Edema and pain reduction using transcutaneous electrical nerve stimulation treatment
Identifieur interne : 004124 ( Pmc/Corpus ); précédent : 004123; suivant : 004125Edema and pain reduction using transcutaneous electrical nerve stimulation treatment
Auteurs : Yeong-Deok Choi ; Jung-Ho LeeSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2016.
Abstract
[Purpose] The purpose of this study was to investigate the impact on the edema and pain when applying transcutaneous electrical nerve stimulation. [Subjects and Methods] Eleven patients who were diagnosed with lymphedema were selected as the subjects of the study. The experimental group received transcutaneous electrical nerve stimulation treatment on edema regions three times per week for four weeks. Surface tape measurement was used to measure changes in lower extremity edema. Pain intensity was measured using the visual analog scale. [Results] The edema decrements in the experimental group were significantly larger than those in the control group. The pain decrements in the experimental group were significantly larger than those in the control group. [Conclusion] In conclusion, application of transcutaneous electrical nerve stimulation was confirmed to be effective in reducing edema and pain.
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DOI: 10.1589/jpts.28.3084
PubMed: 27942125
PubMed Central: 5140805
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Edema and pain reduction using transcutaneous electrical nerve stimulation
treatment</title><author><name sortKey="Choi, Yeong Deok" sort="Choi, Yeong Deok" uniqKey="Choi Y" first="Yeong-Deok" last="Choi">Yeong-Deok Choi</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Lee, Jung Ho" sort="Lee, Jung Ho" uniqKey="Lee J" first="Jung-Ho" last="Lee">Jung-Ho Lee</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27942125</idno><idno type="pmc">5140805</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5140805</idno><idno type="RBID">PMC:5140805</idno><idno type="doi">10.1589/jpts.28.3084</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">004124</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">004124</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Edema and pain reduction using transcutaneous electrical nerve stimulation
treatment</title><author><name sortKey="Choi, Yeong Deok" sort="Choi, Yeong Deok" uniqKey="Choi Y" first="Yeong-Deok" last="Choi">Yeong-Deok Choi</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Lee, Jung Ho" sort="Lee, Jung Ho" uniqKey="Lee J" first="Jung-Ho" last="Lee">Jung-Ho Lee</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] The purpose of this study was to investigate the impact on the edema and pain
when applying transcutaneous electrical nerve stimulation. [Subjects and Methods] Eleven
patients who were diagnosed with lymphedema were selected as the subjects of the study.
The experimental group received transcutaneous electrical nerve stimulation treatment on
edema regions three times per week for four weeks. Surface tape measurement was used to
measure changes in lower extremity edema. Pain intensity was measured using the visual
analog scale. [Results] The edema decrements in the experimental group were significantly
larger than those in the control group. The pain decrements in the experimental group were
significantly larger than those in the control group. [Conclusion] In conclusion,
application of transcutaneous electrical nerve stimulation was confirmed to be effective
