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Cook E, Laycock J, Sivapathasuntharam D, Maturana C, Hilton C, Doherty L, Hewitt C, McDaid C, Torgerson D, Bates P. Surgical versus non-surgical management of lateral compression type-1 pelvic fracture in adults 60 years and older: the L1FE RCT. Health Technol Assess 2024; 28:1-67. [PMID: 38512076 PMCID: PMC11017634 DOI: 10.3310/lapw3412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Lateral compression type-1 pelvic fractures are a common fragility fracture in older adults. Patients who do not mobilise due to ongoing pain are at greater risk of immobility-related complications. Standard treatment in the United Kingdom is provision of pain relief and early mobilisation, unlike fragility hip fractures, which are usually treated surgically based on evidence that early surgery is associated with better outcomes. Currently there is no evidence on whether patients with lateral compression type-1 fragility fractures would have a better recovery with surgery than non-surgical management. Objectives To assess the clinical and cost effectiveness of surgical fixation with internal fixation device compared to non-surgical management of lateral compression type-1 fragility fractures in older adults. Design Pragmatic, randomised controlled superiority trial, with 12-month internal pilot; target sample size was 600 participants. Participants were randomised between surgical and non-surgical management (1 : 1 allocation ratio). An economic evaluation was planned. Setting UK Major Trauma Centres. Participants Patients aged 60 years or older with a lateral compression type-1 pelvic fracture, arising from a low-energy fall and unable to mobilise independently to a distance of 3 m and back due to pelvic pain 72 hours after injury. Interventions Internal fixation device surgical fixation and non-surgical management. Participants, surgeons and outcome assessors were not blinded to treatment allocation. Main outcome measures Primary outcome - average patient health-related quality of life, over 6 months, assessed by the EuroQol-5 Dimensions, five-level version utility score. Secondary outcomes (over the 6 months following injury) - self-rated health, physical function, mental health, pain, delirium, displacement of pelvis, mortality, complications and adverse events, and resource use data for the economic evaluation. Results The trial closed early, at the end of the internal pilot, due to low recruitment. The internal pilot was undertaken in two separate phases because of a pause in recruitment due to the coronavirus disease 2019 pandemic. The planned statistical and health economic analyses were not conducted. Outcome data were summarised descriptively. Eleven sites opened for recruitment for a combined total of 92 months. Three-hundred and sixteen patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reason for ineligibility was that the patient was able to mobilise independently to 3 m and back (n = 161). Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). There were 11 participants, 5 randomised to surgical management with internal fixation device and 6 to non-surgical management. The average age of participants was 83.0 years (interquartile range 76.0, 89.0) and the EuroQol-5 Dimensions, five-level version utility score at 6 months post randomisation (n = 8) was 0.32 (standard deviation 0.37). A limitation of the trial was that study objectives were not addressed due to poor recruitment. Conclusions It was not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial. Future work Exploration of equipoise across different healthcare professional groups. Investigate longer-term patient outcomes. Trial registration This trial is registered as ISRCTN16478561. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Elizabeth Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joanne Laycock
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Camila Maturana
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Laura Doherty
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Peter Bates
- Bart's Health NHS Trust, The Royal London Hospital, London, UK
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Griffin DR, Dickenson EJ, Achana F, Griffin J, Smith J, Wall PD, Realpe A, Parsons N, Hobson R, Fry J, Jepson M, Petrou S, Hutchinson C, Foster N, Donovan J. Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT. Health Technol Assess 2022; 26:1-236. [PMID: 35229713 PMCID: PMC8919110 DOI: 10.3310/fxii0508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care. DESIGN The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals. PARTICIPANTS Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy. INTERVENTION Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked. MAIN OUTCOME MEASURE The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat. RESULTS Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years. LIMITATIONS Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years. CONCLUSION Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN64081839. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Damian R Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Edward J Dickenson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Joanna Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Dh Wall
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Alba Realpe
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nick Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Hobson
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Marcus Jepson
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nadine Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences NIHR, Keele University, Keele, UK
