Supports and barriers to implementation of routine clinical assessment for children with cerebral palsy: a mixed-methods study

Journal article


Kerr, Claire, Shields, Nora, Quarmby, Lyndsay, Roberts, Karen and Imms, Christine 2016. Supports and barriers to implementation of routine clinical assessment for children with cerebral palsy: a mixed-methods study. Disability and Rehabilitation. 40 (4), pp. 425 - 434. https://doi.org/10.1080/09638288.2016.1258736
AuthorsKerr, Claire, Shields, Nora, Quarmby, Lyndsay, Roberts, Karen and Imms, Christine
Abstract

Purpose: The purpose of this study is to investigate supports and barriers to evidence-based routine clinical assessment of children with cerebral palsy.

Method: This mixed methods study included physiotherapists, occupational therapists and speech pathologists providing services to children with cerebral palsy (3–18 years) within five organizations across Australia. Four organizations initiated standardized routine clinical data collection (Commencing organizations), and one had previously mandated routine assessment (Comparison organization). Participants completed the Supports and Barriers Questionnaire (n = 227) and participated in focus groups (n = 8 groups, 37 participants). Quantitative data were summarized descriptively, qualitative data were analyzed thematically and comparisons between organizations assessed.

Results: Organizational structures, resources, therapists within organizations, assessment tools, and children and families were, on average, viewed as supportive of routine clinical assessment. There were no differences between the Comparison and Commencing organizations except ‘therapists within the organization’ were viewed as more supportive by the Commencing organizations (p = 0.037). Five themes were derived from qualitative analyzes: motivation to adopt routine clinical assessment; acquiring and utilizing expertise; ensuring effective ongoing communication; availability and distribution of resources; and therapist perceptions of child and family wishes.

Conclusions: Organizations experience challenges to effective and sustained implementation of routine clinical assessment. Adequate resourcing and positive, clear communication were perceived as critical for success.

Keywordscerebral palsy; routine assessment; implementation
Year2016
JournalDisability and Rehabilitation
Journal citation40 (4), pp. 425 - 434
PublisherTaylor & Francis
ISSN0963-8288
Digital Object Identifier (DOI)https://doi.org/10.1080/09638288.2016.1258736
Scopus EID2-s2.0-85006085557
Open accessOpen access
Page range425 - 434
Research GroupSchool of Allied Health
Author's accepted manuscript
Grant IDNHMRC/1055278
Place of publicationUnited Kingdom
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Kerr, Claire, Salazar-Torres, Jose, McDowell, Brona and Cosgrove, Aidan 2012. Passive Range of Motion in a Population-Based Sample of Children with Spastic Cerebral Palsy Who Walk. Physical & Occupational Therapy in Pediatrics. 32 (2), pp. 139 - 150. https://doi.org/10.3109/01942638.2011.644032
Pelvic kinematics and their relationship to gait type in hemiplegic cerebral palsy
Kerr, Claire, Salazar-Torres, Jose, Cosgrove, Aidan and McDowell, Brona 2011. Pelvic kinematics and their relationship to gait type in hemiplegic cerebral palsy. Gait & Posture. 33 (4), pp. 620 - 624. https://doi.org/10.1016/j.gaitpost.2011.02.004
Hopes and Aspirations for Leisure and Living :Adolescents with Cerebral Palsy Talk about the Future
Cussen, Amy, Imms, Christine and Howie, Linsey 2011. Hopes and Aspirations for Leisure and Living :Adolescents with Cerebral Palsy Talk about the Future. Australian Occupational Therapy Journal. 58 (Suppl s1), pp. 75 - 75. https://doi.org/10.1111/j.1440-1630.2011.00938.x
Linking cerebral palsy upper limb measurements to the international classification of functioning disability and health
Hoare, Brian, Imms, Christine, Randall, Melinda and Carey, Leeanne 2011. Linking cerebral palsy upper limb measurements to the international classification of functioning disability and health. Scandinavian Journal of Rehabilitation Medicine. 43 (11), pp. 987 - 996. https://doi.org/10.2340/16501977-0886
Leisure Participation Patterns of Children in Victoria Australia
Chin, Rachel, McMullen, Sarah, Froude, Elspeth Heather and Imms, Christine 2011. Leisure Participation Patterns of Children in Victoria Australia. Australian Occupational Therapy Journal. 58 (Suppl s1), pp. 101 - 101. https://doi.org/10.1111/j.1440-1630.2011.00938.x
Factors Influencing Children's Readiness to Enter School :Views From Early Childhood Educators
Froude, Elspeth Heather, Imms, Christine, Merrigan, C, Joffe, Beverly, Heine, Chyrisse and Serry, Tanya 2011. Factors Influencing Children's Readiness to Enter School :Views From Early Childhood Educators. Australian Occupational Therapy Journal. 58 (Suppl s1), pp. 23 - 23.
