise groups demonstrated improvement in fatigue and fitness .  PYD was generally well tolerated . CONCLUSION Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms . However , PYD did improve anxiety and sleep , and exercise improved fatigue and fitness . We speculate that PYD may have improved vagal tone , thus benefiting sleep and anxiety ; this notion warrants further study Background : The presence and severity of the chronic pain syndrome fibromyalgia ( FM ) is associated with unresolved stress and emotional regulation difficulties . Written emotional disclosure is intended to reduce stress and may improve health of people with FM . Purpose : This study tests the effects of at-home , written emotional disclosure about stressful experiences on the health of people with FM and uses multiple follow-ups to track the time course of effects of disclosure . Methods : Adults with FM ( intention-to-treat , n = 83 ; completers , n = 72 ) were r and omized to write for 4 days at home about either stressful experiences ( disclosure group ) or neutral time management ( control group ) . Group differences in immediate mood effects and changes in health from baseline to 1-month and 3-month follow-ups were examined . Results : Written disclosure led to an immediate increase in negative mood , which did not attenuate across the 4 writing days . Repeated- measures analyses from baseline to each follow-up point were conducted on both intention-to-treat and completer sample s , which showed similar outcomes . At 1 month , disclosure led to few health benefits , but control writing led to less negative affect and more perceived support than did disclosure . At 3-month follow-up , these negative affect and social support effects disappeared , and written disclosure led to a greater reduction in global impact , poor sleep , health care utilization , and ( marginally ) physical disability than did control writing . Interpretation of these apparent benefits needs to be made cautiously , however , because the disclosure group had somewhat poorer health than controls at baseline and the control group showed some minor worsening over time . Conclusions : Written emotional disclosure can be conducted at home , and there is tentative evidence that disclosure benefits the health of people with FM . The benefits , however , may be delayed for several months after writing and may be of limited clinical significance Background The effectiveness of eHealth interventions in terms of reach and outcomes is now well documented . However , there is a need to underst and not only whether eHealth interventions work , but also what kind of functions and mechanisms enhance their effectiveness . The present investigation contributes to tackling these challenges by investigating the role played by functional interactivity on patients ’ knowledge , empowerment , and health outcomes . Objectives To test whether health knowledge and empowerment mediate a possible relationship between the availability of interactive features on an eHealth application and individuals ’ health outcomes . We present an empirical , model-driven evaluation of the effects of functional interactivity implemented in an eHealth application , based on a brief theoretical review of the constructs of interactivity , health knowledge , empowerment , and health outcomes . We merged these constructs into a theoretical model of interactivity effects that we tested on an eHealth application for patients with fibromyalgia syndrome ( FMS ) . Methods This study used a pretest – posttest experimental design . We recruited 165 patients and r and omly assigned them to three study groups , corresponding to different levels of functional interactivity .  