| | - Jenny Donovan
- Bristol Medical School, University of Bristol, Bristol, UK
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Bruce J, Mazuquin B, Mistry P, Rees S, Canaway A, Hossain A, Williamson E, Padfield EJ, Lall R, Richmond H, Chowdhury L, Lait C, Petrou S, Booth K, Lamb SE, Vidya R, Thompson AM. Exercise to prevent shoulder problems after breast cancer surgery: the PROSPER RCT. Health Technol Assess 2022; 26:1-124. [PMID: 35220995 DOI: 10.3310/jknz2003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Upper limb problems are common after breast cancer treatment. OBJECTIVES To investigate the clinical effectiveness and cost-effectiveness of a structured exercise programme compared with usual care on upper limb function, health-related outcomes and costs in women undergoing breast cancer surgery. DESIGN This was a two-arm, pragmatic, randomised controlled trial with embedded qualitative research, process evaluation and parallel economic analysis; the unit of randomisation was the individual (allocated ratio 1 : 1). SETTING Breast cancer centres, secondary care. PARTICIPANTS Women aged ≥ 18 years who had been diagnosed with breast cancer and were at higher risk of developing shoulder problems. Women were screened to identify their risk status. INTERVENTIONS All participants received usual-care information leaflets. Those randomised to exercise were referred to physiotherapy for an early, structured exercise programme (three to six face-to-face appointments that included strengthening, physical activity and behavioural change strategies). MAIN OUTCOME MEASURES The primary outcome was upper limb function at 12 months as assessed using the Disabilities of Arm, Hand and Shoulder questionnaire. Secondary outcomes were function (Disabilities of Arm, Hand and Shoulder questionnaire subscales), pain, complications (e.g. wound-related complications, lymphoedema), health-related quality of life (e.g. EuroQol-5 Dimensions, five-level version; Short Form questionnaire-12 items), physical activity and health service resource use. The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit gained from an NHS and Personal Social Services perspective. Participants and physiotherapists were not blinded to group assignment, but data collectors were blinded. RESULTS Between 2016 and 2017, we randomised 392 participants from 17 breast cancer centres across England: 196 (50%) to the usual-care group and 196 (50%) to the exercise group. Ten participants (10/392; 3%) were withdrawn at randomisation and 32 (8%) did not provide complete baseline data. A total of 175 participants (89%) from each treatment group provided baseline data. Participants' mean age was 58.1 years (standard deviation 12.1 years; range 28-88 years). Most participants had undergone axillary node clearance surgery (327/392; 83%) and 317 (81%) had received radiotherapy. Uptake of the exercise treatment was high, with 181 out of 196 (92%) participants attending at least one physiotherapy appointment. Compliance with exercise was good: 143 out of 196 (73%) participants completed three or more physiotherapy sessions. At 12 months, 274 out of 392 (70%) participants returned questionnaires. Improvement in arm function was greater in the exercise group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 16.3 (standard deviation 17.6)] than in the usual-care group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 23.7 (standard deviation 22.9)] at 12 months for intention-to-treat (adjusted mean difference Disabilities of Arm, Hand and Shoulder questionnaire score of -7.81, 95% confidence interval -12.44 to -3.17; p = 0.001) and complier-average causal effect analyses (adjusted mean difference -8.74, 95% confidence interval -13.71 to -3.77; p ≤ 0.001). At 12 months, pain scores were lower and physical health-related quality of life was higher in the exercise group than in the usual-care group (Short Form questionnaire-12 items, mean difference 4.39, 95% confidence interval 1.74 to 7.04; p = 0.001). We found no differences in the rate of adverse events or lymphoedema over 12 months. The qualitative findings suggested that women found the exercise programme beneficial and enjoyable. Exercise accrued lower costs (-£387, 95% CI -£2491 to £1718) and generated more quality-adjusted life years (0.029, 95% CI 0.001 to 0.056) than usual care over 12 months. The cost-effectiveness analysis indicated that exercise was more cost-effective and that the results were robust to sensitivity analyses. Exercise was relatively cheap to implement (£129 per participant) and associated with lower health-care costs than usual care and improved health-related quality of life. Benefits may accrue beyond the end of the trial. LIMITATIONS Postal follow-up was lower than estimated; however, the study was adequately powered. No serious adverse events directly related to the intervention were reported. CONCLUSIONS This trial provided robust evidence that referral for early, supported exercise after breast cancer surgery improved shoulder function in those at risk of shoulder problems and was associated with lower health-care costs than usual care and improved health-related quality of life. FUTURE WORK Future work should focus on the implementation of exercise programmes in clinical practice for those at highest risk of shoulder problems. TRIAL REGISTRATION This trial is registered as ISRCTN35358984. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Bruno Mazuquin
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Pankaj Mistry
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Alastair Canaway