Upper limb function and deformity in cerebral palsy :a review of classification systems
McConnell, Karen, Johnston, Linda and Kerr, Claire 2011. Upper limb function and deformity in cerebral palsy :a review of classification systems. Developmental Medicine and Child Neurology. 53 (9), pp. 799 - 805. https://doi.org/10.1111/j.1469-8749.2011.03953.x
Age-related changes in energy efficiency of gait, activity, and participation in children with cerebral palsy
Kerr, Claire, McDowell, Brona, Parkes, Jackie, Stevenson, Mike and Cosgrove, Aidan 2011. Age-related changes in energy efficiency of gait, activity, and participation in children with cerebral palsy. Developmental Medicine and Child Neurology. 53 (1), pp. 61 - 67. https://doi.org/10.1111/j.1469-8749.2010.03795.x
Bracing and splinting interventions in the upper limbs of people with cerebral palsy
Imms, Christine 2011. Bracing and splinting interventions in the upper limbs of people with cerebral palsy. Developmental Medicine and Child Neurology. 53 (4), pp. 293 - 294. https://doi.org/10.1111/j.1469-8749.2010.03881.x
A Systematic Review of the Measurement Properties of the Personal Care Participation, Assessment and Resource Tool (PC-Part)
Darzins, Susan, Imms, Christine and Di Stefano, Marilyn 2011. A Systematic Review of the Measurement Properties of the Personal Care Participation, Assessment and Resource Tool (PC-Part). Australian Occupational Therapy Journal. 58 (Suppl s1), pp. 127 - 128. https://doi.org/10.3109/09638288.2012.690819
Preliminary evidence supports the validity of the strength-dexterity test as a unidimensional scale measuring fingertip force coordination in children and adolescents
Imms, Christine and van Hartingsveltd, Margot 2011. Preliminary evidence supports the validity of the strength-dexterity test as a unidimensional scale measuring fingertip force coordination in children and adolescents. Australian Occupational Therapy Journal. 58 (6), pp. 317 - 319. https://doi.org/10.1111/j.1440-1630.2011.00952.x
Children and Youth with Myleomeningocele's Independence in Managing Clean Intermittent Catheterization in Familiar Settings
Donlau, Marie, Imms, Christine, Mattsson, Gunilla, Mattsson, Sven, Sjors, Anna and Falkmer, Torbjorn 2011. Children and Youth with Myleomeningocele's Independence in Managing Clean Intermittent Catheterization in Familiar Settings. Developmental Medicine and Child Neurology. 100 (3), pp. 429 - 438. https://doi.org/10.1111/j.1651-2227.2010.02044.x
Goal Directed Training of Activity Performance
Hoare, Brian and Imms, Christine 2010. Goal Directed Training of Activity Performance. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 130 - 145
The Young Adult with Complex Disability
Scoullar, Barbara and Imms, Christine 2010. The Young Adult with Complex Disability. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 245 - 259
Botulinum Toxin A as an Adjunct to Treatment in the Management of the Upper Limb in Children with Spastic Cerebral Palsy (UPDATE)
Hoare, Brian, Wallen, Margaret, Imms, Christine, Villanueva, Elmer, Rawicki, Hyam and Carey, Leeanne 2010. Botulinum Toxin A as an Adjunct to Treatment in the Management of the Upper Limb in Children with Spastic Cerebral Palsy (UPDATE). Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD003469.pub4
Psychometric Properties of the 'Extended' Melbourne Assessment of Unilateral Upper Limb Function Based on Rasch Analysis
Randall, Melinda, Pallant, Julie, Imms, Christine and Carey, Leeanne 2010. Psychometric Properties of the 'Extended' Melbourne Assessment of Unilateral Upper Limb Function Based on Rasch Analysis. Developmental Medicine and Child Neurology.