Eligibility to participate in the study required that patients ( 1 ) be fluent in Italian , ( 2 ) have access to the Internet , ( 3 ) report confidence in how to use a computer , and ( 4 ) have received a diagnosis of FMS from a doctor . We used structural equation modeling techniques to analyze changes between the pretest and the posttest results . Results The main finding was that functional interactivity had no impact on empowerment dimensions , nor direct observable effects on knowledge . However , knowledge positively affected health outcomes ( b = –.12 , P = .02 ) , as did the empowerment dimensions of meaning ( b = –.49 , P < .001 ) and impact ( b = –.25 , P < .001 ) . Conclusion The theoretical model was partially confirmed , but only as far as the effects of knowledge and empowerment were concerned . The differential effect of interactive functions was by far weaker than expected . The strong impact of knowledge and empowerment on health outcomes suggests that these constructs should be targeted and enhanced by eHealth applications UNLABELLED Altan L , Korkmaz N , Bingol U , Gunay B. Effect of Pilates training on people with fibromyalgia syndrome : a pilot study . OBJECTIVE To investigate the effects of Pilates on pain , functional status , and quality of life in fibromyalgia , which is known to be a chronic musculoskeletal disorder . DESIGN R and omized , prospect i ve , controlled , and single-blind trial . SETTING Physical medicine and rehabilitation department . PARTICIPANTS Women ( N=50 ) who had a diagnosis of fibromyalgia syndrome ( FMS ) according to the American College of Rheumatology criteria . INTERVENTION The participants were r and omly assigned into 2 groups . In group 1 , a Pilates exercise program of 1 hour was given by a certified trainer to 25 participants 3 times a week for 12 weeks . In group 2 , which was design ed as the control group , 25 participants were given a home exercise ( relaxation/stretching ) program . In both groups , pre- ( week 0 ) and posttreatment ( week 12 and week 24 ) evaluation was performed by one of the authors , who was blind to the group allocation . MAIN OUTCOME MEASURES Primary outcome measures were pain ( visual analog scale ) and Fibromyalgia Impact Question naire ( FIQ ) . Exploratory outcome measures were number of tender points , algometric score , chair test , and Nottingham Health Profile . RESULTS Twenty-five Pilates exercise and 24 relaxation/stretching exercise  participants completed the study . In group 1 , significant improvement was observed in both pain and FIQ at week 12 but only in FIQ at 24 weeks . In group 2 , no significant improvement was obtained in pain and FIQ at week 12 and week 24 . Comparison of the 2 groups showed significantly superior improvement in pain and FIQ in group 1 at week 12 but no difference between the 2 groups at week 24 . CONCLUSIONS We suggest Pilates as an effective and safe method for people with FMS . Our study is the first clinical study design ed to investigate the role of the Pilates method in FMS treatment . We believe that further research with more participants and longer follow-up periods could help assess the therapeutic value of this popular physical exercise method BACKGROUND AND OBJECTIVE Affect and how it is regulated plays a role in pain perception , maintenance of pain , and its resolution . This r and omized , controlled trial evaluated an innovative affective self-awareness ( ASA ) intervention , which was design ed to reduce pain and improve functioning in individuals with fibromyalgia . PARTICIPANTS AND METHODS Forty-five women with fibromyalgia were r and omized to a  manualized ASA intervention ( n = 24 ) or wait-list control ( n = 21 ) . The intervention began with a one-time physician consultation , followed by 3 weekly , 2-h group sessions based upon a mind-body model of pain . Sessions focused on structured written emotional disclosure and emotional awareness exercises . Outcomes in both conditions were measured by a blinded assessor at baseline , post-intervention , and 6-month follow-up . MEASURES The primary outcome was pain severity ( Brief Pain Inventory ) ; secondary outcomes included tender-point threshold and physical function ( SF-36 Physical Component Summary ) . Intent-to-treat analyses compared groups on outcomes using analysis of covariance and on the proportion of patients achieving ≥30 % and ≥50 % pain reduction at 6 months . RESULTS Adjusting for baseline scores , the intervention group had significantly lower pain severity ( p < 0.001 ) , higher self-reported physical function ( p < 0.001 ) , and higher tender-point threshold ( p = 0.02 ) at 6 months compared to the control group . From baseline to 6 months , 45.8 % of the ASA intervention