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DOI:
10.1016/j.apmr.2016.01.006
Reference:
YAPMR 56428
To appear in:
21 December 2015
Please cite this article as: Pichonnaz C, Bassin J-P, Lcureux E, Christe G, Currat D, Aminian K,
Jolles BM, The effect of manual lymphatic drainage following total knee arthroplasty: a randomized
controlled trial, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2016), doi: 10.1016/
j.apmr.2016.01.006.
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Guillaume Christe, PT 1
Damien Currat, PT 1
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Physiotherapy Department, Haute Ecole de Sant Vaud (HESAV), HES-SO // University of Applied
Sciences Western Switzerland, Lausanne, Switzerland.
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Laboratory of Movement Analysis and Measurement, EPFL STI CBT LMAM, Lausanne, Switzerland.
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Two congress presentations and one poster presentation have been made. Only congress abstracts
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Pichonnaz C, Bassin J-P, Martin E, et al. Effets du drainage lymphatique manuel sur l'oedme et
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l'amplitude articulaire passive aprs prothse totale de genou. Paper presented at: Physiocongress
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Pichonnaz C, Bassin J-P, Martin E, et al. Outcome of manual lymphatic drainage on swelling, range of
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motion and pain following total knee arthroplasty. Paper presented at: Journes Francophones de
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Pichonnaz C., Bassin J.-P., Lecureux E., Christe G., Currat D., Jolles B.M. Effects of manual lymphatic
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drainage following total knee arthroplasty: a prospective randomised controlled trial. Poster
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presented at: World Confederation for Physical Therapy Congress, 1-4 May 2015, Singapore.
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The study protocol was approved by the Ethics Commission of Clinical Research Biology and Medicine
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Corresponding author:
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Claude Pichonnaz, Haute Ecole de Sant Vaud (HESAV), HES-SO // University of Applied Sciences
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The study protocol was approved by the Ethics Commission of Clinical Research
The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials
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Acknowledgements: The authors would like to thank, the physiotherapy team of the
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the study organization and implementation, Pascal Morel from the laboratory of
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Movement Analysis and Measurements (EPFL) for his assistance in gait parameter
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analysis and Cline Ancey for her contribution to the manuscript revision and
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submission.
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Abstract
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Objective: To evaluate the effects of manual lymph drainage (MLD) on knee swelling
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and the swellings assumed consequences following total knee arthroplasty (TKA).
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Participants: Two groups of 30 patients were randomized before TKA surgery (65%
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, age 70.78.8 y.o., weight 77.811.3 kg., size 1.640.08 m., BMI 29.94.1
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kgm2)
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added to rehabilitation, in between the second (D2) and the seventh (D7)
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postsurgical days.
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Secondary outcomes were active and passive ROM, pain, knee function and gait
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parameters.
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except for the knee passive flexion contracture at 3M which was smaller and less
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frequent in the MLD group (2.6 [95%CI -5.0 to -0 .21], P=0.04; absolute risk
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reduction 26.6% [95% CI 0.9 to 52.3%]; NNT = 4). Pain decreased between 5.8 and
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8.2 mm on the VAS immediately after MLD, which was significant after four out of five
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MLD treatments.
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Conclusion: The MLD applied early following TKA surgery did not reduce swelling. It
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reduced pain immediately after treatment. Further studies, should investigate if the
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List of abbreviations:
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MLD
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TKA
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NNT
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D2
Second Day
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D7
Seventh Day
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3M
3 Months
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ROM
Range Of Motion
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RCT
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BIS
Bioimpedance Spectroscopy
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BIS R0
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CEAP
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WOMAC
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KSS
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VAS
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AROM
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AAROM
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BMI
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95% CI
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The number of total knee arthroplasties (TKAs) spectacularly grew during the last
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decade due to population aging, the increasing prevalence of obesity and the impact
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Standard rehabilitation is usually focused on pain control and the recovery of range
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determinant of TKA outcomes5, 6. Swelling after total knee arthroplasty (TKA) causes
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pain and range of motion (ROM) limitation7. It also induces gait alteration8,
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TKA. Cryotherapy and compression demonstrated no effect11, 12,13, 14, 15. The effect of
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influence the frequency of swelling but the effect on the magnitude of the swelling
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Postsurgical joint swelling consists of soft-tissue edema, joint effusion and hematoma
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stimulates collateral lymphatic vessels and anastomosis activity 20-22. MLD favors
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TKA24, 25.
