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THE EFFECT OF LUMBAR STABILIZATION EXERCISES ON CHRONIC LOW BACK PAIN PATIENTS

Year 2023, Volume: 30 Issue: 4, 610 - 618, 30.12.2023
https://doi.org/10.17343/sdutfd.1309984

Abstract

Objective
The aim of this study is to investigate the effect
of lumbar stabilization exercises (LSE) on pain,
functional capacity, quality of life, and balance in
patients with chronic low back pain (CLBP), and also
to evaluate the effect on the cross-sectional area of
the lumbar multifidus muscle.
Material and Method
Sixty-six patients with CLBP were enrolled,
randomized, and divided into two groups. LSE,
transcutaneous electrical nerve stimulation (TENS),
and hot pack treatments were performed in Group
1 (n=28). In Group 2 (n=37), TENS and hot pack
treatments were performed only. Pre and 8-week
post-treatment assessments were made. Visual
Analog Scale (VAS) was used to evaluate pain.
Modified Oswestry Disability Index (ODI) and Roland
Morris Disability Questionnaire (RMDQ) were used
to evaluate the functional disability. Short Form-36
(SF-36) was used to measure the quality of life. In
the assessment of balance, a Tetrax® posturography
device (Sunlight Medical Ltd, Israel) was used and fall
index (FI) was calculated. The cross-sectional area of
multifidus muscles was measured by ultrasonography.
Results
Significant improvements regarding the crosssectional
area of multifidus musclesand subparameters
of SF-36 named physical role, pain,
mental health, and energy/vitality were determined in
Group 1 compared to Group 2 (p˂0.05). No significant
difference was present between the groups regarding
FI, VAS score, RMDQ, ODI, and balance.
Conclusion
Lumbar stabilization exercises in patients with chronic
low back pain multifidus positively affects crosssectional
area and quality of life. For our sample,
the addition of lumbar stabilization exercises to
the conventional physical therapy program does
not provides an additional contribution in terms of
balance, pain and disability.

