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Liaghat B, Juul-Kristensen B, Faber DA, Christensen EO, Søgaard K, Skou ST, Søndergaard J, Juhl CB. One-year effectiveness of high-load compared with low-load strengthening exercise on self-reported function in patients with hypermobile shoulders: a secondary analysis from a randomised controlled trial. Br J Sports Med 2024; 58:373-381. [PMID: 38253436 PMCID: PMC10982631 DOI: 10.1136/bjsports-2023-107563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVES To investigate the long-term effectiveness of high-load versus low-load strengthening exercise on self-reported function in patients with hypermobility spectrum disorder (HSD) and shoulder symptoms. METHODS A secondary analysis of a superiority, parallel-group, randomised trial (balanced block randomisation 1:1, electronic concealment) including adult patients (n=100) from primary care with HSD and shoulder pain and/or instability ≥3 months. Patients received 16 weeks of shoulder exercises (three sessions/week): HEAVY (n=50, full-range, high-load, supervised twice/week) or LIGHT (n=50, neutral/mid-range, low-load, supervised three times in total). The 1-year between-group difference in change in self-reported function was measured using the Western Ontario Shoulder Instability Index (WOSI, scale 0-2100, 0=best). Secondary outcomes were self-reported measures including changes in shoulder-related symptoms, function, emotions and lifestyle, quality of life, patient-perceived effect, treatment utility and adverse events. A blinded analyst conducted the analyses using linear mixed model repeated measurements analysis. RESULTS One-year data were available in 86 out of 100 participants (79% women, mean age 37.8 years) (LIGHT 84%, HEAVY 88%). The mean WOSI score between-group difference favoured HEAVY (-92.9, 95% CI -257.4 to 71.5, p=0.268) but was not statistically significant. The secondary outcomes were mostly inconclusive, but patients in HEAVY had larger improvement in the WOSI emotions subdomain (-36.3; 95% CI -65.4 to -7.3, p=0.014). Patient-perceived effect favoured HEAVY anchored in WOSI-emotions (55% vs 31%, p=0.027) and WOSI-lifestyle (50% vs 29%, p=0.042). CONCLUSION High-load shoulder strengthening exercise was not superior to low-load strengthening exercise in improving self-reported function at 1 year. High-load strengthening exercise may be more effective in improving patient emotions about shoulder pain and function, but more robust data are needed to support these findings. TRIAL REGISTRATION NUMBER NCT03869307.
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Affiliation(s)
- Behnam Liaghat
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Centre for Evidence-Based Orthopaedics (CEBO), Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Birgit Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Daniel A Faber
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Emil O Christensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Karen Søgaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren T Skou
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- The Research and Implementation Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Carsten B Juhl
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte, Denmark
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Hou ZC, Ao YF, Hu YL, Jiao C, Guo QW, Li N, Jiang YF, Jiang D. Balance training benefits chronic ankle instability with generalized joint hypermobility: a prospective cohort study. BMC Musculoskelet Disord 2023; 24:71. [PMID: 36707814 PMCID: PMC9881354 DOI: 10.1186/s12891-023-06179-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Balance training is the first choice of treatment for chronic ankle instability (CAI). However, there is a lack of research on the effects of balance training in CAI with generalized joint hypermobility (GJH). This study is to compare the outcomes of balance training in CAI patients with and without GJH. METHODS Forty CAI patients were assigned into the GJH group (Beighton ≥ 4, 20) and non-GJH group (Beighton < 4, 20) and they received same 3-month supervised balance training. Repeated measure ANOVA and independent t test were used to analyze self-reported questionnaires (Foot and ankle ability measure, FAAM), the number of patients experiencing ankle sprain, isokinetic muscle strength and postural control tests (Star excursion balance test, SEBT and Balance errors system, BES) before training, post-training immediately, and post-training 3 months, respectively. RESULTS At baseline, no differences were found between groups with except for GJH group having poorer SEBT in the posteromedial direction (83.6 ± 10.1 vs 92.8 ± 12.3, %) and in the posterolateral direction (84.7 ± 11.7 vs 95.7 ± 8.7, %). Following the balance training, GJH group demonstrated lower re-sprain ratio (immediately after training, 11.1% vs 23.5%, 3 month after training, 16.7% vs 29.4%) than non-GJH group, as well as greater FAAM-S score, plantarflexion strength and dorsiflexion strength at post-training immediately and 3 months, and both groups improved similarly in the FAAM-A score, muscle strength and balance control (SEBT in the posterior-lateral and posterior-medial directions, and BES scores) compared with baseline. CONCLUSIONS CAI patients with GJH gained equally even better postural stability and muscle strength after the balance training than the non-GJH patients. Balance training could still be an effective treatment for CAI patients with GJH before considering surgery. TRIAL REGISTRATION ChiCTR1900023999, June 21st, 2019.
