Comparison of conventional therapy and mulligan mobilization with movement technique in the treatment of shoulder problems: A randomized controlled trial

doi:10.21203/rs.3.rs-5274021/v1

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Comparison of conventional therapy and mulligan mobilization with movement technique in the treatment of shoulder problems: A randomized controlled trial

https://doi.org/10.21203/rs.3.rs-5274021/v1

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Purpose: This study aimed to compare the efficacy of Mulligan mobilization with movement (MWM) and Conservative treatment (CT) in improving pain, AROM, and functional activities on shoulder pathology.

Methods: A prospective randomized, controlled clinical trial was conducted between June and October 2022. Forty one participants were randomly assigned to the CT + MWM (n=19) or CT-only group (n=22). Conventional therapy was applied to the CT group but The MWM technique was performed with 3 sets of 10 repetitions MWM group. All training sessions was applied five a week for 6 weeks in both groups (in total 30 sessions) by the same physiotherapist. The pain was evaluated with the Numeric Pain Rating Scale, AROM with the Universal goniometer, and functionality with the Patient Specific Functional Scale.

Results: In both groups, shoulder flexion, abduction, internal rotation (IR) and external rotation (ER), and AROM angles increased (p<0.05), shoulder pain decreased (p<0.05), and functionality increased (p<0.05). Although there is no statistically significant difference between the groups, the MWM technique applied in addition to CT is more effective in symptoms such as limitation of AROM, pain, and functionality.

Conclusion: MWM may be an effective manual therapy method on reducing of pain, increasing AROM, and improving functional status in patients with shoulder problems. Additionally, MWM technique applied in addition to CT may increase the success of the treatment.

Manuel therapy

Physical therapy

Shoulder

Pain

Functional status

Shoulder dysfunction is the second most common musculoskeletal problem seen in physical therapy and has many underlying causes ¹. Abnormal movements and positions of the scapula relative to the thorax are associated with shoulder pathologies such as tendinitis, Rotator Cuff Syndrome (RCS), Shoulder Impingement Syndrome (SIS), and glenohumeral instability ^2,3. Any muscle imbalance affecting the shoulder complex can alter scapular kinematics and shoulder motion symmetry ⁴. Often, the muscles are exposed to direct trauma, muscle weakness, force pair imbalance, or inhibition due to painful conditions around the shoulder and muscle strain due to microtrauma.

Shoulder pain is the third most common musculoskeletal pain in the clinic after low back pain and knee pain. The most common cause of shoulder pain is secondary to subacromial impingement and often involves lesions to the rotator cuff, and long head of the biceps, or may be due to subacromial bursitis, glenohumeral, and acromioclavicular osteoarthritis ⁵. It includes pain over the shoulder area (often radiating along the ipsilateral arm), restricted shoulder range of motion (ROM), decreased functional activities, and inhibited activities of daily living. Without proper treatment, symptoms can last several months or longer and tend to become chronic ⁶.

An objective evaluation should be made for the patient who applied to physiotherapy with shoulder joint pain and the rehabilitation program should be applied to the patient. Shoulder pain can be caused by one or more joints that make up the shoulder complex. A good assessment includes history taking, inspection, palpation, pain assessment, ROM assessment, special tests, and functional scales ⁷. Physiotherapists do not plan treatment by focusing only on patients' physiological and anatomical characteristics such as ROM, pain and muscle strength, and the mechanism of injury. At the same time, it is important to question the functional limitations of the patients or the negative changes in their social lives caused by the pain ⁸.

Conservative treatment (CT) of shoulder problems consists of a wide range of procedures such as exercise therapy; infiltration of corticosteroid, local anesthetic, prolotherapy, ice/heat therapy, Kinesio taping, electrotherapy, acupuncture, various types of manual therapy based on massage, manipulation, and joint mobilization procedures ^5,9. These procedures aim to reduce pain and restore pain-free shoulder motion to a full range. The effects of conservative treatment in terms of reducing pain, improving ROM, and improving the patient's overall function may depend on the underlying cause of shoulder pain and the types of treatment administered. However, it has been reported that the applications performed in the early period of CT are insufficient in reducing pain and improving joint functions in various diseases ¹⁰. The Mulligan concept is a concept of manual therapy techniques that are often used to reduce pain in peripheral joints in musculoskeletal problems. The technique of mobilization with motion involves the active movement of the patient simultaneously with the physical therapist's practice of manual gliding in the painful joint. With these properties it ensures safety and is used in the treatment of shoulder pain ^11,12. Although there are studies in the literature comparing the effect of Mulligan mobilization with movement (MWM) and CT used in shoulder problems ^13–15, studies evaluating patient-specific functionality are also limited ^16,17. This study aims to determine whether MWM and CT give different results on pain, ROM, and functional activities in participants with shoulder problems diagnosed with RCS and/or SIS.