in reducing edema and pain.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Martin Ginis, Ka" uniqKey="Martin Ginis K">KA Martin Ginis</name></author><author><name sortKey="Ma, Jk" uniqKey="Ma J">JK Ma</name></author><author><name sortKey="Latimer Cheung, Ae" uniqKey="Latimer Cheung A">AE Latimer-Cheung</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Boccardo, F" uniqKey="Boccardo F">F Boccardo</name></author><author><name sortKey="Valenzano, M" uniqKey="Valenzano M">M Valenzano</name></author><author><name sortKey="Costantini, S" uniqKey="Costantini S">S Costantini</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Scallan, Jp" uniqKey="Scallan J">JP Scallan</name></author><author><name sortKey="Zawieja, Sd" uniqKey="Zawieja S">SD Zawieja</name></author><author><name sortKey="Castorena Gonzalez, Ja" uniqKey="Castorena Gonzalez J">JA Castorena-Gonzalez</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Paskett, Ed" uniqKey="Paskett E">ED Paskett</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wou, J" uniqKey="Wou J">J Wou</name></author><author><name sortKey="Williams, Kj" uniqKey="Williams K">KJ Williams</name></author><author><name sortKey="Davies, Ah" uniqKey="Davies A">AH Davies</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pal, Us" uniqKey="Pal U">US Pal</name></author><author><name sortKey="Kumar, L" uniqKey="Kumar L">L Kumar</name></author><author><name sortKey="Mehta, G" uniqKey="Mehta G">G Mehta</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Karasuno, H" uniqKey="Karasuno H">H Karasuno</name></author><author><name sortKey="Ogihara, H" uniqKey="Ogihara H">H Ogihara</name></author><author><name sortKey="Morishita, K" uniqKey="Morishita K">K Morishita</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Elwell, R" uniqKey="Elwell R">R Elwell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gandhi, Sk" uniqKey="Gandhi S">SK Gandhi</name></author><author><name sortKey="Powers, Jc" uniqKey="Powers J">JC Powers</name></author><author><name sortKey="Nomeir, Am" uniqKey="Nomeir A">AM Nomeir</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hwang, Jh" uniqKey="Hwang J">JH Hwang</name></author><author><name sortKey="Kwon, Jy" uniqKey="Kwon J">JY Kwon</name></author><author><name sortKey="Lee, Kw" uniqKey="Lee K">KW Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Feger, Ma" uniqKey="Feger M">MA Feger</name></author><author><name sortKey="Goetschius, J" uniqKey="Goetschius J">J Goetschius</name></author><author><name sortKey="Love, H" uniqKey="Love H">H Love</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bilgili, A" uniqKey="Bilgili A">A Bilgili</name></author><author><name sortKey="Cak R, T" uniqKey="Cak R T">T Çakır</name></author><author><name sortKey="Do An, K" uniqKey="Do An ">ŞK Doğan</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27942125</article-id><article-id pub-id-type="pmc">5140805</article-id><article-id pub-id-type="publisher-id">jpts-2016-619</article-id><article-id pub-id-type="doi">10.1589/jpts.28.3084</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Edema and pain reduction using transcutaneous electrical nerve stimulation
treatment</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Choi</surname><given-names>Yeong-Deok</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lee</surname><given-names>Jung-Ho</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy, Kyungdong University: Bongpo-ri, Toseong-myeon, Goseong-gun, Gangwon-do, Republic of Korea</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Jung-Ho Lee, Department of Physical Therapy, Kyungdong University:
Bongpo-ri, Toseong-myeon, Goseong-gun, Gangwon-do, Republic of Korea. (E-mail: <email xlink:href="ljhcivapt@naver.com">ljhcivapt@naver.com</email>)</corresp></author-notes><pub-date pub-type="epub"><day>29</day><month>11</month><year>2016</year></pub-date><pub-date pub-type="ppub"><month>11</month><year>2016</year></pub-date><volume>28</volume><issue>11</issue><fpage>3084</fpage><lpage>3087</lpage><history><date date-type="received"><day>09</day><month>6</month><year>2016</year></date><date date-type="accepted"><day>19</day><month>7</month><year>2016</year></date></history><permissions><copyright-statement>2016©by the Society of Physical Therapy Science. Published by IPEC
Inc.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] The purpose of this study was to investigate the impact on the edema and pain
when applying transcutaneous electrical nerve stimulation. [Subjects and Methods] Eleven
patients who were diagnosed with lymphedema were selected as the subjects of the study.