group had ≥30 % reduction in pain severity , compared to none of the controls ( p < 0.001 ) . CONCLUSIONS The affective self-awareness  intervention improved pain , tenderness , and self-reported physical function for at least 6 months in women with fibromyalgia compared to wait-list control . This study suggests the value of interventions targeting emotional processes in fibromyalgia , although further studies should evaluate the efficacy of this intervention relative to active controls Introduction The objective of this study was to investigate the effects of moderate-to-high intensity Nordic walking ( NW ) on functional capacity and pain in fibromyalgia ( FM ) . Methods A total of 67 women with FM were recruited to the study and r and omized either to moderate-to-high intensity Nordic Walking ( n = 34 , age 48 ± 7.8 years ) or to a control group engaging in supervised low-intensity walking ( LIW , n = 33 , age 50 ± 7.6 years ) . Primary outcomes were the six-minute walk test ( 6MWT ) and the Fibromyalgia Impact Question naire Pain scale ( FIQ Pain ) . Secondary outcomes were : exercise heart rate in a submaximal ergometer bicycle test , the FIQ Physical ( activity limitations ) and the FIQ total score . Results A total of 58 patients completed the post-test . Significantly greater improvement in the 6MWT was found in the NW group ( P = 0.009 ) , as compared with the LIW group . No between-group difference was found for the FIQ Pain ( P = 0.626 ) . A significantly larger decrease in exercise heart rate ( P = 0.020 ) and significantly improved scores on the FIQ Physical ( P = 0.027 ) were found in the NW group as compared with the LIW group . No between-group difference was found for the change in the FIQ total . The effect sizes were moderate for the above mentioned outcomes . Conclusions Moderate-to-high intensity aerobic exercise by means of Nordic walking twice a week for 15 weeks was found to be a feasible mode of exercise , result ing in improved functional capacity and a decreased level of activity limitations . Pain severity did not change over time during the exercise period . Trial registration Clinical trials.gov identifier NCT00643006 Previous research ers have found that 10-form Tai chi yields symptomatic benefit in patients with fibromyalgia ( FM ) . The purpose of this study was to further investigate earlier findings and add a focus on functional mobility . We conducted a parallel-group r and omized controlled trial FM-modified 8-form Yang-style Tai chi program compared to an education control . Participants met in small groups twice weekly for 90 min over 12 weeks . The primary endpoint was symptom reduction and improvement in self-report physical function , as measured by the Fibromyalgia Impact Question naire ( FIQ ) , from baseline to 12 weeks . Secondary endpoints included pain severity and interference ( Brief Pain Inventory ( BPI ) , sleep ( Pittsburg sleep Inventory ) , self-efficacy , and functional mobility . Of the 101 r and omly assigned subjects ( mean age 54 years , 93 % female ) , those in the Tai chi condition compared with the education condition demonstrated clinical ly and statistically significant improvements in FIQ scores ( 16.5 vs. 3.1 , p = 0.0002 ) , BPI pain severity ( 1.2 vs. 0.4 , p = 0.0008 ) , BPI pain interference ( 2.1 vs. 0.6 , p = 0.0000 ) , sleep ( 2.0 vs. −0.03 , p = 0.0003 ) , and self-efficacy for pain control ( 9.2 vs. −1.5 , p = 0.0001 ) . Functional mobility variables including timed get up and go ( −.9 vs. −.3 , p = 0.0001 ) , static balance ( 7.5 vs. −0.3 , p = 0.0001 ) , and dynamic balance ( 1.6 vs. 0.3 , p = 0.0001 ) were significantly improved with Tai chi compared with education control . No adverse events were noted . Twelve weeks of Tai chi , practice twice weekly , provided worthwhile 
    Output:
    
agent
Strong evidence was found for interventions categorized for this review as  cognitive – behavioral interventions ; relaxation and stress management ; emotional disclosure ; physical activity ;  and  multidisciplinary interventions for improving daily living , pain , depressive symptoms , and fatigue .
There was limited to no evidence for self-management , and few interventions result ed in better sleep .