2.1. Study Desing

A prospective randomized, controlled clinical trial was developed, consisting of two treatment groups. This study was carried out at xxx Physical Therapy and Rehabilitation Center between June and October 2022. Participants were randomly assigned to CT and MWM groups using a simple randomization method by a researcher. This study was approved by the Ethics Committee of the University (2022 − 962). This study was registered with clinicaltrials.gov (Clinical Trials Retrospectively Registration Number: NCT06187571). The written informed consent form was obtained from all patients included in the study by the Principles of the Declaration of Helsinki.

2.2. Participants

Out of 80 patients who were diagnosed with shoulder problems (RSC, SIS) in the clinic, 44 patients who met the inclusion and exclusion criteria were included in the treatment. Patients were divided into two groups by simple randomization method. Three participants from the MWM group withdrew from the study due to worsening symptoms, and the study was completed with 41 patients (Fig. 1). The patients included in the study had not received physical therapy before. Additionally, patients did not receive concurrent physical therapy or any other external intervention due to their shoulder problems during the study period. Study participants were conveniently recruited outpatient practice and scheduled and screened for physcial therapy appointments. Clinical testing was performed to ensure potential candidates met eligibility criteria. Inclusion criteria for the study: Being over 18 years old, having any shoulder problems (RSC, SIS) having a history of shoulder pain lasting at least 3 months, and volunteering to participate in the study. Exclusion criteria: Having systemic or degenerative disease, a neurological disease (eg, Parkinson's Disease, Multiple Sclerosis, Stroke), and having more than one upper extremity pathology.

2.3. Outcome Measure

In the clinic, an assessment questionnaire including sociodemographic questions was applied to the patients. Subsequently, clinical data were obtained by using the Numeric Pain Rating Scale (NPRS), ROM, and Patient Specific Functional Scale (PSFS).

The NPRS was used to assess the shoulder pain during rest, activity, and at night. The patient was asked to mark the point corresponding to the pain "0 no pain and 10 maximal pain". The marked point was recorded as a pain score ¹⁸. Shoulder flexion and abduction were measured in the sitting position, and internal rotation (IR) and external rotation (ER) was measured in the supine position using a Universal goniometer ¹⁹. Active range of motion (AROM) was measured and recorded in degrees. Patient-centered assessment scales are different from region-specific or disease-specific scales in that they are individual and provide a target-specific assessment. These scales differ from each other in terms of usage purpose, application method, and scoring, and PSFS is one of them. Depending on the current pathology, the patient is asked by the physiotherapist about three or five activities that she/he has difficulty doing. The patient is asked to score the activity between 0–10 points (0 points for not being able to do the activity at all; 10 points for being able to do the activity at the level before the current pain started). The overall scale score is determined by taking the average of the activity scores ²⁰, with higher scores indicating better function.

2.4. Interventions

The physiotherapy interventions for MWM and CT groups were performed by a single physiotherapist who had clinical experience in the MWM method. Cold packs, electrotherapy modalities (TENS, US, etc.), Codman exercises, wand, shoulder wheel, finger ladder, scapular mobilization, stretching, and strengthening exercises were applied to the CT group. The MWM technique was applied to the MWM group in addition to the CT. The MWM technique was applied in flexion, abduction, IR, and ER directions. The MWM technique was performed with 3 sets of 10 repetitions. The participant did not feel pain at any stage of MWM practice. In addition, patients were provided with patient education to change activities that cause pain. All training sessions was applied five a week for 6 weeks in both groups (in total 30 sessions) and assessments were made before and after the treatment.