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Anower Hossain
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
- Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, Bangladesh
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Emma J Padfield
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Helen Richmond
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - Loraine Chowdhury
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Clare Lait
- Gloucestershire Care Services NHS Trust, Gloucester, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katie Booth
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Sarah E Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
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4
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Barker KL, Room J, Knight R, Dutton SJ, Toye F, Leal J, Kent S, Kenealy N, Schussel MM, Collins G, Beard DJ, Price A, Underwood M, Drummond A, Cook E, Lamb SE. Outpatient physiotherapy versus home-based rehabilitation for patients at risk of poor outcomes after knee arthroplasty: CORKA RCT. Health Technol Assess 2020; 24:1-116. [PMID: 33250068 DOI: 10.3310/hta24650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Over 100,000 primary knee arthroplasty operations are undertaken annually in the UK. Around 15-30% of patients do not report a good outcome. Better rehabilitation strategies may improve patient-reported outcomes. OBJECTIVES To compare the outcomes from a traditional outpatient physiotherapy model with those from a home-based rehabilitation programme for people assessed as being at risk of a poor outcome after knee arthroplasty. DESIGN An individually randomised, two-arm controlled trial with a blinded outcome assessment, a parallel health economic evaluation and a nested qualitative study. SETTING The trial took place in 14 NHS physiotherapy departments. PARTICIPANTS People identified as being at high risk of a poor outcome after knee arthroplasty. INTERVENTIONS A multicomponent home-based rehabilitation package delivered by rehabilitation assistants with supervision from qualified therapists compared with usual-care outpatient physiotherapy. MAIN OUTCOME MEASURES The primary outcome was the Late Life Function and Disability Instrument at 12 months. Secondary outcomes were the Oxford Knee Score (a disease-specific measure of function); Knee injury and Osteoarthritis Outcome Score; Quality of Life subscale; Physical Activity Scale for the Elderly; EuroQol-5 Dimensions, five-level version; and physical function assessed using the Figure-of-8 Walk Test, 30-Second Chair Stand Test and Single Leg Stance. Data on the use of health-care services, time off work and informal care were collected using participant diaries. RESULTS In total, 621 participants were randomised. A total of 309 participants were assigned to the COmmunity based Rehabilitation after Knee Arthroplasty (CORKA) home-based rehabilitation programme, receiving a median of five treatment sessions (interquartile range 4-7 sessions). A total of 312 participants were assigned to usual care, receiving a median of four sessions (interquartile range 2-6 sessions). The primary outcome, Late Life Function and Disability Instrument function total score at 12 months, was collected for 279 participants (89%) in the home-based CORKA group and 287 participants (92%) in the usual-care group. No clinically or statistically significant difference was found between the groups (intention-to-treat adjusted difference 0.49 points, 95% confidence interval -0.89 to 1.88 points; p = 0.48). There were no statistically significant differences between the groups in any of the patient-reported or physical secondary outcome measures at 6 or 12 months post randomisation. The health economic analysis found that the CORKA intervention was cheaper to provide than usual care (£66 less per participant). Total societal costs (combining health-care costs and other costs) were lower for the CORKA intervention than usual care (£316 less per participant). Adopting a societal perspective, CORKA had a 75% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year. Adopting the narrower health and social care perspective, CORKA had a 43% probability of being cost-effective at the same threshold. LIMITATIONS The interventions were of short duration and were set within current commissioning guidance for UK physiotherapy. Participants and treating therapists could not be blinded. CONCLUSIONS This randomised controlled trial found no important differences in outcomes when post-arthroplasty rehabilitation was delivered using a home-based, rehabilitation assistant-delivered rehabilitation package or a traditional outpatient model. However, the health economic evaluation found that when adopting a societal perspective, the CORKA home-based intervention was cost-saving and more effective than, and thus dominant over, usual care, owing to reduced time away from paid employment for this group. Further research could look at identifying the risk of poor outcome and further evaluation of a cost-effective treatment, including the workforce model to deliver it. TRIAL REGISTRATION Current Controlled Trials ISRCTN13517704. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 65. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jon Room
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Fran Toye
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Seamus Kent
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicola Kenealy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Michael M Schussel
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Gary Collins