Impact of Transition to High School on Leisure Participation of Adolescents with Cerebral Palsy
Imms, Christine, Reilly, Sheena, Carlin, John and Dodd, Karen 2010. Impact of Transition to High School on Leisure Participation of Adolescents with Cerebral Palsy. Developmental Medicine and Child Neurology. 52 (2), pp. 22 - 22.
Introduction to the Clinical Reasoning Approach of the Book
Imms, Christine, Dodd, Karen and Taylor, Nicholas 2010. Introduction to the Clinical Reasoning Approach of the Book. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 1 - 6
Modified Constraint Induced Therapy for Young Children
Wallen, Margaret and Imms, Christine 2010. Modified Constraint Induced Therapy for Young Children. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 114 - 129
Further evidence of validity of the Gait Deviation Index
Molloy, M, McDowell, Brona, Kerr, Claire and Cosgrove, Aidan 2010. Further evidence of validity of the Gait Deviation Index. Gait & Posture. 31 (4), pp. 479 - 482. https://doi.org/10.1016/j.gaitpost.2010.01.025
Measure Twice, Cut Once: Understanding the Reliability and Validity of the Clinical Measurement Tools Used in Health Research
Imms, Christine and Greaves, Susan 2010. Measure Twice, Cut Once: Understanding the Reliability and Validity of the Clinical Measurement Tools Used in Health Research. in: Research Methods in Health: Foundations for Evidence-Based Practice Australia: Oxford University Press. pp. 173 - 195
What is Cerebral Palsy?
Imms, Christine and Dodd, Karen 2010. What is Cerebral Palsy? in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 7 - 30
Eight Weeks of Occupational Therapy Home Programme, Compared to No Programme, Resulted in Improved Achievement of Child and Family- Selected Goals by Children with Cerebral Palsy
Imms, Christine, Cowan, Rebecca, Ertekin, Elvan, Klein, Gabi-Leigh and Galvin, Jane 2010. Eight Weeks of Occupational Therapy Home Programme, Compared to No Programme, Resulted in Improved Achievement of Child and Family- Selected Goals by Children with Cerebral Palsy. Australian Occupational Therapy Journal. 57 (6), pp. 444 - 445. https://doi.org/10.1111/j.1440-1630.2010.00907.x
Assessing Bimanual Performance in Young Children with Hemiplegic Cerebral Palsy : A Systematic Review
Greaves, Susan, Imms, Christine, Dodd, Karen and Krumlinde-Sundholm, Lena 2010. Assessing Bimanual Performance in Young Children with Hemiplegic Cerebral Palsy : A Systematic Review. Developmental Medicine and Child Neurology. 52 (5), pp. 413 - 421. https://doi.org/10.1111/j.1469-8749.2009.03561.x
Repeat Botulinum Toxin-A in the Upper Limb of Children with Hemiplegia : A Randomized Controlled Trial
Olesch, Christine, Greaves, Susan, Imms, Christine, Reid, Susan and Kerr, Graham 2010. Repeat Botulinum Toxin-A in the Upper Limb of Children with Hemiplegia : A Randomized Controlled Trial. Developmental Medicine and Child Neurology. 52 (1), pp. 79 - 86. https://doi.org/10.1111/j.1469-8749.2009.03387.x
Intensive Upper Limb Therapy Following Botulinum-A in Young Children with Hemiplegic Cerebral Palsy : Results from a Randomised Controlled Trial