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Affiliation(s)
- Zong-chen Hou
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Ying-fang Ao
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Yue-lin Hu
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Chen Jiao
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Qin-wei Guo
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Nan Li
- grid.411642.40000 0004 0605 3760Research Center of Clinical Epidemiology, Peking University Third Hospital, No.49 North Garden Road, Beijing, 100191 Haidian China
| | - Yan-fang Jiang
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
| | - Dong Jiang
- grid.419897.a0000 0004 0369 313XDepartment of Sports Medicine of Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Engineering Research Center of Sports Trauma Treatment Technology and Devices, Ministry of Education, No.49 North Garden Road, 100191 Beijing, China
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Steinberg N, Tenenbaum G, Witchalls J, Waddington G. The impact of unexpected platform perturbation on ankle proprioception ability in static and dynamic starting positions. Gait Posture 2022; 98:167-172. [PMID: 36137355 DOI: 10.1016/j.gaitpost.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 02/02/2023]
Abstract
AIMS To examine the relationship between ankle proprioception and the ability to maintain balance with increased magnitudes of unexpected perturbations; and to compare the participants' ability to maintain balance following perturbations when starting from static and dynamic positions. METHODS Sixty physical education students (average 24.6 years) were tested for proprioception ability (AUC scores) and balance challenges presented on a perturbation treadmill. The degree at which participants lost postural balance was recorded in seven starting positions: standing-eyes-open (SO), standing-eyes-closed (SC), tandem-dominant (TD), tandem non-dominant, (TND) single-leg lateral side perturbation (SLP), single-leg medial side perturbation (SMP), and walking. Perturbation scores were analysed divided by tertiles. Multidimensional Unfolding SPSS Statistics 25 (PREFSCAL) was used to examine the relationships between data sets. RESULTS AUC scores of both dominant and non-dominant legs were significantly correlated with SO (r = 0.316; r = 0.445), SC (r = 0.364; r = 0.413), TD (r = 0.346; r = 0.308), and walking (r = 0.265; r = 0.439), respectively. In the dominant-leg, AUC scores of individuals with below-median SO scores were significantly worse compared to those with median SO scores (p = .046). In the non-dominant leg, individuals with above-median SC had significantly better AUC scores compared to those with lower-than-median SC (p = .008). Those with median and above-median SO and walking achieved better AUC scores than those with below-median (SO: p = .049, p = .004; walking: p = .016, p < .001, respectively). In dimension I, the SLP and SMP were located opposite one another; in dimension II, the TD and TND were located at the upper side, whereas SC, SO and walking were at the lowest side. CONCLUSIONS AUC scores were significantly correlated with the level at which postural balance was lost, whereby the better the proprioception ability, the better the ability to maintain balance. As such, the ability to maintain balance is harder in tandem positions than in standing and walking positions. This ability differed when perturbations were to the lateral or medial sides.
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Affiliation(s)
- Nili Steinberg
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel.
| | - Galit Tenenbaum
- Wingate College of Physical Education and Sports Sciences, Wingate Institute, Netanya, Israel
| | - Jeremy Witchalls
- Research Institute for Sport and Exercise, University of Canberra, Australia
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Long M, Kiru L, Kassam J, Strutton PH, Alexander CM. An investigation of the control of quadriceps in people who are hypermobile; a case control design. Do the results impact our choice of exercise for people with symptomatic hypermobility? BMC Musculoskelet Disord 2022; 23:607. [PMID: 35739514 PMCID: PMC9219138 DOI: 10.1186/s12891-022-05540-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background People with symptomatic hypermobility have altered proprioception however, the origin of this is unclear and needs further investigation to target rehabilitation appropriately. The objective of this investigation was to explore the corticospinal and reflex control of quadriceps and see if it differed between three groups of people: those who have symptomatic hypermobility, asymptomatic hypermobility and normal flexibility. Methods Using Transcranial Magnetic Stimulation (TMS) and electrical stimulation of peripheral nerves, motor evoked potentials (MEPs) and Hoffman (H) reflexes of quadriceps were evoked in the three groups of people. The threshold and latency of MEPs and the slope of the input–output curves and the amplitude of MEPs and H reflexes were compared across the groups. Results The slope of the input–output curve created from MEPs as a result of TMS was steeper in people with symptomatic hypermobility when compared to asymptomatic and normally flexible people (p = 0.04). There were no other differences between the groups. Conclusion Corticospinal excitability and the excitability at the motoneurone pool are not likely candidates for the origin of proprioceptive loss in people with symptomatic hypermobility. This is discussed in the light of other work to suggest the receptor sitting in hypermobile connective tissue is a likely candidate. This suggests that treatment aimed at improving receptor responsiveness through increasing muscle tone, may be an effective rehabilitation strategy.