References

  • 1. Hartvigsen J, Hancock MJ, Kongsted A, Quinette L, Ferreira M, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367. https:// doi:10.1016/S0140-6736(18)30480-X
  • 2. Van Tulder MW. Treatment of low back pain: myths and facts. Schmerz 2001;15(6):499-503. https://doi:10.1007/ s004820100038
  • 3. Alleva J, Hudgins T, Belous J, Kristin Origenes A. Chronic low back pain. Dis Mon 2016;62(9):330-333. https://doi:10.1016/j. disamonth.2016.05.012
  • 4. Saragiotto BT, de Almeida MO, Yamato TP, Maher CG. Multidisciplinary Biopsychosocial Rehabilitation for Nonspecific Chronic Low Back Pain. Physical therapy 2016;96(6):759-763. https://doi:10.2522/ptj.20150359
  • 5. Saragiotto BT, Maher CG, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, et al. Motor control exercise for chronic non-specific low-back pain. The Cochrane database of systematic reviews 2016;2016(1):CD012004. https:// doi:10.1002/14651858.CD012004
  • 6. Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo R, Cabral CMN, et al. Pilates for Low Back Pain: Complete Republication of a Cochrane Review. Spine 2016;41(12):1013- 1021. https://doi:10.1097/BRS.0000000000001398
  • 7. Coggon D, Ntani G, Palmer KT, Felli VE, Harari F, Quintana LA, et al. Drivers of international variation in prevalence of disabling low back pain: Findings from the Cultural and Psychosocial Influences on Disability study. European journal of pain 2019;23(1):35-45. https://doi:10.1002/ejp.1255
  • 8. Goubert D, Oosterwijck JV, Meeus M, Danneels L. Structural Changes of Lumbar Muscles in Non-specific Low Back Pain: A Systematic Review. Pain physician 2016;19(7):E985-E1000.
  • 9. Reeves NP, Cholewicki J, van Dieen JH, Kawchuk G, Hodges PW. Are Stability and Instability Relevant Concepts for Back Pain? The Journal of orthopaedic and sports physical therapy 2019;49(6):415-424. https://doi:10.2519/jospt.2019.8144
  • 10. Faur C, Patrascu JM, Haragus H, Anglitoiu B. Correlation between multifidus fatty atrophy and lumbar disc degeneration in low back pain. BMC Musculoskelet Disord. 2019 Sep 5;20(1):414. doi: 10.1186/s12891-019-2786-7.
  • 11. Chung S, Lee J, Yoon J. Effects of stabilization exercise using a ball on multifidus cross-sectional area in patients with chronic low back pain. Journal of sports science & medicine 2013;12(3):533-541.
  • 12. França FR, Burke TN, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics2010;65(10):1013-1017. https://doi:10.1590/s1807-59322010001000015
  • 13. Nascimento P, Costa LOP, Araujo AC, Poitras S, Bilodeau M. Effectiveness of interventions for non-specific low back pain in older adults. A systematic review and meta-analysis. Physiotherapy 2019;105(2):147-162. https://doi:10.1016/j. physio.2018.11.004
  • 14. Yakut E, Duger T, Oksuz C, Yorukan S, Ureten K, Turan D, et al. Validation of the Turkish version of the Oswestry Disability Index for patients with low back pain. Spine 2004;29(5):581- 585. https://doi:10.1097/01.brs.0000113869.13209.03
  • 15. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141-144. https:// doi:10.1097/00007632-198303000-00004
  • 16. Ceran F, Ozcan A. The relationship of the Functional Rating Index with disability, pain, and quality of life in patients with low back pain. Medical science monitor: international medical journal of experimental and clinical research 2006;12(10):CR435- CR439.
  • 17. Kocyigit H. Kisa Form-36 (KF-36)'nm Türkçe versiyonunun güvenilirliği ve geçerliliği. İlaç ve tedavi dergisi 1999;12:102-106.
  • 18. Akkaya N, Doganlar N, Celik E, Aysse SE, Akkaya S, Gungor HR, et al. Test-Retest Reliability of Tetrax(R) Static Posturography System in Young Adults with Low Physical Activity Level. International journal of sports physical therapy2015;10(6):893-900.
  • 19. Hides JA, Richardson CA, Jull GA. Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle. Comparison of two different modalities. Spine 1995;20(1):54- 58. https://doi:10.1097/00007632-199501000-00010
  • 20. Liu IS, Chai HM, Yang JL, Wang SF. Inter-session reliability of the measurement of the deep and superficial layer of lumbar multifidus in young asymptomatic people and patients with low back pain using ultrasonography. Manual therapy 2013;18(6):481-486. https://doi:10.1016/j.math.2013.04.006
  • 21. Nabavi N, Mosallanezhad Z, Haghighatkhah HR, Mohseni Bandpeid MA. Reliability of rehabilitative ultrasonography to measure transverse abdominis and multifidus muscle dimensions. Iranian journal of radiology: a quarterly journal published by the Iranian Radiological Society 2014;11(3):e21008. doi:10.5812/iranjradiol.21008
  • 22. Rahmani N, Kiani A, Mohseni-Bandpei MA, Abdollahi I. Multifidus muscle size in adolescents with and without back pain using ultrasonography. Journal of bodywork and movement therapies 2018;22(1):147-151. https://doi:10.1016/j. jbmt.2017.05.016
  • 23. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of lumbar multifidus muscle: normal reference ranges for measurements and practical guidance on the technique. Manual therapy 2005;10(2):116-126. https://doi:10.1016/j.math.2004.08.013
  • 24. Hlaing SS, Puntumetakul R, Khine EE, Boucaut R. Effects of core stabilization exercise and strengthening exercise on proprioception, balance, muscle thickness and pain related outcomes in patients with subacute nonspecific low back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2021 Nov 30;22(1):998. doi: 10.1186/s12891-021-04858-6.
  • 25. Kumar SP. Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo-controlled crossover study. North American journal of medical sciences 2011;3(10):456- 461. https://doi:10.4297/najms.2011.3456
  • 26. Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, et al. A metaanalysis of core stability exercise versus general exercise for chronic low back pain. PloS one 2012;7(12):e52082. https:// doi:10.1371/journal.pone.0052082
  • 27. Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279-1287. doi: 10.1136/bjsports-2019-100886.
  • 28. Bae CR, Jin Y, Yoon BC, Kim NH, Park KW, Lee SH. Effects of assisted sit-up exercise compared to core stabilization exercise on patients with non-specific low back pain: A randomized controlled trial. J Back Musculoskelet Rehabil. 2018;31(5):871- 880. doi: 10.3233/BMR-170997.
  • 29. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131(1-2):31-37. https://doi:10.1016/j.pain.2006.12.008.
  • 30. Unsgaard-Tondel M, Fladmark AM, Salvesen O, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Physical therapy 2010;90(10):1426-1440. https://doi:10.2522/ptj.20090421
  • 31. Kim S, Kim H, Chung J. Effects of Spinal Stabilization Exercise on the Cross-sectional Areas of the Lumbar Multifidus and Psoas Major Muscles, Pain Intensity, and Lumbar Muscle Strength of Patients with Degenerative Disc Disease. Journal of physical therapy science 2014;26(4):579-582. https:// doi:10.1589/jpts.26.579
  • 32. Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on multifidus muscle crosssectional area among young elite cricketers with low back pain. The Journal of orthopaedic and sports physical therapy 2008;38(3):101-108. https://doi:10.2519/jospt.2008.2658
  • 33. Cho I, Jeon C, Lee S, Lee D, Hwangbo G. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. Journal of physical therapy science 2015;27(6):1983-1985. https:// doi:10.1589/jpts.27.1983
  • 34. Vasseljen O, Fladmark AM. Abdominal muscle contraction thickness and function after specific and general exercises: a randomized controlled trial in chronic low back pain patients. Manual therapy 2010;15(5):482-489. https://doi:10.1016/j. math.2010.04.004
  • 35. Gökmen NE, Eroglu N. Kronik bel ağrısı olan hastalarda pilates ve lomber stabilizasyon egzersizlerinin etkinliğinin karşılaştırılması. Uludağ Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Ana Bilim Dali Tıpta Uzmanlık Tezi. Bursa Uludag University. 2015.

