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Keywords:

  • Stroke;
  • time use;
  • rehabilitation;
  • multidisciplinary collaboration;
  • nursing;
  • Skilled Nursing Facilities (SNF)

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

Purpose

To describe the time use of patients with stroke in five Skilled Nursing Facilities (SNFs) in the Netherlands, focusing on the time spent on therapeutic activities, nontherapeutic activities, interaction with others, and the location where the activities took place.

Evidence suggest that task-oriented interventions are the most effective for patients with stroke and that some of these interventions are relevant and feasible for use by nurses. The question arises to what extent elderly patients who had a stroke and rehabilitate in a SNF receive therapeutic training and engage in therapeutic activities.

Design

Descriptive, observational design. Therapeutic and nontherapeutic activities of patients were observed at 10-minute intervals during one weekday (8 a.m.–4:30 p.m.) using behavioral mapping.

Findings

Forty-two patients with stroke with a mean age of 76 years participated in the study. The patients spent 56% of the day on therapeutic activities, whereas 44% of the day was spent on nontherapeutic activities. Most therapeutic time was spent on nursing care (9%) and physical therapy (4%). Patients stayed an average 41% of the day in their own room and were alone 49% of the day. Therapeutic time use was significantly related to improved functional status, patients with higher functional status spent more time on therapeutic activities.

Conclusion

Patients spent more than half of the day on therapeutic activities.

Clinical relevance

Nurses are faced with the challenge of activating patients with stroke and to assist them to engage in purposeful task-oriented exercises including daily activities. Thereby better rehabilitation results and recovery of patients may be reached.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

Geriatric rehabilitation differs from rehabilitation in hospitals and rehabilitation centers (Van Heugten & Benjaminsen, 2005). Dutch skilled nursing facilities (SNFs) provide adapted multidisciplinary rehabilitation programs to elderly patients with stroke, aiming at discharge patients to their own homes or to an assisted living situation. Patients receiving rehabilitation in SNFs are generally aged and frail and in the SNFs the pace of rehabilitation is slower (Van Heugten & Benjaminsen, 2005). In these SNFs the multidisciplinary team consists of nurses, physical therapists, occupational therapists, speech language therapists, psychologists, dieticians, and elderly care physicians (Koopmans, Lavrijsen, Hoek, Went & Schols, 2010). These professionals provide multidisciplinary continuous care, support, and treatment to elderly patients with stroke.

Substantial evidence supports a multidisciplinary team collaboration of professionals who are specialized in the care and treatment of patients with stroke (Langhorne, Bernhardt & Kwakkel, 2011). Good multidisciplinary collaboration between various disciplines improves the rehabilitation outcomes of patients with stroke (Strasser et al., 2008). Also, an early start of rehabilitation and more intensive participation in rehabilitation and therapeutic activities has positive effects on recovery (Kwakkel et al., 2004). Some widely accepted principles in rehabilitation are task-oriented and context-specific training, which target the goals that are relevant for the needs of patients (Langhorne et al., 2011). Recent reviews have shown that task-oriented training in mobility and activities of daily living are the best way to rehabilitate patients after stroke, leading to a better functional status and a better quality of life (French et al., 2010; Kwakkel et al., 2004; Rensink, Schuurmans, Lindeman & Hafsteinsdottir, 2009; Van Peppen et al., 2004). Task-oriented training includes a wide range of interventions such as treadmill training, walking training, bicycling programs, endurance training and circuit training, sit-to-stand exercises, and reaching tasks for improving balance. In addition, arm training using functional tasks such as grasping objects, constraint-induced (movement) therapy (CIMT), and mental imagery are also task-oriented interventions (Rensink et al., 2009). Many of these simple task-oriented interventions, especially if tailored to the patient's needs, are effective in improving patient outcomes and are highly relevant for nurses to use in the daily care of patients with stroke (Rensink et al., 2009). In rehabilitation, nurses work in close interaction with patients. Through concrete support, the self reliance of patients will be increased (Routasalo, Arve & Lauri, 2004). An Australian study, investigating the experiences and perceptions of nurses in rehabilitation nursing practice, found that carefully and collaboratively designed and sensitively implemented work-based practice development initiatives can change the context and culture of inpatient care resulting in enhancing both the patient's and nurse's engagement in rehabilitation (Pryor & Buzio, 2010).