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Two RCTs demonstrated a positive effect of MLD on swelling following distal radius
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TKA29. However, a significant effect was found on active knee flexion. Girth
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measurements were used to evaluate swelling in this study. Though reliable and
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that does not present these drawbacks. The BIS measurement is not altered by the
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used31. The BIS R0 parameter is related to volume (R = 0.73) and knee girth (R =
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correlation (ICC) > 0.96 and > 0.97, respectively) and better responsiveness than
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The objective of this study was to evaluate the effects of MLD on swelling and on the
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consequences of swelling, i.e., pain, passive and active ranges of motion in the knee,
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function and gait. Swelling was considered as the main study outcome. It was
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hypothesized that MLD would have a significant effect on swelling measured using
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METHODS
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Surgery of the University Hospital of [blinded for review]. Ethical approval was
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granted by the local ethics committee (Protocol # 224/06), and all subjects gave their
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written consent before enrollment. The MLD, added to the standard rehabilitation
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MLD were undertaken in the treatment group on working days between the second
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day (D2) and the seventh day (D7) following surgery. Five 30-minutes of tape-
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recorded relaxation based on ericksonian hypnosis and autogenic training was used
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as a placebo.
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The treatments were applied by five physiotherapists with experience in MLD who
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completed two training sessions for standardization. The same therapist performed
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all of the study treatments for a given patient. The treatment was standardized
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numbers. Study eligibility was determined based on inspection of the patient file. An
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of appearance.
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The participants underwent primary TKA operations for osteoarthritis according to the
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standard procedures of the department from July 2008 to November 2010. All
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were non-standard surgery, any lymphatic system pathology, concomitant lower limb
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All participants followed the standard rehabilitation program of the department twice
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daily until hospital discharge. Mean hospital stay was following surgery 10.4 +/- 3.0
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strengthening and continuous passive motion started on the first post-operative day.
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Full weight-bearing gait was initiated on the second post-operative day. Ice was
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applied for 25 minutes 3 times a day. Patients who could walk safely and had
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rehabilitation, while those who did not meet these conditions pursued physiotherapy
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in a rehabilitation center.
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The sample size was calculated based on the effect found in the most comparable
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study existing at the time of this study design (6.4 +/- 6.3%)28. We used a
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conservative approach and calculated the sample size considering that a treatment
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effect smaller than 5% would have limited clinical significance. It was found that using
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a 5% difference between groups and a 6.3% SD, 25 participants per group were
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needed to reach a power of 0.80 power with a < 0.05. Thirty patients per group
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Measurement Protocol
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The participants were measured the day before surgery (baseline) and at D2 before
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beginning the study treatments. They were then measured at day seven (D7) and at
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3 months (3M) after surgery. The swelling (BIS and volume), active and passive
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ROM, pain and function using the Western Ontario and McMaster Universities
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Osteoarthritis Index (WOMAC), knee society score (KSS) and gait parameters were
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evaluated.
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The evaluations were performed by two evaluators who were blinded to the allocated
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treatment. One of them, who was randomly chosen by coin toss, performed all of the
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measurements, while the second evaluator supervised the procedures and noted the
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The swelling measurement was performed on both of the lower limbs as described in
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Pichonnaz et al31.
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Swelling volume based on tape measurements was calculated using the truncated
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cone method34 as this method is considered valid and reliable35. Tape measurements
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were taken at 4-cm intervals starting from the patella + 1 cm level. The most proximal
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measurement was performed at the highest level of the thigh where it was possible
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not to skew the tape and the most distal point above the largest cross-sectional area
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of the ankle.
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device a). The BIS R0 of the healthy leg was measured first. One outer electrode was
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placed on the most distal girth measurement level of the leg and one on the most
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proximal girth measurement level of the thigh on the contralateral side. One inner
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electrode was placed 12 cm above the outer leg electrode and one on the most
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proximal girth measurement level of the measured thigh (FIGURE 1). Thus, the
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swelling between the two inner electrodes (between the proximal thigh to 12 cm
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above the malleoli) was evaluated. The same area was taken into consideration for
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the volume calculation. Then, the BIS R0 and volume lower limb percentage
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differences between the healthy side and the involved side were calculated.