2.5. Statistical analysis

The Statistical Package for Social Sciences (version 22.0; SPSS, Chicago, IL) software was used for statistical analysis. Descriptive statistics were calculated for all variables, and data are shown as mean standard deviation, and median (minimum-maximum). Descriptive features were compared using the Independent Samples T-test and the Chi-square test. Comparative analysis between groups and within the groups was performed by using the Mann–Whitney U test and Wilcoxon, and p < 0.05 was considered statistically significant.

Post-treatment shoulder flexion ROM in Menek et al.'s ¹³ study was used to determine sample size, and at least 22 sample sizes (5% type I error and 80% power, d = 0.81 effect size) were required for each group.

Data from 41 patients were analyzed in the study. Age, body mass index, gender, dominant and affected extremity, education level, occupation, and shoulder problems were found to be similar between the MWM and CT groups (p > 0.05) (Table 1.).

Table 1

Descriptive properties of groups
		MWM (n = 19)	CT (n = 22)	t, χ2	p
Age, years, X ± SD		48.26 ± 13.05	52.77 ± 10.17	t = 1.243	0 < 0.221
BMI, kg/m², X ± SD		26.85 ± 3.53	26.39 ± 3.15	t = 0.437	0 < 0.665
Gender, n (%)	Female	8 (42.1)	14 (63.6)	χ2 = 0.168	0.217
Gender, n (%)	Male	11 (57.9)	8 (36.4)	χ2 = 0.168	0.217
Dominant extremity, n (%)	Right	10 (52.6)	17 (77.3)	χ2 = 2.753	0.097
Dominant extremity, n (%)	Left	9 (47.4)	5 (22.7)	χ2 = 2.753	0.097
Non-dominant extremity, n (%)	Right	10 (52.6)	17 (77.3)	χ2 = 2.753	0.097
Non-dominant extremity, n (%)	Left	9 (47.4)	5 (22.7)	χ2 = 2.753	0.097
Educational level, n (%)	Primary school	3 (15.8)	12 (54.5)	χ2 = 7.152	0.067
	Middle school	2 (10.5)	2 (9.1)
	High school	7 (36.8)	5 (22.7)
	University	7 (36.8)	3 (13.6)
Occupation, n (%)	Working	8 (42.1)	6 (27.3)	χ2 = 0.997	0.318
Occupation, n (%)	Not Working	11 (57.9)	16 (72.7)	χ2 = 0.997	0.318
Diagnosis, n (%)	RCS	17 (89.5)	19 (86.4)	χ2 = 0.092	0.762
Diagnosis, n (%)	SIS	2 (10.5)	3 (13.6)	χ2 = 0.092	0.762
BMI: Body Mass Index, MWM: Mulligan Mobilization With Movement, CT: Conservative Treatment, RCS: Rotator Cuff Syndrome, SIS: Shoulder Impingement Syndrome, t: Independent Samples T-test, χ2: Chi-square test, p < 0.05

After treatment, when AROM measurements are examined; shoulder flexion, abduction, IR, and ER AROM angles increased in both groups (p < 0.05). The increase in shoulder normal joint movement measurements was more pronounced in the group that applied the MWM group (Table 2).

Table 2

Intragroup and intergroup comparison of the shoulder
Shoulder ROM (°)		MWM (n = 19)	CT (n = 22)	Intergroup comparison	Between-Group Effect Sizes
Shoulder ROM (°)		Median (min;max)	Median (min;max)	p-value	F
Flexion	Pre-treatment	100.00 (25;178)	133.50 (53;178)	0.170	0.241
Flexion	Post-treatment	173.00 (90;180)	160.00 (76;179)	0.295	0.241
Intragroup comparison p-value		< 0.001	< 0.001
Abduction	Pre-treatment	82.00 (11;173)	117.00 (45;177)	0.067	0.549
Abduction	Post-treatment	171.00 (87;180)	152.50 (87;178)	0.191	0.549
Intragroup comparison p-value		< 0.001	< 0.001
Internal rotation	Pre-treatment	32.00 (10;66)	43.00 (14;80)	0.173	0.934
Internal rotation	Post-treatment	62.00 (23;71)	61.50 (29;80)	0.844	0.934
Intragroup comparison p-value		< 0.001	< 0.001
External rotation	Pre-treatment	32.00 (0;82)	44.50 (5;83)	0.158	0.420
External rotation	Post-treatment	70.00 (17;86)	63.50 (17;85)	0.969	0.420
Intragroup comparison p-value		< 0.001	< 0.001
ROM: Range of motion, MWM: Mulligan Mobilization With Movement, CT: Conservative Treatment, p < 0.05