Several authors investigated the time use of stroke patients in different rehabilitation settings concerning therapeutic and nontherapeutic activities and reported varying results. Therapeutic activities in these studies included all therapeutic treatment and care activities that health care professionals, including nurses, carried out with the patient (Bear-Lehman, Bassile & Gillen, 2001; Bernhardt, Chitravas, Meslo, Thrift & Indredavik, 2008; Huijben-Schoenmakers, Gamel & Hafsteinsdottir, 2009; inson, 1989; de Weerdt et al., 2000; de Wit et al., 2005). In rehabilitation wards, stroke patients spent 23.4%–27.5% of the day on therapeutic activities (de Wit et al., 2005), whereas in hospitals, this time varied between 13.7%–75% of the day (Bear-Lehman et al., 2001; Tinson, 1989). Only one small study investigated the time use of elderly stroke patients in nursing homes and showed that elderly stroke patients spend only a limited amount of time (20%) on therapeutic activities, whereas 80% of the day was spent on nontherapeutic activities. For the largest part of the day (60%), the patients were alone and passive (Huijben-Schoenmakers et al., 2009). The large differences in the time spent on therapeutic activities in the before mentioned rehabilitation settings may be explained by differences in observation period, the time since the stroke incidence, the stroke phase, the setting where the study was conducted and the small samples used.

The study

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

Aim

The aim of this study was to describe the time use of stroke patients rehabilitating in SNFs focusing on the time spent on therapeutic activities, nontherapeutic activities, social interaction with others, and the location where the activities took place. It was hypothesized that patients with a lower functional status would spend more time on therapeutic activities. Time spent on therapeutic activities was examined in relation to age, gender, functional status, and the specific SNF in which the patient stays.

Design

This observational and descriptive study was part of a larger research study, the Geriatric Rehabilitation in AMPutation and Stroke study (GRAMPS) (Spruit-van Eijk et al., 2010).

Sample

The study was conducted in five Dutch SNFs. Included were patients with a clinical diagnosis of stroke as defined by the World Health Organization (WHO) (Goldstein et al., 1989) and those who were staying on the participating wards or admitted to the wards during the study. The aim of rehabilitation was discharge to their own homes or to an independent or assisted living situation. Patients who were too ill to participate were excluded.

Data collection

Demographic and illness-related characteristics were collected including: age, gender, marital status, living situation before stroke, length of stay in the hospital, and in the SNF as well as health history including diagnosis, comorbidities, and the time and type of stroke.

Time use was measured with behavioral mapping (BM), which is an observation method used for investigating time use (de Weerdt et al., 2000). According to BM, patients are observed at 10-minute intervals during the day, using an observational plan where activities are divided into several categories: therapeutic activities, non-therapeutic activities, interactions with others, and the location where these activities take place. The observational scheme used in this study was based on previous studies (Huijben-Schoenmakers et al., 2009; de Weerdt et al., 2000; de Wit et al., 2005). Those previous studies, however, interpreted eating/drinking, transport/travel, communication, and activities of daily living as nontherapeutic, whereas in this study we defined these activities as therapeutic because according to Routasalo et al. (2004) they contribute positively to stroke rehabilitation. Therefore, in this study, the following 14 activities were recorded as therapeutic activities: nursing care activities, physical therapy, occupational therapy, speech language therapy (SLT), care by a psychologist, guidance by a dietician, medical care by an elderly care physician, fitness, eating/drinking, transport/travel, communication, independent practice/training, and active leisure activities (for example puzzling). Nursing care included care in activities of daily living as washing, dressing, physical, and emotional support including care activities such as wound care, administering injections, and medication. Nontherapeutic activities were as follows: sitting, laying or sleeping, and passive leisure. Interaction that the patient had with others was registered as interaction with the nurse, elderly care physician, therapist, other patients, visitor(s), or no interaction when the patient was alone. The location where the activities took place was registered in seven categories: patient's bedroom, therapy room/activity room, hall (corridor), dining/living room, lounge, bathroom, outside the ward, outside the institution (outdoor), and other locations. The observations were conducted during the most active part of the day from 8 a.m.–4:30 p.m.

The functional status of the patients, representing disability and handicap, was measured with the Barthel Index (BI) which is one of the most widely used instruments in stroke rehabilitation (Mahoney & Barthel, 1965). The BI rates 10 functions on a scale from 0 (fully dependent) to 20 (independent), representing the patient's ability to carry out the everyday activities. The total score ranges from 0 to 20. A score of 0–9 indicates severe dependency, a score of 10–19 indicates moderate independency, and a score of 20 indicates total independency (Collin, Wade, Davies & Horne, 1988; Hachisuka, Ogata, Ohkuma, Tanaka & Dozono, 1997; Mahoney & Barthel, 1965). The inter-rater reliability agreement of the BI was found to be 64%–99% (Richards, Peters, Coast & Gunnell, 2000).