Although the evidence supports interventions within the scope of occupational therapy practice for people with fibromyalgia , few interventions were occupation based
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE A subset of fibromyalgia ( FM ) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 ( IGF-1 ) axis , as evidence d by low serum levels of IGF-1 and a reduced growth hormone ( GH ) response to physiologic stimuli . There is evidence that pyridostigmine ( PYD ) improves the acute response of GH to exercise in FM patients . The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms . METHODS FM patients were r and omized to 1 of the following 4 groups : PYD plus exercise , PYD plus diet recall but no exercise , placebo plus exercise , and placebo plus diet recall but no exercise . The primary outcome measures were the visual analog scale ( VAS ) score for pain , tender point count , and total myalgic score . Secondary outcome measures were the total score on the Fibromyalgia Impact Question naire ( FIQ ) and FIQ VAS scores for individual symptoms ( fatigue , poor sleep , stiffness , and anxiety ) , as well as quality of life ( QOL ) and physical fitness ( lower body strength/endurance , upper and lower body flexibility , balance , and time on the treadmill ) . RESULTS A total of 165 FM patients completed baseline measurements ; 154 ( 93.3 % ) completed the study . The combination of PYD and exercise did not improve pain scores .  PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups . Compared with the nonexercise groups , the 2 exercise groups demonstrated improvement in fatigue and fitness .  PYD was generally well tolerated . CONCLUSION Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms . However , PYD did improve anxiety and sleep , and exercise improved fatigue and fitness . We speculate that PYD may have improved vagal tone , thus benefiting sleep and anxiety ; this notion warrants further study Background : The presence and severity of the chronic pain syndrome fibromyalgia ( FM ) is associated with unresolved stress and emotional regulation difficulties . Written emotional disclosure is intended to reduce stress and may improve health of people with FM . Purpose : This study tests the effects of at-home , written emotional disclosure about stressful experiences on the health of people with FM and uses multiple follow-ups to track the time course of effects of disclosure . Methods : Adults with FM ( intention-to-treat , n = 83 ; completers , n = 72 ) were r and omized to write for 4 days at home about either stressful experiences ( disclosure group ) or neutral time management ( control group ) . Group differences in immediate mood effects and changes in health from baseline to 1-month and 3-month follow-ups were examined . Results : Written disclosure led to an immediate increase in negative mood , which did not attenuate across the 4 writing days . Repeated- measures analyses from baseline to each follow-up point were conducted on both intention-to-treat and completer sample s , which showed similar outcomes . At 1 month , disclosure led to few health benefits , but control writing led to less negative affect and more perceived support than did disclosure . At 3-month follow-up , these negative affect and social support effects disappeared , and written disclosure led to a greater reduction in global impact , poor sleep , health care utilization , and ( marginally ) physical disability than did control writing . Interpretation of these apparent benefits needs to be made cautiously , however , because the disclosure group had somewhat poorer health than controls at baseline and the control group showed some minor worsening over time . Conclusions : Written emotional disclosure can be conducted at home , and there is tentative evidence that disclosure benefits the health of people with FM . The benefits , however , may be delayed for several months after writing and may be of limited clinical significance Background The effectiveness of eHealth interventions in terms of reach and outcomes is now well documented . However , there is a need to underst and not only whether eHealth interventions work , but also what kind of functions and mechanisms enhance their effectiveness . The present investigation contributes to tackling these challenges by investigating the role played by functional interactivity on patients ’ knowledge , empowerment , and health outcomes . Objectives To test whether health knowledge and empowerment mediate a possible relationship between the availability of interactive features on an eHealth application and individuals ’ health outcomes . We present an empirical , model-driven evaluation of the effects of functional interactivity implemented in an eHealth application , based on a brief theoretical review of the constructs of interactivity , health knowledge , empowerment , and health outcomes . We merged these constructs into a theoretical model of interactivity effects that we tested on an eHealth application for patients with fibromyalgia syndrome ( FMS ) . Methods This study used a pretest – posttest experimental design . We recruited 165 patients and r and omly assigned them to three study groups , corresponding to different levels of functional interactivity .  