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,School of Medicine and Health, University of Exeter, Exeter, UK
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5
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Brealey S, Northgraves M, Kottam L, Keding A, Corbacho B, Goodchild L, Srikesavan C, Rex S, Charalambous CP, Hanchard N, Armstrong A, Brooksbank A, Carr A, Cooper C, Dias J, Donnelly I, Hewitt C, Lamb SE, McDaid C, Richardson G, Rodgers S, Sharp E, Spencer S, Torgerson D, Toye F, Rangan A. Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT. Health Technol Assess 2020; 24:1-162. [PMID: 33292924 DOI: 10.3310/hta24710] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments. DESIGN This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out. SETTING The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018. PARTICIPANTS Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology. INTERVENTIONS The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy. MAIN OUTCOME MEASURES The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important. RESULTS The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST. LIMITATIONS Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial. CONCLUSIONS None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs. FUTURE WORK Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence. TRIAL REGISTRATION Current Controlled Trials ISRCTN48804508. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Lucksy Kottam
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Cynthia Srikesavan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Saleema Rex
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Charalambos P Charalambous
- Department of Orthopaedics, Blackpool Victoria Hospital, Blackpool, UK.,School of Medicine, University of Central Lancashire, Preston, UK
| | - Nigel Hanchard
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | | | | | - Andrew Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sara Rodgers
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Sally Spencer
- Postgraduate Medical Institute, Edge Hill University, Ormskirk, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Francine Toye
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK.,The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Barker KL, Newman M, Stallard N, Leal J, Minns Lowe C, Javaid MK, Noufaily A, Adhikari A, Hughes T, Smith DJ, Gandhi V, Cooper C, Lamb SE. Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT. Health Technol Assess 2019; 23:1-318. [PMID: 31456562 DOI: 10.3310/hta23440] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role. OBJECTIVE The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session. DESIGN This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies. SETTING This trial was based in 21 NHS physiotherapy departments. PARTICIPANTS The participants were people with symptomatic OVF. INTERVENTIONS Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT). MAIN OUTCOME MEASURES Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version. RESULTS A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events. CONCLUSIONS This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects. TRIAL REGISTRATION Current Controlled Trials ISRCTN49117867. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Meredith Newman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nigel Stallard
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Catherine Minns Lowe
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Angela Noufaily
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anish Adhikari
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tamsin Hughes
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David J Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Varsha Gandhi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Abstract
BACKGROUND It is important to investigate attitudes to acupuncture, because therapists' and patients' expectations may affect the treatment outcome. AIM To explore the use of and belief in acupuncture among oncological physiotherapists and to explore patients' interest in receiving acupuncture during cancer therapy and their belief in its effectiveness. METHODS 522 patients (80% female, mean age 67 years) reported on their interest in receiving acupuncture for nausea during radiotherapy treatment; a subgroup (n=198) additionally disclosed their belief in the effectiveness of acupuncture. 117 Swedish oncological physiotherapists (96% female, mean age 48 years) answered a questionnaire regarding their use of and belief in acupuncture. RESULTS Of the patients initiating cancer therapy, 359 (69%) were interested in receiving acupuncture. The patients believed acupuncture to be effective for pain (79%), nausea (79%) and vasomotor symptoms (48%). Of the 117 physiotherapists, 66 (56%) practised acupuncture. Physiotherapists generally believed in the effectiveness of acupuncture. For pain, 89% believed that acupuncture was effective and 42% of them practised it. Similar responses were noted for chemotherapy-induced nausea (86% and 38%, respectively) and vasomotor symptoms (80% and 28%, respectively). Younger physiotherapists and patients were more likely to believe in the effectiveness of acupuncture compared with older ones. CONCLUSIONS More than two thirds of patients with cancer were interested in receiving acupuncture during therapy. Patients and oncological physiotherapists believed that acupuncture was effective for cancer pain, nausea and vasomotor symptoms. Further studies of acupuncture for cancer-related symptoms and of the effect of patients' and clinicians' therapeutic relationships, including treatment expectations, would be welcome.