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Affiliation(s)
- Michael Long
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Louise Kiru
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jamila Kassam
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul H Strutton
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK. .,Department of Therapies, Charing Cross Hospital, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
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How Does Lower Limb Respond to Unexpected Balance Perturbations? New Insights from Synchronized Human Kinetics, Kinematics, Muscle Electromyography (EMG) and Mechanomyography (MMG) Data. BIOSENSORS 2022; 12:bios12060430. [PMID: 35735577 PMCID: PMC9220852 DOI: 10.3390/bios12060430] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022]
Abstract
Making rapid and proper compensatory postural adjustments is vital to prevent falls and fall-related injuries. This study aimed to investigate how, especially how rapidly, the multiple lower-limb muscles and joints would respond to the unexpected standing balance perturbations. Unexpected waist-pull perturbations with small, medium and large magnitudes were delivered to twelve healthy young adults from the anterior, posterior, medial and lateral directions. Electromyographical (EMG) and mechanomyographical (MMG) responses of eight dominant-leg muscles (i.e., hip abductor/adductors, hip flexor/extensor, knee flexor/extensor, and ankle dorsiflexor/plantarflexors) together with the lower-limb joint angle, moment, and power data were recorded. The onset latencies, time to peak, peak values, and/or rate of change of these signals were analyzed. Statistical analysis revealed that: (1) agonist muscles resisting the delivered perturbation had faster activation than the antagonist muscles; (2) ankle muscles showed the largest rate of activation among eight muscles following both anteroposterior and mediolateral perturbations; (3) lower-limb joint moments that complied with the perturbation had faster increase; and (4) larger perturbation magnitude tended to evoke a faster response in muscle activities, but not necessarily in joint kinetics/kinematics. These findings provided insights regarding the underlying mechanism and lower-limb muscle activities to maintain reactive standing balance in healthy young adults.
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Masterclass: Hypermobility and hypermobility related disorders. Musculoskelet Sci Pract 2022; 57:102465. [PMID: 34808594 DOI: 10.1016/j.msksp.2021.102465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/27/2021] [Accepted: 10/10/2021] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Hypermobile joints display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility may present in a single joint, a few joints or in multiple joints and may be congenital or acquired with training, disease or injury. Hypermobile joints may be asymptomatic or may be associated with pain, fatigue, multisystemic complaints and significant disability. Furthermore, joint hypermobility may be a sign of an underlying hereditary disorder of connective tissue. PURPOSE This masterclass aims to provides a state-of-the-art review of the aetiology, epidemiology, clinical presentation, assessment and management of joint hypermobility and hypermobility related disorders using an evidence based and biopsychosocial approach. The new framework for classifying the spectrum of joint hypermobility disorders along with new diagnostic criteria for the hypermobile Ehlers Danlos syndrome, published by an international consortium of clinical experts and researchers in 2017 is integrated into the paper. IMPLICATIONS FOR PRACTICE People with joint hypermobility related disorders present to healthcare professionals with a wide range of symptoms which extend beyond the musculoskeletal system. Early recognition and treatment are key to effective management. A biopsychosocial and patient empowerment approach to functional restoration is recommended.