After the treatment, when the pain scores of both groups were evaluated; rest, activity, and night pain decreased (p < 0.05). While the decrease in activity and night pain symptoms was greater with the MWM group, rest pain was reduced at a similar rate in both groups. After the treatment, there was an increase in the functionality of both groups (p < 0.05); the increase was more pronounced in the group in which the MWM group was applied (Table 3).

Table 3

Intragroup and intergroup comparison of pain and functionality
Pain			MWM (n = 19)	CT (n = 22)	Intergroup comparison	Between-Group Effect Sizes
Pain			Median (min;max)	Median (min;max)	p-value	F
Rest	Pre-treatment		2.00 (0;8)	2.00 (0;10)	0.989	0.860
Rest	Post-treatment		0.00 (0;5)	0.00 (0;4)	0.820	0.860
Intragroup comparison p-value			0.007	0.001
Activity	Pre-treatment		6.00 (0;5)	5.00 (1;10)	0.052	0.258
Activity	Post-treatment		1.00 (0;4)	1 (0;8)	1.000	0.258
Intragroup comparison p-value			< 0.001	< 0.001
Night	Pre-treatment		6.00 (0;10)	6.00 (0;10)	0.654	0.878
Night	Post-treatment		1.00 (0;7)	2.00 (0;9)	0.466	0.878
Intragroup comparison p-value			< 0.001	< 0.001
Functionality (score)
PSFS		Pre-treatment	1.00 (0;5.67)	1.33 (0;10)	0.979	0.636
PSFS		Post-treatment	8.33 (3.33;10)	6.67 (3;10)	0.145	0.636
Intragroup comparison p-value			< 0.001	< 0.001
MWM: Mulligan Mobilization With Movement, CT: Conservative Treatment, PSFS: Patient Specific Functional Scale, p < 0.05

As a result of this study, in which we investigated the effectiveness of the MWM technique in the treatment of patients with shoulder problems, it was found that the shoulder pain of the patients decreased and their AROM and functionality increased. The main conclusion of this study is that although there is no statistically significant difference between the two groups, the MWM technique applied in addition to conventional physical therapy is more effective in symptoms such as limitation of AROM, pain, and functionality. However, we found that both of the treatments had positive effects on the symptoms of patients.

The normal shoulder stabilizing mechanisms are compromised commonly in altered normal structural alignment of the bony constituents of the shoulder girdle, and rotator cuff muscle weakness. The most common pathology among shoulder problems is rotator cuff lesions and impingement syndrome is the most common among them ^21,22. In this study, the most common shoulder problems were 87.8% RCS and 12.2% SIS.

Kinematic studies of patients with impingement, rotator cuff tears, and loss of capsuloligamentous integrity, have demonstrated abnormal or excessive superior and anterior translation of the humeral head in the glenoid fossa ^23,24. It would appear that excessive translation of the humeral head along the glenoid results in pain, ROM, and functional impairment. Physiotherapy and rehabilitation are commonly used interventions to improve pain, ROM, and physical disability in patients with shoulder dysfunction ²⁵. Physiotherapy approaches are often first used in the conservative management of patients with musculoskeletal dysfunction of the shoulder (such as stretching, strengthening exercises, and electrotherapeutic modalities, combined with manual techniques). Haik et al. ²⁶ reported that exercise therapy was effective in improving function, pain, and ROM in shoulder dysfunction. By adding mobilizations to the exercises, the reduction of pain can be accelerated in the short term. Mulligan ²⁷ advocated that a single application of MWM is clinically beneficial by improving joint pain and ROM. Previous studies have reported that there is a significant correlation between shoulder ROM and function, in particular, abduction, forward flexion, and rotation (internal and external) are associated with various upper extremity activities ²⁸.