The experimental group received transcutaneous electrical nerve stimulation treatment on
edema regions three times per week for four weeks. Surface tape measurement was used to
measure changes in lower extremity edema. Pain intensity was measured using the visual
analog scale. [Results] The edema decrements in the experimental group were significantly
larger than those in the control group. The pain decrements in the experimental group were
significantly larger than those in the control group. [Conclusion] In conclusion,
application of transcutaneous electrical nerve stimulation was confirmed to be effective
in reducing edema and pain.</p></abstract><kwd-group><kwd>Edema</kwd><kwd>Pain</kwd><kwd>TENS</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Recently, the world has been affected by diverse changes, such as new developments in
medicine, the acceleration of aging in society, increases in chronic diseases, and increases
in demand for high-grade medical services as a result of the enhancement of the health
consciousness of people worldwide. The need for physical therapy has rapidly increased, as
patients with chronic conditions and aging populations have increased, as have the number of
people with disabilities due to accidents<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>.</p><p>Although the possibility of exacerbation of lower extremity edema and lower extremity pain
and fatigue is very high—because the lower extremities are far from the heart, blood pushing
out from the heart toward the lower extremities cannot be easily returned to the heart, and
poor blood circulation in the lower extremities leads to waste congestion—interest in and
management of the lower extremities are quite insufficient. In addition, researchers have
reported that chronic lower extremity venous edema accompanied by varicose veins, lower
extremity edema, and pain occurs only as a result of working in a standing posture for eight
hours per day<xref rid="r2" ref-type="bibr">2</xref><sup>)</sup>.</p><p>Depending on its causes, lymphedema can be divided into primary lymphedema and secondary
lymphedema. It can be further divided into acute and chronic lymphedema, depending upon the
duration of occurrence. Primary lymphedema is secondarily caused by lymphatic vessel
aplasia, hypoplasia, or atresia, which can occur at any time. In addition, primary
lymphedema occurs more frequently in females than in males, and in particular, it frequently
occurs in the lower extremities, below the knees<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>.</p><p>Because lymphedema cannot be completely cured once it has occurred, preventing further
exacerbation and minimizing edema are essential. However, the threats and risk factors of
lymphedema are underestimated, despite its frequent occurrence and diagnosis in medical
clinics<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>.</p><p>In severe cases, as the proteins exuded from blood vessels into tissues are deposited,
edema is known to cause fibrosis of joints, muscles, nerves, and blood vessels, bacterial
infection, joint contracture, pain, and restriction of the activities of daily living.
Effective treatment of edema, regardless of its cause, increases blood flow through the
lymphatic vessels and veins and includes lifting treatment, electrical stimulation, joint
movement, pneumatic compression, elastic support bandage compression, and massage<xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>.</p><p>Electrical stimulation treatment includes iontophoresis, electrical nerve stimulation, and
repetitive magnetic stimulation. Transcutaneous electrical nerve stimulation (TENS), which
is an electrical stimulation method, is known to effectively relieve pain in myofascial pain
syndrome and can induce muscular contraction when the intensity and duration of stimulation
are adjusted<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>. As mobile equipment has
been developed to facilitate patient access to these treatments, electrical stimulation can
be used without respect to location and is currently used by clinics in many areas for pain
relief and functional improvement<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>.</p><p>However, studies on the treatment of lower extremity edema using TENS are rather sparse.