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Affiliation(s)
- Anna Enblom
- Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, Linköping, Sweden
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Affiliation(s)
- Arthur Yin Fan
- McLean Center for Complementary and Alternative Medicine, PLC, Vienna, Virginia, USA
| | - Hongjian He
- Oriental Family Medicine, Clearwater, Florida, USA
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Solberg M, Alræk T, Mdala I, Klovning A. A pilot study on the use of acupuncture or pelvic floor muscle training for mixed urinary incontinence. Acupunct Med 2015; 34:7-13. [PMID: 26362793 PMCID: PMC4789711 DOI: 10.1136/acupmed-2015-010828] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2015] [Indexed: 11/13/2022]
Abstract
Objectives To determine the feasibility and acceptability of traditional Chinese medicine (TCM) acupuncture and pelvic floor muscle training (PFMT) in reducing symptoms and bothersomeness in women with mixed urinary incontinence (MUI); and to estimate the sample size for a full scale trial. Methods Thirty-four women with MUI were randomly assigned to either 12 sessions of TCM acupuncture, 12 sessions of PFMT, or to a waiting list control group. Outcome measures included an assessment of interest to participate in the trial, identification of successful recruitment strategies, the appropriateness of eligibility criteria, and compliance with treatment. Clinical outcomes were assessed at baseline and 12 weeks, and included the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI SF), expectations of treatment effect, and adverse events. Results Recruitment was feasible and randomisation worked adequately by means of SurveyMonkey. SurveyMonkey does not permit stratification by ICIQ-UI SF baseline score. Fourteen of 22 women found the treatment options acceptable. The dropout rate was high, especially in the control group (6/12). Outcome forms were completed by 20 of 34 women. The median (IQR) changes of the ICIQ-UI SF scores in the acupuncture, physiotherapy, and waiting list group were 5.5 (2.3 to 6.8), 1.0 (−3.0 to 4.5), and 1.5 (−1.5 to 3.0), respectively, suggesting the need for a full scale trial. Conclusions Women with MUI were willing to participate in this study. There is a need for adjusting eligibility criteria. A sample size of 129 women, 43 in three arms, is required. No major adverse events occurred.
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Affiliation(s)
- Mona Solberg
- Faculty of Medicine, Department of Health Sciences, Institute of Health and Society, University of Oslo, Norway
| | - Terje Alræk
- Faculty of Health Science, Department of Community Medicine, The National Research Center in Complementary and Alternative Medicine, NAFKAM, UiT The Arctic University of Norway, Tromsø, Norway Norwegian School of Health Sciences, Kristiania University College Oslo, Oslo, Norway
| | - Ibrahimu Mdala
- Faculty of Medicine, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Atle Klovning
- Faculty of Medicine, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Abstract
BACKGROUND Transcutaneous electrical nerve stimulation over acupuncture points (acu-TENS) has been reported to improve clinical outcomes. The objectives of the present study were to investigate whether acupuncture point sensations were experienced during acu-TENS, and whether such sensations were associated with any concomitant changes in autonomic nervous system activity. METHODS This study adopted a single-blinded, randomised, controlled trial methodology. A total of 36 healthy subjects were randomly assigned to an experimental group (acu-TENS on right LI4 and LI11 points); control group (acu-TENS to bilateral kneecaps); or placebo group (sham acu-TENS on right LI4 and LI11 points). Heart rate (HR), mean arterial blood pressure (MAP), SD of the NN interval (SDNN) and low frequency to high frequency ratio (LF/HF) were measured before, during and after intervention. The Hong Kong Chinese version of the Massachusetts General Hospital Acupuncture Sensation Scale (C-MMASS) index was used for quantifying the acupuncture point stimulation sensations. RESULTS The experimental group showed a significant increase in HR (mean (SD) 73.5 (6.3) to 75.9 (6.7) bpm, p=0.027), MAP (88.5 (4.5) to 91.0 (4.1) mm Hg, p=0.004), SDNN (143.36 (8.58) to 153.69 (7.64) ms, p=0.002) and LF/HF (1.26 (0.19) to 1.31 (0.21), p=0.037) during the intervention. The control group showed a significant increase in SDNN (140.21 (8.72) to 143.39 (9.47) ms, p=0.009) and LF/HF (1.21 (0.09) to 1.23 (0.12), p=0.033). There were no significant physiological changes in the placebo group. Overall C-MMASS indices for the experimental, control and placebo groups were 3.23 (0.3), 2.14 (0.6) and 0.29 (0.32), respectively. The between-group difference was statistically significant (F=139.24, df=2, p<0.05). However, correlation analysis did not support any association between sensation intensity and physiological responses in any groups (γ ranged from -0.36 to 0.25). CONCLUSIONS This study showed that 'acupuncture point sensations' were experienced during acu-TENS to LI4 and LI11, but such sensations were not associated with physiological responses induced during the stimulation.
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Affiliation(s)
- David T W Yu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, , Hong Kong, China
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MUSZYNSKI J. [Back to phytotherapy in modern therapeutics (transl.)]. Rev Flora Med 1948; 15:363-385. [PMID: 18104016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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MOM JE. [Some considerations about hydrotherapy in the context of general physical therapy]. Ned Tijdschr Geneeskd 1948; 92:1691-1696. [PMID: 18876065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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13
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HADEN H. Physiotherapy. Proc Transvaal Mine Med Off Assoc 1947; 27:1-5. [PMID: 20265385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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