KRONİK BEL AĞRILI HASTALARDA LOMBER STABİLİZASYON EGZERSİZLERİNİN ETKİSİ

Year 2023, Volume: 30 Issue: 4, 610 - 618, 30.12.2023
https://doi.org/10.17343/sdutfd.1309984

Abstract

Amaç
Bu çalışmanın amacı kronik bel ağrısı olan hastalarda
lomber stabilizasyon egzersizlerinin (LSE) ağrı,
fonksiyonel kapasite, yaşam kalitesi ve denge üzerine
etkisini araştırmak, ayrıca lomber multifidus kası kesitsel
alanına etkisini değerlendirmektir.
Gereç ve Yöntem
Çalışmaya kronik bel ağrısı tanısı alan 66 hasta alındı.
Hastalar randomize edilerek iki gruba ayrıldı. Birinci
gruba (Grup 1, n=28) lomber stabilizasyon egzersizleri,
TENS ve Hotpack tedavileri, ikinci gruba (Grup
2, n=37) ise sadece TENS, Hotpack tedavileri verildi.
Hastalar tedavi öncesi ve tedavi sonrası 8. haftada
değerlendirildi. Ağrı için Visuel Analog Skala (VAS),
fonksiyonel dizabilite için Roland Morris Sorgulama
Anketi ve Oswestry Özürlülük İndeksi, yaşam kalitesi
için Kısa Form-36 (SF-36) ile değerlendirme yapıldı.
Denge değerlendirmesinde Tetrax® posturografi cihazı
(SunlightMedicalLtd, İsrail) kullanıldı ve düşme
indeksi (FI) hesaplandı. Multifidus kası kesit alanı ultrasonografi
ile ölçüldü.
Bulgular
Gruplar arası karşılaştırıldığında multifidus kası kesitsel
alanı, SF-36`nın fiziksel rol güçlüğü, ağrı, ruhsal
sağlık ve enerji/vitalite/ canlılık alt parametrelerinde
LSE alan hastalarda daha anlamlı iyileşme gözlendi(
p˂0.05). Düşme indeksi, VAS skorları, Roland Morris
Sorgulama Anketi ve Oswestry Özürlülük İndeksi
skorlarında gruplar arasında anlamlı farklılık saptanmadı.
Sonuç
Lomber stabilizasyon egzersizleri, kronik bel ağrısı
olan hastalarda multifidus kesit alanını ve yaşam kalitesini
olumlu yönde etkilemektedir. Bizim örneklemimiz
için lomber stabilizasyon egzersizlerinin konvansiyonel
fizik tedavi programına eklenmesi denge, ağrı
ve dizabilite açısından ek katkı sağlamamaktadır.