In this study, we evaluated the degrees of flexion, abduction, and IR/ER AROM, which are important in terms of functionality. Many treatment options focus on improving ROM. In physiotherapy applications, the most common exercise and joint mobilization methods are preferred in addition to CT. One of the methods used for joint mobilization, MWM will improve the ROM by correcting the biomechanical defect of the joint ²⁹. A study by Kachingwe et al. ¹⁴ applied different methods in the treatment of patients with SIS: therapist-guided exercise (posterior capsular stretching, postural exercises, scapular mobilization, and rotator cuff strengthening) to the first group, glenohumeral mobilization and exercise to the second group, MWM and exercise to the third group, patient education to the fourth group. At the end of the treatment, shoulder ROM increased in the second and third groups, while no change was observed in the other groups. In addition, the increase in the MWM group was more significant than in the glenohumeral mobilization group. In another study, the effect of the MWM technique in patients with adhesive capsulitis was examined. As a result, it was found that the IR ROM increased more in the MWM group compared to CT ¹⁵. Romero et al. ³⁰ investigated the effect of MWM on shoulder ROM, functionality, and pain in their study on patients with RCS. They applied traditional physiotherapy (postural training, active exercise) to one group and traditional physiotherapy and MWM to another group. As a result, an increase in shoulder flexion, abduction, IR, and ER joint AROM, a decrease in pain level, and an improvement in functionality were observed, equivalent to many studies in the literature ^14,15,30.

When the literature is examined, there are many studies on MWM to increase shoulder joint ROM ^13,31,32, and this study also proved that MWM increases shoulder joint motion. Additionally, it is accepted that a minimal clinically important difference (MCID) of 6° to 11° is needed to be certain that true change has occurred with goniometric measurements of the shoulder ³³. The increase in ROM angles in both groups at the end of treatment provides convincing evidence that the CT and MWM technique provides clinical advantages. In this results, it was seen that CT had a positive effect on AROM results, but more significant results were obtained when combined with MWM. If MWM alone had been applied, the results might not have improved as much. In addition, we believe that painless, mobilization with activity caused a greater increase in ROM.

Hyperalgesia and related movement disorders associated with shoulder disorders cause functional deficiencies in the daily activities of the patient ³². As an indicator of the severity of the problem, Smith et al. ³⁴ reported that 83% of people with shoulder dysfunction were unable to sleep on the involved side because of pain. Physical therapy encompasses a large range of treatments. There are therapeutic modalities designed to alleviate pain directly (heat/ice, ultrasound, electrotherapy), and stretching and strengthening exercises intended to relieve pain by improving shoulder function ²². In this study, cold/hot application, ROM exercises (Wand exercise, shoulder wheel, etc.), stretching and strengthening exercises, scapular mobilization, and proprioceptive exercises were applied to the patients as CT. Ginn et al. ³⁵ in a study examining the effects of CT (exercise therapy, passive joint mobilization, corticosteroid injection, electrotherapy) in individuals with shoulder pain, they found that there was a decrease in pain intensity and functional improvement in the long term. In the literature, many studies show that the MWM method reduces pain ^13,32,36. Menek et al. ¹³ reported that MWM decreased pain scores at rest and activity more significantly in individuals with RCS compared to the control group. Neelapa et al. ³² applied exercise to one group of patients with shoulder pain and the MWM technique to the other group. They reported that there was a greater decrease in Visual Analog Score (VAS) in the MWM applied group at the end of 3 sessions.

In this study, where we examined the effect of MWM, it was found that activity and night pain decreased more than the control group, and rest pain decreased at a similar rate. Mintken et al. ³⁷ reported that the NPRS showed high test-retest reliability (intraclass correlation coefficient, 0.74) and a MCID of 1.1 points in patients with shoulder pain. Considering this value, in this study, it was found that rest pain decreased by 2 cm in both groups, while activity and night pain decreased by more than 5 cm in the MWM group. The mechanism of action of MWM has been suggested to activate a non-opioid descending pain inhibitory system causing mechanical hypoalgesia. In addition, it is suggested that MWM has mechanical effects, restoring normal biomechanics to the dysfunctional joint, and allowing a greater pain-free ROM ^38,39. We believe that the reason for this is that the MWM technique is a mobilization method with the active participation of the patient, thus reducing the pain more easily. In addition, the therapist constantly monitors the patient during the technique to ensure that no pain reoccurs, and if pain begins, the therapist explores different treatment planes and/or degrees of assistive motion to ensure pain-free movement.