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The pain at rest and when walking was evaluated using a visual analog scale
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(VAS)36. The pain was also evaluated by the treating physiotherapist before and after
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each treatment session to measure the immediate effect of MLD. The active range of
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extension were evaluated using a hand held goniometer. This tool is valid and
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The knee function was evaluated using computerized gait analysis and two clinical
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questionnaires, namely the KSS39 and the WOMAC40. These approaches investigate
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when applicable, i.e., at baseline, D7 and 3M for gait analysis and at baseline and
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The gait analysis was performed using an inertial sensor-based movement analysis
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body-worn system b). This system is valid for the analysis of spatio-temporal
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parameters following TKA44-46. The sensors were placed on the anterior faces of the
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thighs and legs, at the junction of the proximal third and the distal two-thirds of the
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limb segment. The patients walked 30 meters both ways at their usual pace. The
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measurement at D7 was taken using crutches. The return trip was taken into
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were documented to investigate their influence on treatment outcome (age, sex, size,
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weight, body mass index (BMI), stay in rehabilitation center, number of physiotherapy
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sessions).
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Statistical Analysis
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The outcomes and control variables were compared between the treatment and
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control groups at each time point using the Wilcoxon rank sum test or the Chi-square
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test as applicable. The change in swelling from D2 to D7, i.e., during the treatment
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period, was compared using the Wilcoxon signed rank test. The significance level
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The number needed to treat to obtain a clinically significant improvement was also
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calculated for treatment outcomes when a significant difference between groups was
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VAS 47, 5 for ROM 39, 48, and 15 points on the WOMAC49. The statistical analysis
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was performed using SPSS statistical software, version 18 (SPSS, Chicago, Illinois)
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RESULTS
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detailing the recruitment process is presented in FIGURE 2. All exclusions were due
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difference was found between the treatment and the control group. Similarly, no
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significant difference between groups was found for the gait parameters or their
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coefficients of variation.
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At D7, the treated group showed no significant difference compared with the control
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group for any of the measured outcomes (TABLE 2). At 3M, the mean knee passive
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flexion contracture was -2.6 lower in the treatmen t group (95% confidence interval
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(95%CI) -5.0 to -0.21; P<0.05) (FIGURE 3). All other differences between groups
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were non-significant. The frequency of knee flexion contracture 5 was 27.6% in the
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MLD group vs. 54.2% in the control group. The absolute risk reduction of a 5 knee
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passive flexion contracture at 3M was 26.6% [95% CI 0.9 to 52.3%], and the NNT
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was 4.
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During the D2-D7 treatment period, the swelling volume increased by 1.9%4.0 in the
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MLD group and 4.1%7.9 in the control group. The change over time was not
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significantly different between groups (P=0.24). For the BIS R0, the increase was
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5.6%6.2 in the MLD group and 7.7%5.8 in the control group (P=0.19).
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No significant difference between groups was found at D7 and 3M for the gait
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The mean pain level decrease ranged from 5.8 to 8.2 mm on the VAS immediately
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after treatment in the MLD group and from 2.7 to 8.7 in the control group (TABLE 4).
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The decrease was significant after four out of 5 MLD treatments, but no significant
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Controlling for potential confounding factors for the period from D7 3M showed no
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differences between the MLD and the control group for the stay in a rehabilitation
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center (14 stay/10 no stay vs. 14 stay/15 no stay, P = 0.47), the number of
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ambulatory physical therapy sessions (19.97.3 vs. 18.79.3, P=0.70) and the use of
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MLD by the treating therapist (10 MLD/14 no MLD vs. 16 MLD/13 no MLD, P=0.33).
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DISCUSSION
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Results interpretation
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This RCT aimed to evaluate the effects of MLD on knee swelling and the swellings
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The primary outcome, swelling, was measured using two measurement methods to
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knee swelling was found at D7 and 3M, either using the limb volume or BIS R0
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These findings using limb volume and bioimpedance spectroscopy (BIS R0) are
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concordant with those of Ebert et al29 who found no difference in limb girth
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measurement in a similar context. The limb volume and BIS measurements produced
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concordant results. However, this study confirmed the higher responsiveness of BIS
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R0.32
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The MLD had no significant effect on the swelling consequences except the knee
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flexion contracture were significantly lower in the MLD group. The mean difference
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between groups was slightly superior to the 2.3 st andard error of measurement of
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goniometry37. The mean control group flexion contracture increased 1.6 between D7
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and 3M, likely contributing to the significant findings. The MLD contributed thus to
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preserve rather than to improve knee extension between D7 and 3M. Ebert et al.29
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described the same evolution pattern and also found better extension in the MLD
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group but without reaching statistical significance (P = 0.07). The NNT highlighted
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that the MLD prevented a knee flexion contracture 5 each time 4 patients were
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treated.