Hoare, Brian, Imms, Christine and Carey, Leeanne 2010. Intensive Upper Limb Therapy Following Botulinum-A in Young Children with Hemiplegic Cerebral Palsy : Results from a Randomised Controlled Trial. Developmental Medicine and Child Neurology. 52 (Suppl s2), pp. 13 - 13. https://doi.org/10.1111/j.1469-8749.2009.03595.x
Modified constraint-induced movement therapy or bimanual occupational therapy following injection of botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: a randomised controlled trial methods paper
Hoare, Brian, Imms, Christine, Rawicki, Hyam and Carey, Leeanne 2010. Modified constraint-induced movement therapy or bimanual occupational therapy following injection of botulinum toxin-A to improve bimanual performance in young children with hemiplegic cerebral palsy: a randomised controlled trial methods paper. BMC Neurology. 10 (1), pp. 58 - 78. https://doi.org/10.1186/1471-2377-10-58
The Adult Years
Imms, Christine, Dodd, Karen and Taylor, Nicholas 2010. The Adult Years. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 260 - 281
Overview of Therapy
Imms, Christine, Dodd, Karen and Taylor, Nicholas 2010. Overview of Therapy. in: Physiotherapy and Occupational Therapy for People with Cerebral Palsy: A Problem-based Approach to Assessment and Management United Kingdom: Mac Keith Press. pp. 40 - 72
Test-retest reliability of a 1-min walk test in children with bilateral spastic cerebral palsy (BSCP)
McDowell, Brona C., Humphreys, Lee, Kerr, Claire Frances and Stevenson, Mike 2009. Test-retest reliability of a 1-min walk test in children with bilateral spastic cerebral palsy (BSCP). Gait & Posture. 29 (2), pp. 267 - 269. https://doi.org/10.1016/j.gaitpost.2008.09.010
Stability of caregiver-reported manual ability and gross motor function classifications of cerebral palsy
Imms, Christine, Carlin, John and Eliasson, Ann-Christin 2009. Stability of caregiver-reported manual ability and gross motor function classifications of cerebral palsy. Developmental Medicine and Child Neurology. 52 (2), pp. 153 - 159. https://doi.org/10.1111/j.1469-8749.2009.03346.x
Characteristics influencing participation of Australian children with cerebral palsy
Imms, Christine, Reilly, Sheena, Carlin, John and Dodd, Karen 2009. Characteristics influencing participation of Australian children with cerebral palsy. Disability and Rehabilitation. 31 (26), pp. 2204 - 2215. https://doi.org/10.3109/09638280902971406
Newborn individualised developmental care and assessment programme for infants born less than 32 weeks' gestation did not improve neurodevelopmental outcomes at one and two years more than standard developmental care
Imms, Christine and Brown, Nisha 2009. Newborn individualised developmental care and assessment programme for infants born less than 32 weeks' gestation did not improve neurodevelopmental outcomes at one and two years more than standard developmental care. Australian Occupational Therapy Journal. 56 (6), pp. 439 - 441. https://doi.org/10.1111/j.1440-1630.2009.00824.x
Factors influencing participation of children with cerebral palsy in Australia
Imms, Christine, Reilly, Sheena, Carlin, John and Dodd, Karen 2009. Factors influencing participation of children with cerebral palsy in Australia. Developmental Medicine and Child Neurology. 51 (2), pp. 23 - 24.