When the studies were examined, the problems involving the body structure and functions of the patients (such as pain, strength, and ROM) were evaluated more ^15,30,32,35. However, in the daily life activities of individuals, the examination of PSFS is insufficient. In the assessment of the patient, the functional evaluation scales specific to the individual and unique to the region are extremely important in determining the effectiveness of the treatment. In this study, unlike other studies, the PSFS was used to increase the patient's participation, to provide an opportunity to evaluate and score their situations. Kachingwe et al. ¹⁴ have examined different treatment methods in SIS. While there was an improvement in functionality in the exercise, mobilization, and MWM group compared to the control group, the percentage change in the MWM group was greater. Satpute etl al. ³¹ demonstrated that the MWM group applied with exercise showed more functional improvement than the exercise group. Ajit et al. ⁴⁰ reported that the MWM technique provides a decrease in VAS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and an increase in acromiohumeral distance in patients with shoulder impingement syndrome. In another study conducted on patients with RCS, it was reported that the MWM technique provided more functional improvement, although it was not statistically significant, compared to the control group ³⁰. In addition, Menek et al. ¹³ reported that the DASH score decreased more in the MWM group compared to the control group, and there was a functional improvement in both groups. In Menek et al. ¹³ study, which included a similar treatment to this study, while CT included codman exercises, wand, shoulder wheel, finger ladder, cold pack, TENS, US, and stretching and strengthening exercises, the MWM technique was applied in flexion, abduction, ER, and IR directions. Consistent with other studies ^13,14,31,40, functional improvement was found in both the MWM and control groups in this study. In addition, unlike other studies ^13,14,31,40, in this study in which PSFS was determined and evaluated, improvement was higher in the MWM group. Although there were similar results between the groups, the MWM technique relieves the shoulder joint and increases the ROM. We think that the increase in functionality combined with the increased ROM will lead to further improvement in the MWM group.

This study has some limitations. First, the patients' most affected shoulder flexion, abduction, and IR/ER AROM angles were examined, but adduction and extension AROM angles were not evaluated. Secondly, our participants were not only a specific group, RCS and SIS patients with shoulder problems were included in the study. Therefore, the absence of patients with different diagnoses affects generalization. There is a need for large-scale studies with different diagnoses that also examine the long-term effects of treatment.

MWM was found (but not statistically significant) to be much more effective in reducing pain and improving flexion, abduction, IR and ER AROM, and functionality in individuals with shoulder problems when compared to the CT group. This study provides evidence that MWM techniques can be an important adjunct to CT in the treatment of individuals with shoulder problems. While evaluating patients with shoulder problems, functional conditions should be added to the evaluation. In particular, the use of scales that evaluate the individual limitations of the patient and the patients actively participate in the evaluation allows physiotherapists to improve which functions.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Ethical Approval: This study was approved by the Ethics Committee of the University (2022-962). This study was registered with clinicaltrials.gov (Clinical Trials Retrospectively Registration Number: NCT06187571). The written informed consent form was obtained from all patients included in the study by the Principles of the Declaration of Helsinki.

Author Contribution

CRediT authorship contribution statementNezehat Özgül Ünlüer: Writing – review & editing, Writing – original draft, Validation, Methodology, Formal analysis, Data curation, Conceptualization, Supervision. Wala'a Andeges: Methodology, Data curation, Formal analysis. Yasemin Ateş Sarı: Writing – review & editing, Methodology, Data curation, Formal analysis. NÖÜ was responsible for the study design, manuscript revision, review and proofread. WA was responsible for study design, data collection. YAS was responsible for data analysis and interpretation. All authors read and approved the final manuscript.

Acknowledgement

We would like to thank all participants for contributing towards this study.

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Comparison of conventional therapy and mulligan mobilization with movement technique in the treatment of shoulder problems: A randomized controlled trial

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Abstract

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1. INTRODUCTION

2. METHODS

2.1. Study Desing

2.2. Participants

2.3. Outcome Measure

2.4. Interventions

2.5. Statistical analysis

3. RESULTS

4. DISCUSSION

5. CONCLUSION

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Author Contribution

Acknowledgement

References

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