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dissatisfaction51.
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swelling was unexpected, as knee contracture and swelling are theoretically related7.
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The mechanisms explaining this effect remain hypothetical. The slight effect of MLD
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on swelling observed in this study might have been sufficient to influence knee
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extension. MLD may also have mechanical effects on the soft tissues during popliteal
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Finally, improved extension may result from muscular relaxation due to pain relief.
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The pain decreased immediately after the MLD treatments, reaching clinical
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significance for four out of five treatments. In a postsurgical context in which pain was
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generalizable but transient and was of limited magnitude and not superior to
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relaxation. Despite these limitations, this effect might facilitate knee mobilization and
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gait training.
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methods (KSS, WOMAC and gait analysis) were used41-43. This indicates that the
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lower knee flexion contracture in the MLD group did not translate into improved knee
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Study limitations
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The placebo treatment (relaxation) was chosen for its absence of an effect on
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swelling. Yet, it may also have had a superior effect on pain compared to a true
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post-treatment pain. The absence of blinding for this outcome may have influenced
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inhibition5, 9. This outcome was not measurable due to pain and range of motion
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limitations at the early stage following surgery. Further research should include such
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clinical questionnaires55.
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The rehabilitation program may have influenced the study outcomes but is not likely
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to have influenced the differences between groups. Exercise may for example have
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patients environments and activities could not be fully controlled between D7 and
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3M. Importantly, no difference was found between groups for the measured
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physical therapy sessions and the use of MLD by the treating therapist.
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The study sample size calculation was based on the result of a previous study that
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found a medium to large effect size for MDL (Cohens d = 0.79)28. The statistical
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power of the present study was limited as a positive, but much lower effect, was
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found. A type one error cannot be excluded for significant results, as multiple
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outcomes were tested. However, the coherence of the effects on AROM and AAROM
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knee extension at different stages, and the results of Eberts et al study29, suggest
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that the effect found on flexion contractures at 3 months was valid. A Bonferroni
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Further research is needed to increase the evidence of the effect of MLD on knee
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extension following TKA. A study including only patients with flexion contracture
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would produce a more precise picture of the effect of MLD on knee flexion
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CONCLUSIONS
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This RCT compared the effect of MLD on swelling and the consequences of swelling
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following TKA surgery. This result reinforces the evidence against the use of MLD for
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swelling reduction in this context. Conversely, MLD decreased the frequency and
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TKA. A transient effect on pain was also observed, which might be useful to facilitate
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Further studies, should investigate if the positive effect of MLD on knee extension
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observed in this study is replicable. More research is also needed to develop and
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knee joint range of motion and circumference measurements after total knee arthroplasty:
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WOMAC: a health status instrument for measuring clinically important patient relevant
outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J
Rheumatol 1988;15(12):1833-40.
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Witvrouw E, Victor J, Bellemans J, Rock B, Van Lummel R, Van der Slikke R et al. A
correlation study of objective functionality and WOMAC in total knee arthroplasty. Knee
Surgery, Sports Traumatology, Arthroscopy 2002;10(6):347-51.
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Lingard EA, Katz JN, Wright RJ, Wright EA, Sledge CB, Kinemax Outcomes G.
Validity and responsiveness of the Knee Society Clinical Rating System in comparison with
the SF-36 and WOMAC. J Bone Joint Surg Am 2001;83-A(12):1856-64.