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Bates AV, McGregor AH, Alexander CM. Prolonged standing behaviour in people with joint hypermobility syndrome. BMC Musculoskelet Disord 2021; 22:1005. [PMID: 34852804 PMCID: PMC8638551 DOI: 10.1186/s12891-021-04744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/28/2021] [Indexed: 11/22/2022] Open
Abstract
Background Joint Hypermobility Syndrome (JHS) is a rare Heritable Disorder of Connective tissue characterised by generalised joint laxity and chronic widespread pain. Joint Hypermobility Syndrome has a large impact on patients’ day to day activities, and many complain of symptoms when standing for prolonged periods. This study investigates whether people with JHS exhibit the same behaviours to deal with the effects of prolonged standing as people with equal hypermobility and no pain, and people with normal flexibility and no pain. Methods Twenty three people with JHS, 22 people with Generalised Joint Hypermobility (GJH), and 22 people with normal flexibility (NF) were asked to stand for a maximum of 15 min across two force-plates. Fidgets were counted and quantified using a cumulative sum algorithm and sway parameters of the quiet standing periods between fidgets were calculated. Results Average standing time for participants with JHS was 7.35 min and none stood for the full 15 min. All participants with GJH and NF completed 15 min of standing. There were no differences in fidgeting behaviour between any groups. There was a difference in anteroposterior sway (p = .029) during the quiet standing periods. Conclusion There is no evidence to suggest people with JHS exhibit different fidgeting behaviour. Increased anteroposterior-sway may suggest a muscle weakness and strengthening muscles around the ankle may reduce postural sway and potentially improve the ability to stand for prolonged periods.
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Affiliation(s)
| | - Alison H McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Therapies, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, W6 8RF, UK
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Simmonds JV. Advances in assessment of hypermobility-related disorders. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2021; 187:453-457. [PMID: 34741798 DOI: 10.1002/ajmg.c.31943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/17/2021] [Accepted: 10/22/2021] [Indexed: 11/11/2022]
Abstract
There has been increasing recognition in recent years of the prevalence and impact of symptoms which extend beyond the musculoskeletal system on the lives of people with hypermobility-related disorders. This has led researchers to develop more comprehensive assessment tools to help direct and monitor treatment. This article presents some of the latest assessment and diagnostic developments and their implications for practice from a physical therapy perspective.
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Affiliation(s)
- Jane V Simmonds
- Great Ormond Street Institute of Child Health, University College London, London, UK.,London Hypermobility Unit, Wellington Hospital and Central Health Physiotherapy, London, UK
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Bates AV, McGregor AH, Alexander CM. Comparing sagittal plane kinematics and kinetics of gait and stair climbing between hypermobile and non-hypermobile people; a cross-sectional study. BMC Musculoskelet Disord 2021; 22:712. [PMID: 34412618 PMCID: PMC8377885 DOI: 10.1186/s12891-021-04549-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 07/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Joint Hypermobility Syndrome (JHS) presents with a range of symptoms including widespread joint hypermobility and chronic arthralgia. The study objective was to investigate whether impairments in JHS are due to hypermobility or another factor of JHS by identifying impairments in gait and stair-climbing tasks; an activity that is demanding and so may better show differences between the cohorts. Methods Sixty-eight adults participated; 23 JHS, 23 Generalised Joint Hypermobility (GJH), and 22 Normal Flexibility (NF). Inclusion criteria for JHS participants were a positive classification using the Brighton Criteria, for GJH a Beighton Score ≥ 4, and for NF a Beighton Score < 4 with no hypermobile knees. Participants were recorded with a 10-camera Vicon system whilst they performed gait and stair-climbing. Temporal-spatial, and sagittal plane kinematic and kinetic outcome measures were calculated and input to statistical analyses by statistical parametric mapping (SPM). Results During the gait activity JHS had significantly greater stride time and significantly lower velocity than NF, and significantly greater stride time, lower velocity, and lower stride length than GJH. SPM analysis showed no significant differences between groups in gait kinematics. There were significant differences between groups for gait moments and powers; people with JHS tended to have lower moments and generate less power at the ankle, and favour power generation at the knee. A similar strategy was present in stair ascent. During stair descent people with JHS showed significantly more hip flexion than people with NF. Conclusions As there was only one significant difference between GJH and NF we conclude that impairments cannot be attributed to hypermobility alone, but rather other factor(s) of JHS. The results show that both gait and stair-climbing is impaired in JHS. Stair-climbing results indicate that JHS are using a knee-strategy and avoiding use of the ankle, which may be a factor for clinicians to consider during treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04549-2.
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Affiliation(s)
- Alexander Vernon Bates
- Department of Surgery and Cancer, Imperial College London, London, UK. .,Department of Therapies, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, W6 8RF, UK.
| | - Alison H McGregor
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Caroline M Alexander
- Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Physiotherapy, Imperial College Healthcare NHS Trust, London, UK
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