Therefore, the present study was conducted to examine the effects of TENS on pain relief in
lower extremity lymphedema patients.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>In the present study, 11 patients who were diagnosed with lower extremity lymphedema among
patients who visited a hospital and who agreed to participate in the study were randomly
assigned to an experimental group (TENS group) of six patients who received TENS treatment
or a control group of five patients who received drug treatment. The experimental group
received TENS treatment on edema regions three times per week for four weeks, and the
control group took drugs prescribed by the doctor three times per week for four weeks. A
preliminary evaluation was conducted before the interventions, and an ex post facto
evaluation was conducted four weeks after the last intervention was completed. A general
explanation of the study, including its content and purpose, was provided to the study
subjects. All the subjects understood the purpose of the study. All provided written
informed consent prior to participation according as the ethical standards of the
Declaration of Helsinki.</p><p>Surface tape measurement, generally used to evaluate increases in the volume of
extremities, was used to measure changes in lower extremity edema. Regarding the measurement
technique, the tape measure was not pulled taut, and the skin was not pressed against at any
time by the tape measure. Measurement was conducted three times, and the average value of
these three measurements was recorded as the measured value (cm). The circumference of the
calf was measured with the subjects in a sitting position and the knee joint bent to 90°,
with the measurement being taken in the region ranging from the thickest part of the calf to
the front of the tibia.</p><p>Pain intensity was measured using the visual analog scale. The visual analog scale consists
of a 100 mm-long straight line. The left end of the straight line represents no pain, with a
score of 0 points, and the right end of the line represents a state of maximum pain, with a
score of 100 points. The therapist verbally asked the patient the degree of current pain and
marked the degree of pain indicated by the patient as the measured value on the line.</p><p>The transcutaneous electrical nerve stimulation treatment was implemented using stimulation
in the form of 100 Hz asymmetrical biphasic pulsed waves delivered by a portable Enraf
Nonius 911 ENS (Netherlands). Surface electrodes were attached to the calf region, and
stimulation at intensities lower than 39 mA, where muscle contraction occurs, was
administered. The intensity at which local sensitization occurred without too much
discomfort was determined by increasing the stimulation in 1 mA increments beginning at 10
mA. Stimulation at this intensity was sustained for 20 minutes.</p><p>The data obtained in the present study were statistically processed using IBM SPSS
Statistics for Windows, version 20.0, and all measured values are presented as means and
standard deviations. Paired sample t-tests were used to evaluate the differences between the
before-experiment and after-experiment values in each group, and independent sample t-tests
were conducted to examine intergroup differences in terms of the amount of change after the
interventions between the two groups. The statistical significance level was set to
0.05.</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p>An intergroup comparison of the amount of change in the circumference of the lower
extremities between the experimental group and the control group showed statistically
significant differences: the edema decrements in the experimental group were significantly
larger than those in the control group (<xref rid="tbl_001" ref-type="table">Table
1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Comparison of edema between groups</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Pre-test (cm)</th><th align="center" rowspan="1" colspan="1">Post-test (cm)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">TENS group (n=6)*</td><td align="center" rowspan="1" colspan="1">45.8 ± 5.1</td><td align="center" rowspan="1" colspan="1">37.9 ± 5.1</td></tr><tr><td align="left" rowspan="1" colspan="1">Control group (n=5)*</td><td align="center" rowspan="1" colspan="1">42.6 ± 6.1</td><td align="center" rowspan="1" colspan="1">39.75 ± 4.8</td></tr><tr><td align="left" rowspan="1" colspan="1">Intergroup</td><td align="center" colspan="2" rowspan="1">0.29<sup>#</sup></td></tr></tbody></table><table-wrap-foot><p>Values are shown as the mean ± standard deviation. *p<0.05 (intragroup),
#p<0.05 (intergroup)</p></table-wrap-foot></table-wrap>).</p><p>In terms of intragroup comparison of lower extremity pain before and after the experiment,
both the experimental group and the control group showed statistically significant
differences. Intergroup comparison of the amount of change in lower extremity pain between
the experimental group and the control group also showed statistically significant
differences. The amount of change in the experimental group was significantly larger than in
the control group. The pain decrements in the experimental group were significantly larger
than those in the control group (<xref rid="tbl_002" ref-type="table">Table