Procedure

The researcher and three research assistants conducted all assessments. The observation of patients took place on randomly selected weekdays and was conducted at 10-minute intervals, starting at 8 a.m. and finishing at 4:30 p.m. Each patient was observed during one day. At each time point, the observer recorded the patient's activities, his/her interaction with others, and the location were the activities took place.

The research assistants were trained in the observation technique, and a manual was provided describing the data collection procedure which ensured standardization of the observations. Rehabilitation staff was informed about the nature of the study, but they were not given information about when observations would take place.

Ethical considerations

Patients were provided with written and verbal information explaining the aims and procedures of the study and were assured of the voluntary character of their participation and of the anonymity of the data. Also, they were given time to think about if they were willing to participate, and if they were willing to participate they were asked for informed consent, which was signed by the patient and the researcher/research assistant. The study was approved by the medical ethics committee of the district Nijmegen-Arnhem, the Netherlands.

Data Analysis

For a comparison of baseline data, descriptive statistics were used. Means and medians were calculated for continuous data and percentages were calculated for dichotomous data. Frequencies of observations were calculated to determine the time use of the stroke patients in the participating SNFs. Associations between therapeutic activities and age (<65 years and ≥65 years), gender, functional status (three categories as described in the measurements section), and the five participating SNFs, were calculated with the Kruskal–Wallis test. This test was used as the data were not normally distributed, more than two unpaired samples were measured and because the test variables were ordinal (Pallant, 2001). The data were analyzed using SPSS 17.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

Patient characteristics

A total of 45 patients met the inclusion criteria, of which 42 patients participated in the study. Three patients did not give their informed consent for reasons unknown. The mean age of patients was 76 years (SD ± 11.4). Twenty-four women (57%) participated in the study as compared with 18 (43%) men. The mean BI score was 11.8 (±5.7). Of the patients, 14 (33%) had a score of 0–9 indicating severe dependency, 24 (57%) patients had a BI of 10–19 indicating moderate dependency, and a total of 4 (10%) patients were totally independent. The patients had various comorbidities, and the most frequently reported were as follows: Diabetes Mellitus, hypertension, heart, and lung diseases. The characteristics of the patients are described in Table 1.

Table 1. Baseline characteristics of the included patients
Social demographic characteristicsPatients (n = 42) (%)
  1. Note: SNF = Skilled Nursing Facility.

Age
<65 years11 (26)
65 year and older31 (74)
Mean years (SD)76 (11.4)
Range53–95
Gender
Men18 (43)
Women24 (57)
Living Situation
Alone21 (50)
Living together21 (50)
Marital status
Married16 (39)
Unmarried10 (24)
Cohabiting1 (2)
Widow(er)14 (33)
Separated1 (2)
Children
Yes35 (83)
No7 (17)
Stroke type
Hemorrhage11 (29)
Infarct30 (71)
First stroke33 (79)
Comorbidity21 (50)
Type of comorbidity
Heart and lung diseases8 (19)
Diabetes Mellitus7 (17)
Hypertension6 (14%)
Time since stroke
<1 month17 (40.5)
1–6 months19 (45.2)
>6 months6 (14.3)
Length of stay in SNF
<1 month25 (59.5)
1–6 months14 (33.4)
>6 months3 (7.1)
Functional status
Mean (SD)11.8 (5.7)
BI 0–914 (33)
BI 10–1924 (57)
BI 204 (10)
Number of patients in SNFs
SNF 17 (17)
SNF 213 (31)
SNF 311 (26)
SNF 45 (12)
SNF 56 (14)
  Patients ( n  = 42) (%)

Therapeutic activities

On average, the patients spent 56.1% of the day on therapeutic activities, the rest of the day they spent on non-therapeutic activities (Table 2). Of therapeutic activities, eating and drinking took the largest part of the time (14.9%), followed by communication (11.9%). Patients spent 8.5% of the day on active leisure activities, and 1.2% of the day on practicing independently. Patients received nursing care for 8.6% of the day and this includes all nursing care and ADL activities. Patients were engaged in all therapies for 7.6% of the day, in which more time was spent on physical therapy (4.4%) than occupational therapy (1.1%). The time spent on speech language therapy, care by a psychologist, guidance by a dietician, and medical care by an elderly care physician was less than 1% of the day for each therapy.

Table 2. Time spent on therapeutic and nontherapeutic activities, location, and interaction with others during the daya
 Total (n = 42) Minutes%
  1. a

    8 a.m.–4:30 p.m.