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Lindemann U, Becker C, Unnewehr I, Muche R, Aminin K, Dejnabadi H et al. Gait
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Dejnabadi H. Analysis of gait and coordination for arthroplasty outcome evaluation
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Jolles BM, Grzesiak A, Eudier A, Dejnabadi H, Voracek C, Pichonnaz C et al. A
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514
a) Impedimed SFB7 : Impedimed, 1/50 Parker Ct, Pinkenba QLD 4008, Australia
515
RI
PT
503
504
505
506
507
508
509
510
511
512
513
SC
Suppliers
516
Figure legend
518
519
520
521
523
From: [added]
TE
D
522
M
AN
U
517
525
526
527
528
529
530
531
532
AC
C
EP
524
19
ACCEPTED MANUSCRIPT
TABLE 1. Patient characteristics before treatment
TABLE 1
Control
Mean (SD)
Treatment
Mean (SD)
P
value
Baseline
TE
D
EP
D2
AC
C
60
13.3
34.2
108.6
115.7
(8.5)
(8.5)
(9.0)
(14.1)
(13.5)
30
62.1
71.3
76.5
1.65
28.2
0.2
2.5
118.7
125.1
RI
PT
(9.12)
(10.08)
(0.08)
(4.23)
(5.0)
(7.5)
(12.1)
(12.0)
SC
30
67.7
70.1
79.0
1.65
29.9
1.8
3.3
117.4
126.5
M
AN
U
6.8 (6.5)
(8.5)
(12.5)
(0.08)
(3.9)
(4.5)
(11.5)
(20.4)
(20.7)
6.3 (6.2)
0.65
0.52
0.50
0.94
0.08
0.23
0.65
0.38
0.92
0.85
4.5
21.3
48.3
48.1
(5.9)
(21.7)
(25.5)
(16.0)
4.6
23.6
54.5
49.7
(6.1)
(25.7)
(26.1)
(15.8)
0.95
0.86
0.36
0.88
65.3
44.0
10.3
4.0
30.0
(13.7)
(15.4)
(2.71)
(1.74)
(11.9)
66.2
47.9
10.2
4.2
33.6
(15.4)
(16.9)
(3.3)
(2.0)
(12.3)
0.85
0.40
0.77
0.50
0.34
30
12.9
33.1
108.9
116.4
(9.7)
(10.1)
(16.2)
(16.0)
30
13.7
35.5
108.4
115.1
(7.2)
(7.7)
(12.0)
(10.8)
0.65
0.45
0.73
0.54
9.5 (7.0)
8.7 (5.7)
10.3 (8.1)
0.56
5.8 (5.2)
28.6 (25.2)
52.9 (25.8)
5.9 (4.8)
31.0 (28.4)
48.7 (28.7)
5.6 (5.7)
25.9 (21.5)
57.3 (21.8)
0.66
0.71
0.23
ACCEPTED MANUSCRIPT
TABLE 2. Outcomes in the control and treatment groups after treatment
TABLE 2
0.58
0.51
0.92
0.66
6.4 (5.5)
6.8 (4.9)
5.9 (6.1)
0.37
SC
RI
PT
29
15.3 (6.5)
40.8 (6.6)
59.4 (12.1)
69.6 (13.3)
2.4 (3.8)
3.0 (4.1)
21.4 (19.3)
21.8 (22.1)
33.3 (20.9) 29.7 (18.8)
TE
D
EP
P
value
27
17.0 (10.7)
41.8 (6.5)
58.6 (11.2)
68.4 (11.5)
3 Months
Number of patients (n)
53
24
Limb volume difference (%)
3.9 (5.5)
3.7
Limb BIS R0 difference (%)
17.9 (10.2)
16.6
Knee AROM flexion (deg.)
108.6 (14.1) 108.9
Knee AAROM flexion (deg.)
115.7 (13.5) 116.4
Knee AROM flexion contracture
(deg.)
4.4 (5.3)
5.6
Knee AAROM flexion contracture
(deg.)
3.2 (4.5)
4.6
VAS pain at rest (mm)
8.1 (11.6)
7.1
VAS pain during gait (mm)
12.8 (14.4)
8.4
KSS knee assessment (points)
74.2 (15.7)
74.9
KSS function assessment (points)
78.6 (16.0)
78.8
WOMAC total score (points)
24.6 (14.0)
22.2
WOMAC pain score (points)
5.1 (3.2)
4.5
WOMAC stiffness score (points)
2.6 (1.4)
2.6
WOMAC function score (points)
16.8 (10.3) 15.0
AC
C
Treatment
Mean (SD)
56
16.2 (8.8)
41.3 (6.5)
59.0 (11.5)
69.0 (12.3)
M
AN
U
D7
Number of patients (n.)
Limb volume difference (%)
Limb BIS R0 difference (%)
Knee AROM flexion (deg.)
Knee AAROM flexion (deg.)
Knee AROM flexion contracture
(deg.)
Knee AAROM flexion contracture
(deg.)