2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Comparison of pain between groups (Mean ± SD)</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Pre-test (mm)</th><th align="center" rowspan="1" colspan="1">Post-test (mm)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">TENS group (n=6)*</td><td align="center" rowspan="1" colspan="1">62.74 ± 12.75</td><td align="center" rowspan="1" colspan="1">27.62 ± 11.37</td></tr><tr><td align="left" rowspan="1" colspan="1">Control group (n=5)*</td><td align="center" rowspan="1" colspan="1">69.11 ± 10.46</td><td align="center" rowspan="1" colspan="1">47.39 ± 12.57</td></tr><tr><td align="left" rowspan="1" colspan="1">Intergroup</td><td align="center" colspan="2" rowspan="1">0.00<sup>#</sup></td></tr></tbody></table><table-wrap-foot><p>Values are shown as the mean ± standard deviation. *p<0.05 (intragroup),
#p<0.05 (intergroup)</p></table-wrap-foot></table-wrap>).</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>The lymphatic system plays a role in absorbing excess water, proteins, fat, and dead cells
in the empty spaces around cells and returning them to the blood vessel system. It
transports wastes from tissues while enabling the human body to maintain its body fluid
balance. Edema refers to an increased fluid volume in the body when the distribution of
water, which is normally well distributed, becomes unbalanced. That is, when fat accumulates
in blood vessels, leading to poor blood circulation, or there is an obstacle preventing the
flow of lymph fluid, the homeostasis of the moisture content of cells is broken, leading to
the development of edema<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>.</p><p>When the hydrostatic water pressure increases at the distal ends of the veinlets in the
microcirculatory system, the filtration pressure increases, causing an increase in body
fluid inflow from the blood vessels into the interstitial tissues, leading to edema. Edema
causes a heavy feeling and a feeling of constriction, and it also causes discomfort because
of the increased length of diffusion for movement of nutrients, causing nutrients to not be
properly supplied and wastes to not be properly excreted. This condition is defined as lower
extremity edema<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>.</p><p>The causes of lower extremity edema are diverse and include heart disease, overwork, and
hypertension. Edema also can appear when amygdalitis or upper respiratory inflammation
occurred. In addition, edema can occur in cases of high mental stress, poor nutrition, diets
with salty foods or packaged foods, and excessive alcohol consumption, as a result of
adverse drug effects of hormone drugs or anti-inflammatory analgesic drugs, or due to
abnormalities in hormone secretions occurring before and after menstruation in females<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>.</p><p>In the case of chronic lymphedema that has progressed for three months or longer, the
possibility of pitting edemas is low, and most cases are stage 2 or 3 lymphedema accompanied
by tissue changes including thickening and hardening of the skin and subcutaneous tissues.
Lymphedema in these cases may show changes, is likely to cause cellulitis and chronic skin
ulcers, and is likely to have been reported as unresponsive to existing treatment methods,
such as pneumatic compression, massage, and complex decongestive physical therapy<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>. Therefore, the importance of initial
treatment of edema has been magnified, and in the case of chronic edema, the necessity of
new treatment methods has come to the fore.</p><p>Electrical stimulation treatments are one of the initial treatment methods of edema that
enable quantitative management of the intensity, duration, and frequency of treatment for
consistent and accurate treatment of the region of edema<xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>. In a study conducted by Bilgili et al. that examined the effects
of TENS on the pain, joint range of motion (ROM), and edema of pain syndrome patients, the
subjects were randomly divided into groups to examine treatment results. The researchers
reported that, according to the results of the study, pain and edema decreased, while joint
ROM increased in the experimental group that received TENS therapy<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>.</p><p>Likewise, in the present study, it was found that edema and pain statistically
significantly decreased in the experimental group that received TENS when compared with the
levels in the control group. These results are considered attributable to the fact that
electrical stimulation caused repetitive muscle contraction and relaxation, such that the
microenvironments of the muscle cells were controlled to maintain the homeostasis of
cellular osmotic pressure and promote the decomposition of pain-causing substances.</p><p>Limitations of the present study include the fact that treatment effects cannot be
generalized, because the number of study subjects was small, the onset of disease in the
patients was not uniform, and intervention effects were not continuously observed over time.
In addition, only edema and pain were evaluated, and a dynamic evaluation according to
changes in cell levels and gait was not conducted. The author hopes that studies will be
conducted in the future that address these limitations with more study subjects and
evaluations conducted using multilateral methods over time.</p></sec></body><back><ref-list><title>REFERENCES</title><ref id="r1"><label>1</label><mixed-citation publication-type="journal"><person-group><name><surname>Martin Ginis</surname><given-names>KA</given-names></name><name><surname>Ma</surname><given-names>JK</given-names></name><name><surname>Latimer-Cheung</surname><given-names>AE</given-names></name><etal>et al.</etal></person-group>: <article-title>A systematic review of review articles addressing factors
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