Therapeutic activities (total)291.756.1
Nursing care (including ADL care)44.78.6
Physical therapy22.94.4
Occupational therapy5.71.1
Speech therapy4.70.9
Psychotherapy1.00.2
Guidance by dietician0.50.1
Medical care1.00.2
Fitness
Food/Drink77.514.9
Transport/travel21.34.1
Communication61.911.9
Independent practice/training6.21.2
Active leisure44.28.5
Other therapeutic activities
Nontherapeutic activities (total)226.243.5
Sitting105.620.3
Laying of sleeping103.519.9
Passive leisure9.91.9
Other activities7.31.4
Location
Patient's room211.640.7
Therapy room/activity room28.65.5
Corridor24.44.7
Dining/living room198.638.2
Lounge8.31.6
Bathroom17.73.4
Outside the ward22.94.4
Outside the institution (outdoor)4.70.9
Other locations2.60.5
Social interaction with others
Nurse55.610.7
Physician2.60.5
Therapist38.57.4
Other patients84.216.2
Visitor69.713.4
Other persons7.81.5
Nobody/no interaction256.449.3

Nontherapeutic activities

Nontherapeutic activities accounted for 43.5% of the day. Patients were sitting passively for 20.3% of the time and laying or sleeping for 19.9% of the time.

Social interaction

The total time spent on interaction with others accounted for 50.7% of the day whereas they spent 49.3% of the day alone. On average, they spent 10.7% of the time interacting with nurses. Patients spent 10.2% of the day interacting with nurses in SNF number one, 8.3% of the day in SNF number two, 14.2% of the day in SNF number three, 10.8% in SNF number four 10.8%, and 9.9% in SNF number five (Table 2).

Location of activity

The patients spent 40.7% of the time in their own room, 38.2% of the time in the living room, and they stayed only for a limited part of the day in the therapy room (5.5%).

Functional status and activity

Time use on therapeutic activities was positively associated with functional status (Kruskal–Wallis test χ2 = 13.133; df = 2; = .001) (Table 3). Patients with a BI score of 20 spent 63% of the day on therapeutic activities and this was similar for patients with a BI score of 10–19 (62%), whereas the patients with a BI score of 0–9 spent 45% of the day on therapeutic activities.

Table 3. Therapeutic activities: outcomes of subgroup analysis
 χ2p value
  1. a

    Significance difference.

Barthel Index13.133.001a
Age0.023.879
Gender0.246.620
SNFs2.397.663

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

The findings of this study showed that elderly stroke patients who are rehabilitating in a SNF spent just over half of the day on therapeutic activities, consequently, almost half a day they stayed alone in their own room. Of therapeutic time, most of the patients' time was spent on nursing care, followed by physical therapy, and occupational therapy. A significant association was found between the level of functioning of the patient and the time used on therapeutic activities. Contrary to expectations, patients with a better functional status spent more time on therapeutic activities than those with lower functional status.

The findings in this study need to be considered in relation to the strengths and limitations. All observational studies have the potential for bias. A limitation of the study is the small sample size and the convenience sample, which may have increased the risk of selection bias. Also, all observations took place on weekdays between 8 a.m.–4:30 p.m. Due to organizational difficulties, it was not possible to conduct observations on evenings and weekends. This may have resulted in information bias. Although observation days were randomly selected, sometimes patients did not take part in therapy every day, which may have resulted in information bias. As inherent in all observational studies, the presence of the observers could have affected behavior of patients and professionals. On the other hand, to reduce the risk of affecting behavior of the participants, a tight observation scheme was used. Moreover, the observers adhered strictly to the observation scheme and tried to secure not being intrusive when observing the participants in their daily activities. A recent study shows that patients who were discharged had a mean MMSE score of 22 point (22/30). There were no differences in MMSE score between patients who discharged to home and who stays in a nursing home (Buijck, Zuidema, Spruit-van Eijk, Geurts & Koopmans, 2011.