Sensory processing abilities of children who have sustained traumatic brain injuries
Galvin, Jane, Froude, Elspeth and Imms, Christine 2009. Sensory processing abilities of children who have sustained traumatic brain injuries. American Journal of Occupational Therapy. 63 (6), pp. 701 - 709. https://doi.org/10.5014/ajot.63.6.701
The relationship between physical performance and self-perception in children with and without cerebral palsy
Ziebell, Melanie, Imms, Christine, Froude, Elspeth, McCoy, Anne and Galea, Mary 2009. The relationship between physical performance and self-perception in children with and without cerebral palsy. Australian Occupational Therapy Journal. 56 (1), pp. 24 - 32. https://doi.org/10.1111/j.1440-1630.2008.00775.x
The effects of industry standard averaging and filtering techniques in kinematic gait analysis
Molloy, M., Salazar-Torres, Jose J., Kerr, Claire Frances, McDowell, Brona C. and Cosgrove, Aidan P. 2008. The effects of industry standard averaging and filtering techniques in kinematic gait analysis. Gait & Posture. 28 (4), pp. 559 - 562. https://doi.org/10.1016/j.gaitpost.2008.03.012
The validity of an existing gait classification system when applied to a representative population of children with hemiplegia
McDowell, Brona C., Kerr, Claire Frances, Kelly, Connor, Salazar-Torres, Jose J. and Cosgrove, Aidan 2008. The validity of an existing gait classification system when applied to a representative population of children with hemiplegia. Gait & Posture. 28 (3), pp. 442 - 447. https://doi.org/10.1016/j.gaitpost.2008.02.003
The evidence-base for upper extremity intervention for children with cerebral palsy
Imms, Christine 2008. The evidence-base for upper extremity intervention for children with cerebral palsy. in: A.C.Eliasson and P, Burtner (ed.) Improving hand function in cerebral palsy : Theory, evidence and intervention Mac Keith Press. pp. 396 - 417
Children with cerebral palsy participate: A review of the literature
Imms, Christine 2008. Children with cerebral palsy participate: A review of the literature. Disability and Rehabilitation. 30 (24), pp. 1867 - 1884. https://doi.org/10.1080/09638280701673542
Establishing validity of a modified Melbourne assessment for children ages 2 to 4 years
Randall, Melinda, Imms, Christine and Carey, Leeanne 2008. Establishing validity of a modified Melbourne assessment for children ages 2 to 4 years. American Journal of Occupational Therapy. 62 (4), pp. 373 - 383. https://doi.org/10.5014/ajot.62.4.373
Review of the children's assessment of participation and enjoyment and the preferences for activity of children
Imms, Christine 2008. Review of the children's assessment of participation and enjoyment and the preferences for activity of children. Physical & Occupational Therapy in Pediatrics. 28 (4), pp. 389 - 404. https://doi.org/10.1080/01942630802307135
Activity Level Assessment of the Upper Limb in Children with Hemiplegic Cerebral Palsy. Treatment Innovation and its Impact on Measurement
Hoare, Brian, Imms, Christine and Carey, Leeanne 2008. Activity Level Assessment of the Upper Limb in Children with Hemiplegic Cerebral Palsy. Treatment Innovation and its Impact on Measurement. Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM) Biennial Conference. Australia: Australasian Academy of Cerebral Palsy and Developmental Medicine. pp. 1 - 10
Diversity of participation in children with cerebral palsy
Imms, Christine, Reilly, Sheena, Carlin, John and Dodd, Karen 2008. Diversity of participation in children with cerebral palsy. Developmental Medicine and Child Neurology. 50 (5), pp. 363 - 369. https://doi.org/10.1111/j.1469-8749.2008.02051.x
Participation of Australian Children with Cerebral Palsy in Activities Outside School
Imms, Christine, Reilly, Sheena, Carlin, John and Dodd, Karen 2008. Participation of Australian Children with Cerebral Palsy in Activities Outside School. Developmental Medicine and Child Neurology. 50 (113), pp. 17 - 17.
Energy efficiency in gait, activity, participation, and health status in children with cerebral palsy
Kerr, Claire Frances, Parkes, Jackie, Stevenson, Mike, Cosgrove, Aidan P. and McDowell, Brona C. 2008. Energy efficiency in gait, activity, participation, and health status in children with cerebral palsy. Developmental Medicine and Child Neurology. 50 (3), pp. 204 - 210. https://doi.org/10.1111/j.1469-8749.2008.02030.x
Goal-Directed Training: Linking Theories of Treatment to Clinical Practice for Improved Functional Activities in Daily Life
Mastos, M., Miller, K., Eliasson, Ann-Christin and Imms, Christine 2007. Goal-Directed Training: Linking Theories of Treatment to Clinical Practice for Improved Functional Activities in Daily Life. Clinical Rehabilitation. 21 (1), pp. 47 - 55. https://doi.org/10.1177/0269215506073494
Critically Appraised Papers : Parents of Children with Developmental Coordination Disorder (i) Experienced Uncertainty as they Come to Understand their Children and (ii) Described a Trajectory of Changing Difficulties as their Children Got Older
Imms, Christine, Poulsen, Anne and Case-Smith, Jane 2007. Critically Appraised Papers : Parents of Children with Developmental Coordination Disorder (i) Experienced Uncertainty as they Come to Understand their Children and (ii) Described a Trajectory of Changing Difficulties as their Children Got Older. Australian Occupational Therapy Journal. 54 (3), pp. 242 - 244.