References

  • 1. Hartvigsen J, Hancock MJ, Kongsted A, Quinette L, Ferreira M, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367. https:// doi:10.1016/S0140-6736(18)30480-X
  • 2. Van Tulder MW. Treatment of low back pain: myths and facts. Schmerz 2001;15(6):499-503. https://doi:10.1007/ s004820100038
  • 3. Alleva J, Hudgins T, Belous J, Kristin Origenes A. Chronic low back pain. Dis Mon 2016;62(9):330-333. https://doi:10.1016/j. disamonth.2016.05.012
  • 4. Saragiotto BT, de Almeida MO, Yamato TP, Maher CG. Multidisciplinary Biopsychosocial Rehabilitation for Nonspecific Chronic Low Back Pain. Physical therapy 2016;96(6):759-763. https://doi:10.2522/ptj.20150359
  • 5. Saragiotto BT, Maher CG, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, et al. Motor control exercise for chronic non-specific low-back pain. The Cochrane database of systematic reviews 2016;2016(1):CD012004. https:// doi:10.1002/14651858.CD012004
  • 6. Yamato TP, Maher CG, Saragiotto BT, Hancock MJ, Ostelo R, Cabral CMN, et al. Pilates for Low Back Pain: Complete Republication of a Cochrane Review. Spine 2016;41(12):1013- 1021. https://doi:10.1097/BRS.0000000000001398
  • 7. Coggon D, Ntani G, Palmer KT, Felli VE, Harari F, Quintana LA, et al. Drivers of international variation in prevalence of disabling low back pain: Findings from the Cultural and Psychosocial Influences on Disability study. European journal of pain 2019;23(1):35-45. https://doi:10.1002/ejp.1255
  • 8. Goubert D, Oosterwijck JV, Meeus M, Danneels L. Structural Changes of Lumbar Muscles in Non-specific Low Back Pain: A Systematic Review. Pain physician 2016;19(7):E985-E1000.
  • 9. Reeves NP, Cholewicki J, van Dieen JH, Kawchuk G, Hodges PW. Are Stability and Instability Relevant Concepts for Back Pain? The Journal of orthopaedic and sports physical therapy 2019;49(6):415-424. https://doi:10.2519/jospt.2019.8144
  • 10. Faur C, Patrascu JM, Haragus H, Anglitoiu B. Correlation between multifidus fatty atrophy and lumbar disc degeneration in low back pain. BMC Musculoskelet Disord. 2019 Sep 5;20(1):414. doi: 10.1186/s12891-019-2786-7.
  • 11. Chung S, Lee J, Yoon J. Effects of stabilization exercise using a ball on multifidus cross-sectional area in patients with chronic low back pain. Journal of sports science & medicine 2013;12(3):533-541.
  • 12. França FR, Burke TN, Hanada ES, Marques AP. Segmental stabilization and muscular strengthening in chronic low back pain: a comparative study. Clinics2010;65(10):1013-1017. https://doi:10.1590/s1807-59322010001000015
  • 13. Nascimento P, Costa LOP, Araujo AC, Poitras S, Bilodeau M. Effectiveness of interventions for non-specific low back pain in older adults. A systematic review and meta-analysis. Physiotherapy 2019;105(2):147-162. https://doi:10.1016/j. physio.2018.11.004
  • 14. Yakut E, Duger T, Oksuz C, Yorukan S, Ureten K, Turan D, et al. Validation of the Turkish version of the Oswestry Disability Index for patients with low back pain. Spine 2004;29(5):581- 585. https://doi:10.1097/01.brs.0000113869.13209.03
  • 15. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983;8(2):141-144. https:// doi:10.1097/00007632-198303000-00004
  • 16. Ceran F, Ozcan A. The relationship of the Functional Rating Index with disability, pain, and quality of life in patients with low back pain. Medical science monitor: international medical journal of experimental and clinical research 2006;12(10):CR435- CR439.
  • 17. Kocyigit H. Kisa Form-36 (KF-36)'nm Türkçe versiyonunun güvenilirliği ve geçerliliği. İlaç ve tedavi dergisi 1999;12:102-106.
  • 18. Akkaya N, Doganlar N, Celik E, Aysse SE, Akkaya S, Gungor HR, et al. Test-Retest Reliability of Tetrax(R) Static Posturography System in Young Adults with Low Physical Activity Level. International journal of sports physical therapy2015;10(6):893-900.
  • 19. Hides JA, Richardson CA, Jull GA. Magnetic resonance imaging and ultrasonography of the lumbar multifidus muscle. Comparison of two different modalities. Spine 1995;20(1):54- 58. https://doi:10.1097/00007632-199501000-00010
  • 20. Liu IS, Chai HM, Yang JL, Wang SF. Inter-session reliability of the measurement of the deep and superficial layer of lumbar multifidus in young asymptomatic people and patients with low back pain using ultrasonography. Manual therapy 2013;18(6):481-486. https://doi:10.1016/j.math.2013.04.006