Eligibility to participate in the study required that patients ( 1 ) be fluent in Italian , ( 2 ) have access to the Internet , ( 3 ) report confidence in how to use a computer , and ( 4 ) have received a diagnosis of FMS from a doctor . We used structural equation modeling techniques to analyze changes between the pretest and the posttest results . Results The main finding was that functional interactivity had no impact on empowerment dimensions , nor direct observable effects on knowledge . However , knowledge positively affected health outcomes ( b = –.12 , P = .02 ) , as did the empowerment dimensions of meaning ( b = –.49 , P < .001 ) and impact ( b = –.25 , P < .001 ) . Conclusion The theoretical model was partially confirmed , but only as far as the effects of knowledge and empowerment were concerned . The differential effect of interactive functions was by far weaker than expected . The strong impact of knowledge and empowerment on health outcomes suggests that these constructs should be targeted and enhanced by eHealth applications UNLABELLED Altan L , Korkmaz N , Bingol U , Gunay B. Effect of Pilates training on people with fibromyalgia syndrome : a pilot study . OBJECTIVE To investigate the effects of Pilates on pain , functional status , and quality of life in fibromyalgia , which is known to be a chronic musculoskeletal disorder . DESIGN R and omized , prospect i ve , controlled , and single-blind trial . SETTING Physical medicine and rehabilitation department . PARTICIPANTS Women ( N=50 ) who had a diagnosis of fibromyalgia syndrome ( FMS ) according to the American College of Rheumatology criteria . INTERVENTION The participants were r and omly assigned into 2 groups . In group 1 , a Pilates exercise program of 1 hour was given by a certified trainer to 25 participants 3 times a week for 12 weeks . In group 2 , which was design ed as the control group , 25 participants were given a home exercise ( relaxation/stretching ) program . In both groups , pre- ( week 0 ) and posttreatment ( week 12 and week 24 ) evaluation was performed by one of the authors , who was blind to the group allocation . MAIN OUTCOME MEASURES Primary outcome measures were pain ( visual analog scale ) and Fibromyalgia Impact Question naire ( FIQ ) . Exploratory outcome measures were number of tender points , algometric score , chair test , and Nottingham Health Profile . RESULTS Twenty-five Pilates exercise and 24 relaxation/stretching exercise  participants completed the study . In group 1 , significant improvement was observed in both pain and FIQ at week 12 but only in FIQ at 24 weeks . In group 2 , no significant improvement was obtained in pain and FIQ at week 12 and week 24 . Comparison of the 2 groups showed significantly superior improvement in pain and FIQ in group 1 at week 12 but no difference between the 2 groups at week 24 . CONCLUSIONS We suggest Pilates as an effective and safe method for people with FMS . Our study is the first clinical study design ed to investigate the role of the Pilates method in FMS treatment . We believe that further research with more participants and longer follow-up periods could help assess the therapeutic value of this popular physical exercise method BACKGROUND AND OBJECTIVE Affect and how it is regulated plays a role in pain perception , maintenance of pain , and its resolution . This r and omized , controlled trial evaluated an innovative affective self-awareness ( ASA ) intervention , which was design ed to reduce pain and improve functioning in individuals with fibromyalgia . PARTICIPANTS AND METHODS Forty-five women with fibromyalgia were r and omized to a  manualized ASA intervention ( n = 24 ) or wait-list control ( n = 21 ) . The intervention began with a one-time physician consultation , followed by 3 weekly , 2-h group sessions based upon a mind-body model of pain . Sessions focused on structured written emotional disclosure and emotional awareness exercises . Outcomes in both conditions were measured by a blinded assessor at baseline , post-intervention , and 6-month follow-up . MEASURES The primary outcome was pain severity ( Brief Pain Inventory ) ; secondary outcomes included tender-point threshold and physical function ( SF-36 Physical Component Summary ) . Intent-to-treat analyses compared groups on outcomes using analysis of covariance and on the proportion of patients achieving ≥30 % and ≥50 % pain reduction at 6 months . RESULTS Adjusting for baseline scores , the intervention group had significantly lower pain severity ( p < 0.001 ) , higher self-reported physical function ( p < 0.001 ) , and higher tender-point threshold ( p = 0.02 ) at 6 months compared to the control group . From baseline to 6 months , 45.8 % of the ASA intervention group had ≥30 % reduction in pain severity , compared to none of the controls ( p < 0.001 ) . CONCLUSIONS The affective self-awareness  intervention improved pain , tenderness , and self-reported physical function for at least 6 months in women with fibromyalgia compared to wait-list control . This study suggests the value of interventions targeting emotional processes in fibromyalgia , although further studies should evaluate the efficacy of this intervention relative to active controls Introduction The objective of this study was to investigate the effects of moderate-to-high intensity Nordic walking ( NW ) on functional capacity and pain in fibromyalgia ( FM ) . Methods A total of 67 women with FM were recruited to the study and r and omized either to moderate-to-high intensity Nordic Walking ( n = 34 , age 48 ± 7.8 years ) or to a control group engaging in supervised low-intensity walking ( LIW , n = 33 , age 50 ± 7.6 years ) . Primary outcomes were the six-minute walk test ( 6MWT ) and the Fibromyalgia Impact Question naire Pain scale ( FIQ Pain ) . Secondary outcomes were : exercise heart rate in a submaximal ergometer bicycle test , the FIQ Physical ( activity limitations ) and the FIQ total score . Results A total of 58 patients completed the post-test . Significantly greater improvement in the 6MWT was found in the NW group ( P = 0.009 ) , as compared with the LIW group . No between-group difference was found for the FIQ Pain ( P = 0.626 ) . A significantly larger decrease in exercise heart rate ( P = 0.020 ) and significantly improved scores on the FIQ Physical ( P = 0.027 ) were found in the NW group as compared with the LIW group . No between-group difference was found for the change in the FIQ total . The effect sizes were moderate for the above mentioned outcomes . Conclusions Moderate-to-high intensity aerobic exercise by means of Nordic walking twice a week for 15 weeks was found to be a feasible mode of exercise , result ing in improved functional capacity and a decreased level of activity limitations . Pain severity did not change over time during the exercise period . Trial registration Clinical trials.gov identifier NCT00643006 Previous research ers have found that 10-form Tai chi yields symptomatic benefit in patients with fibromyalgia ( FM ) . The purpose of this study was to further investigate earlier findings and add a focus on functional mobility . We conducted a parallel-group r and omized controlled trial FM-modified 8-form Yang-style Tai chi program compared to an education control . Participants met in small groups twice weekly for 90 min over 12 weeks . The primary endpoint was symptom reduction and improvement in self-report physical function , as measured by the Fibromyalgia Impact Question naire ( FIQ ) , from baseline to 12 weeks . Secondary endpoints included pain severity and interference ( Brief Pain Inventory ( BPI ) , sleep ( Pittsburg sleep Inventory ) , self-efficacy , and functional mobility . Of the 101 r and omly assigned subjects ( mean age 54 years , 93 % female ) , those in the Tai chi condition compared with the education condition demonstrated clinical ly and statistically significant improvements in FIQ scores ( 16.5 vs. 3.1 , p = 0.0002 ) , BPI pain severity ( 1.2 vs. 0.4 , p = 0.0008 ) , BPI pain interference ( 2.1 vs. 0.6 , p = 0.0000 ) , sleep ( 2.0 vs. −0.03 , p = 0.0003 ) , and self-efficacy for pain control ( 9.2 vs. −1.5 , p = 0.0001 ) . Functional mobility variables including timed get up and go ( −.9 vs. −.3 , p = 0.0001 ) , static balance ( 7.5 vs. −0.3 , p = 0.0001 ) , and dynamic balance ( 1.6 vs. 0.3 , p = 0.0001 ) were significantly improved with Tai chi compared with education control . No adverse events were noted . Twelve weeks of Tai chi , practice twice weekly , provided worthwhile 
    Output:
    