Participation of Children Who Have Cerebral Palsy
Imms, Christine, Reilly, Sheena and Carlin, John 2007. Participation of Children Who Have Cerebral Palsy. Developmental Medicine and Child Neurology. 49 (111), pp. 33 - 34.
Group-Based Task-Related Training for Children with Cerebral Palsy: A Pilot Study
Crompton, Jodi, Imms, Christine, McCoy, Anne, Randall, Melinda, Eldridge, Beverly, Scoullar, Barbara and Galea, Mary 2007. Group-Based Task-Related Training for Children with Cerebral Palsy: A Pilot Study. Physical & Occupational Therapy in Pediatrics. 27 (4), pp. 43 - 65. https://doi.org/10.1300/J006v27n04_04
Constraint-Induced Movement Therapy in the Treatment of the Upper Limb in Children with Hemiplegic Cerebral Palsy: a Cochrane Systematic Review
Hoare, Brian, Imms, Christine, Carey, Leeanne and Wasiak, Jason 2007. Constraint-Induced Movement Therapy in the Treatment of the Upper Limb in Children with Hemiplegic Cerebral Palsy: a Cochrane Systematic Review. Clinical Rehabilitation. 21 (8), pp. 675 - 686. https://doi.org/10.1177/0269215507080783
Being in Pain: a Phenomenological Study of Young People with Cerebral Palsy
Castle, Kirstyn, Imms, Christine and Howie, Linsey 2007. Being in Pain: a Phenomenological Study of Young People with Cerebral Palsy. Developmental Medicine and Child Neurology. 49 (6), pp. 445 - 449. https://doi.org/10.1111/j.1469-8749.2007.00445.x
Critically Appraised Paper: Helping Adults with Schizophrenia or Schizo-Affective Disorder Stop Smoking Resulted in Positive Short-Term Health Benefits
Imms, Christine and Nichol, Maggie 2007. Critically Appraised Paper: Helping Adults with Schizophrenia or Schizo-Affective Disorder Stop Smoking Resulted in Positive Short-Term Health Benefits. Australian Occupational Therapy Journal. 54 (1), pp. 75 - 76.
Editorial: Critically Appraised Papers Related to Children with Autism
Wallen, Margaret and Imms, Christine 2006. Editorial: Critically Appraised Papers Related to Children with Autism. Australian Occupational Therapy Journal. 53 (3), pp. 237 - 238.
Daily Activities of families with a child with Severe Autism Revolved Around the Need to Occupy and Pacify the Child: Families Felt Robbed of Meaning and Satisfaction in Family Life: Commentary
Imms, Christine, Rodger, Sylvia and Ziviani, Jenny 2006. Daily Activities of families with a child with Severe Autism Revolved Around the Need to Occupy and Pacify the Child: Families Felt Robbed of Meaning and Satisfaction in Family Life: Commentary. Australian Occupational Therapy Journal. 53 (2), pp. 136 - 137.
Searching for Evidence in Pediatric Occupational Therapy Using Free versus Subscription Databases: A Comparison of Outcomes
Lovarini, Meryl, Wallen, Margaret and Imms, Christine 2006. Searching for Evidence in Pediatric Occupational Therapy Using Free versus Subscription Databases: A Comparison of Outcomes. Physical & Occupational Therapy in Pediatrics. 26 (3), pp. 19 - 38. https://doi.org/10.1300/J006v26n03_03
Editorial: The International Classification of Functioning, Disability and Health: They're Talking Our Language
Imms, Christine 2006. Editorial: The International Classification of Functioning, Disability and Health: They're Talking Our Language. Australian Occupational Therapy Journal. 53 (2), pp. 65 - 66.