  • 21. Nabavi N, Mosallanezhad Z, Haghighatkhah HR, Mohseni Bandpeid MA. Reliability of rehabilitative ultrasonography to measure transverse abdominis and multifidus muscle dimensions. Iranian journal of radiology: a quarterly journal published by the Iranian Radiological Society 2014;11(3):e21008. doi:10.5812/iranjradiol.21008
  • 22. Rahmani N, Kiani A, Mohseni-Bandpei MA, Abdollahi I. Multifidus muscle size in adolescents with and without back pain using ultrasonography. Journal of bodywork and movement therapies 2018;22(1):147-151. https://doi:10.1016/j. jbmt.2017.05.016
  • 23. Stokes M, Rankin G, Newham DJ. Ultrasound imaging of lumbar multifidus muscle: normal reference ranges for measurements and practical guidance on the technique. Manual therapy 2005;10(2):116-126. https://doi:10.1016/j.math.2004.08.013
  • 24. Hlaing SS, Puntumetakul R, Khine EE, Boucaut R. Effects of core stabilization exercise and strengthening exercise on proprioception, balance, muscle thickness and pain related outcomes in patients with subacute nonspecific low back pain: a randomized controlled trial. BMC Musculoskelet Disord. 2021 Nov 30;22(1):998. doi: 10.1186/s12891-021-04858-6.
  • 25. Kumar SP. Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo-controlled crossover study. North American journal of medical sciences 2011;3(10):456- 461. https://doi:10.4297/najms.2011.3456
  • 26. Wang XQ, Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, et al. A metaanalysis of core stability exercise versus general exercise for chronic low back pain. PloS one 2012;7(12):e52082. https:// doi:10.1371/journal.pone.0052082
  • 27. Owen PJ, Miller CT, Mundell NL, Verswijveren SJJM, Tagliaferri SD, Brisby H, Bowe SJ, Belavy DL. Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis. Br J Sports Med. 2020 Nov;54(21):1279-1287. doi: 10.1136/bjsports-2019-100886.
  • 28. Bae CR, Jin Y, Yoon BC, Kim NH, Park KW, Lee SH. Effects of assisted sit-up exercise compared to core stabilization exercise on patients with non-specific low back pain: A randomized controlled trial. J Back Musculoskelet Rehabil. 2018;31(5):871- 880. doi: 10.3233/BMR-170997.
  • 29. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, et al. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain 2007;131(1-2):31-37. https://doi:10.1016/j.pain.2006.12.008.
  • 30. Unsgaard-Tondel M, Fladmark AM, Salvesen O, Vasseljen O. Motor control exercises, sling exercises, and general exercises for patients with chronic low back pain: a randomized controlled trial with 1-year follow-up. Physical therapy 2010;90(10):1426-1440. https://doi:10.2522/ptj.20090421
  • 31. Kim S, Kim H, Chung J. Effects of Spinal Stabilization Exercise on the Cross-sectional Areas of the Lumbar Multifidus and Psoas Major Muscles, Pain Intensity, and Lumbar Muscle Strength of Patients with Degenerative Disc Disease. Journal of physical therapy science 2014;26(4):579-582. https:// doi:10.1589/jpts.26.579
  • 32. Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on multifidus muscle crosssectional area among young elite cricketers with low back pain. The Journal of orthopaedic and sports physical therapy 2008;38(3):101-108. https://doi:10.2519/jospt.2008.2658
  • 33. Cho I, Jeon C, Lee S, Lee D, Hwangbo G. Effects of lumbar stabilization exercise on functional disability and lumbar lordosis angle in patients with chronic low back pain. Journal of physical therapy science 2015;27(6):1983-1985. https:// doi:10.1589/jpts.27.1983
  • 34. Vasseljen O, Fladmark AM. Abdominal muscle contraction thickness and function after specific and general exercises: a randomized controlled trial in chronic low back pain patients. Manual therapy 2010;15(5):482-489. https://doi:10.1016/j. math.2010.04.004
  • 35. Gökmen NE, Eroglu N. Kronik bel ağrısı olan hastalarda pilates ve lomber stabilizasyon egzersizlerinin etkinliğinin karşılaştırılması. Uludağ Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Ana Bilim Dali Tıpta Uzmanlık Tezi. Bursa Uludag University. 2015.
There are 35 citations in total.

Details

Primary Language English
Subjects Health Services and Systems (Other)
Journal Section Araştırma Makaleleri
Authors

Kayra Barut 0000-0002-4743-3888

Engin Taştaban 0000-0001-9094-2904

Ömer Şendur 0000-0002-0718-9438

Publication Date December 30, 2023
Submission Date June 5, 2023
Acceptance Date October 14, 2023
Published in Issue Year 2023 Volume: 30 Issue: 4

Cite

Vancouver Barut K, Taştaban E, Şendur Ö. THE EFFECT OF LUMBAR STABILIZATION EXERCISES ON CHRONIC LOW BACK PAIN PATIENTS. Med J SDU. 2023;30(4):610-8.

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