VAS pain at rest (mm)
VAS pain during gait (mm)
Control
Mean (SD)
(5.7)
(9.3)
(16.2)
(16.0)
(5.6)
(5.2)
(10.3)
(9.7)
(15.5)
(16.7)
(11.2)
(2.4)
(1.4)
(8.4)
1.8 (3.4)
21.0 (16.5)
36.8 (22.5)
0.21
0.90
0.18
29
4.1
19.1
108.4
115.1
0.75
0.67
0.73
0.54
(5.4)
(11.0)
(12.0)
(10.9)
3.2 (4.8)
2.0
9.0
16.7
73.5
78.3
26.7
5.6
2.7
18.3
0.11
(3.5)
<0.05*
(12.9)
0.52
(16.8)
0.06
(16.1)
0.81
(15.8)
0.90
(16.0)
0.43
(3.8)
0.38
(1.4)
0.83
(11.6) 0.50
ACCEPTED MANUSCRIPT
TABLE 3. Gait parameters in the control and treatment groups after treatment
Mean (SD)
Mean (SD)
AC
C
EP
TE
D
3 Months
Number of patients (n)
53
Gait speed (m/s)
1.03 (0.21)
Stride length (m)
1.19 (0.17)
Stride cadence (stride/min) 51.90 (5.30)
Limp (%)
2.59 (1.58)
Knee flexion during gait
(deg.)
49.16 (7.93)
Peak swing speed (deg./s) 297.94 (51.64)
Stance time percentage
(%)
60.23 (2.74)
Swing time percentage (%) 39.77 (2.77)
Double support time (%)
21.32 (4.39)
Mean (SD)
value
27
0.49 (0.17)
0.96 (0.21)
30.36 (6.13)
10.63 (9.03)
29
0.50 (0.22)
0.96 (0.21)
30.13 (8.94)
7.17 (5.08)
0.93
0.90
0.86
0.20
24.55 (10.67)
136.70 (45.24)
22.13 (8.36)
134.99 (46.84)
0.39
0.81
64.98 (7.43)
35.02 (7.43)
36.93 (12.13)
66.08 (7.38)
33.92 (7.38)
38.34 (13.19)
0.53
0.53
0.60
24
1.03 (0.23)
1.18 (0.20)
52.15 (5.02)
2.53 (1.71)
29
1.03 (0.18)
1.19 (0.13)
51.68 (5.63)
2.64 (1.46)
0.93
0.85
0.75
0.58
49.10 (7.91)
300.62 (55.24)
49.22 (8.10)
295.55 (49.16)
0.93
0.57
60.20 (3.05)
39.80 (3.05
20.78 (4.26)
60.30 (2.56)
39.74 (2.56
21.80 (4.52)
0.67
0.68
0.46
M
AN
U
D7
Number of patients (n)
56
Gait speed (m/s)
0.50 (0.20)
Stride length (m)
0.96 (0.21)
Stride cadence (stride/min) 30.24 (7.52)
Limp (%)
8.97 (7.54)
Knee flexion during gait
(deg.)
23.39 (9.61)
Peak swing speed (deg./s) 135.88 (45.56)
Stance time percentage
(%)
65.51 (7.35)
Swing time percentage (%) 34.49 (7.35)
Double support time (%)
37.61 (12.53)
RI
PT
SC
TABLE 3
ACCEPTED MANUSCRIPT
TABLE 4. Immediate effect on pain in the control and treatment groups
Treatment 1
Treatment 2
Treatment 3
Treatment 4
Treatment 5
Mean (SD)
Mean (SD)
-6.3
-6.9
-3.7
-2.7
-8.7
(17.9)
(12.5)*
(8.8)*
(15.8)
(17.6)*
-5.8
-6.3
-8.2
-7.1
-5.7
AC
C
EP
TE
D
M
AN
U
SC
(14.6)*
(18.2)
(13.8)*
(11.5)*
(11.7)*
P-value
0.39
0.76
0.11
0.20
0.65
RI
PT
TABLE 4
AC
C
EP
FIGURE 1.
TE
D
M
AN
U
SC
RI
PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Assessed for eligibility (n= 520)
Not meeting inclusion criteria
(n= 464)
ALLOCATION
Allocated to placebo (n=30)
Received allocated intervention (n= 27)
Did not receive allocated intervention
(n= 3) (post-surgical complications)
SC
D7 FOLLOW-UP
M
AN
U
RI
PT
D7 ANALYSIS
TE
D
3M FOLLOW-UP
EP
3M ANALYSIS
AC
C
FIGURE 2.
ACCEPTED MANUSCRIPT
AC
C
EP
TE
D
M
AN
U
SC
RI
PT
Figure 3