When considering prior studies conducted on the time use of patients with stroke, it is important to point out the difference between this group of stroke patients and the stroke patients in other studies. Similar to the study of Huijben-Schoenmakers et al. (2009), which was conducted in a nursing home, the patients in our study were about 10 years older than the patients included in other studies. These other studies were conducted in the post acute or acute phase on rehabilitation wards in rehabilitation centers and hospitals (de Wit et al., 2005; Weerdt de et al. 2000). Our study showed that age was not associated with therapeutic time. In our study, younger patients received an equal portion of therapeutic activities compared with older patients, which is in contrary to the findings of Tinson (1989), who showed that older patients spent more time on therapy. Lang et al. (2009) studied possible correlates that could influence therapy intensity but found no correlation between age and therapy intensity. It is uncertain if older patients need more therapy, if so, this raises concerns about tailoring activities in SNFs to patient needs. Furthermore insight in therapy intensity, tailored to patient needs is considered necessary. This study can help design intervention programs specifically for SNFs where patient therapeutic time is much less than for patients residing in hospitals and rehabilitation centers, and research has shown time spent in therapy is an important factor for recovery for all patients regardless of age (Kwakkel, 2006; Kwakkel et al., 2004).

In this study, less time was spent on therapeutic activities than in other studies (Huijben-Schoenmakers et al., 2009; de Wit et al., 2005), although in our study eating and drinking, communication, travel, and ADL activities were registered as therapeutic activities, which was not the case in the other studies. We considered these activities as therapeutic because the therapeutic importance of these activities is endorsed by the geriatric rehabilitation nursing model of Routasalo et al. (2004). The patients in this study received physical therapy for only 4% each day, which is equal to the findings of Huijben-Schoenmakers et al. (2009) but much less than the reported 40% found in the (rehabilitation center) study conducted by de Wit et al. (2005) in four European countries, namely Belgium, Great Britain, Germany and Switzerland. Even time spent on other therapies such as occupational therapy and speech therapy was less in our study than in earlier studies of Huijben-Schoenmakers et al. (2009) and de Wit et al. (2005). The lower therapy time we found may partly be explained by the fact that our study took place in SNFs. The patients in our study had worse functional status, were older and had more comorbidities than patients included in earlier studies in hospitals and rehabilitation centers. Furthermore, distribution of financial resources may differ between countries and healthcare facilities within countries. However, to date only one study has been conducted on time use of patients with stroke in a nursing home (comparable with SNFs), which makes it difficult to draw conclusions. The patients in this study did not have much contact with nurses during the day (8 a.m.–4:30 p.m.). Only 10% of the day patients had some kind of interaction with nurses, consecutively less than 10% of the day was spent on ADL activities with nurses. Nevertheless, many studies have described the important role that nurses have in rehabilitation of patients with stroke (Rensink et al., 2009; Routasalo et al., 2004; Pryor & Buzio, 2010; Kirkevold, 1997). Nurses can help to restore functional status, increase well-being and enhance quality of life of patients. Nurses have an important role in motivating patients to comply to their rehabilitation programs and giving emotional support to informal caregivers. Clinical Practice Guidelines (CPGs) such as the Clinical Nursing Rehabilitation Guideline Stroke (Hafsteinsdóttir & Schuurmans, 2009; Rensink et al., 2009) include recommendations focusing on the daily rehabilitation care and treatment of stroke patients. During the daily care, nurses need to stimulate patients to do simple exercises such as reach for objects (Wu, Wong, Lin & Chen, 2001), standing up from a chair several times during the day (Cheng, Wu, Liaw, Wong & Tang, 2001) and exercise walking with patients (Nilsson et al., 2001). Other studies have shown the importance of involving informal caregivers (partner or family member) in the care and training of patients with stroke (Kalra et al., 2004; Maeshima et al., 2003). Based on these studies, nurses need to supervise and encourage informal caregivers to conduct simple exercises with the patients, including walking exercises (Latham et al., 2005). This may contribute to the functional recovery and improve the psychological and social well-being of the patients as well as the informal caregiver (Kalra et al., 2004). It is important to encourage the patients to train in tasks/activities that are important and relevant for them and which the patients themselves have chosen. This improves the motivation for exercising (Wu et al., 2001). Based on the findings of this study and CPGs published (Hafsteinsdóttir & Schuurmans, 2009; Rensink et al., 2009), nurses need to select exercises and tailor these to the individual patients′ needs and thereby they may contribute in a positive way to the rehabilitation outcome of these patients. Investigation into the origin of the passive nature of patients with stroke and what the best way is to motivate them, is necessary so that nurses and other professionals are better able to encourage them to comply with rehabilitation programs. Also, further research is needed into the role of nurses in the rehabilitation care of stroke patients. Lastly, nurses need to develop intervention programs focusing on improving time use of patients and aiming to improve the functional outcome of patients with stroke. Intervention and training programs may include simple task-oriented training exercises that patients can do individually, in groups or with caregivers. Also, intervention programs may include training exercises focusing on dysphagia, communication problems, and fall prevention for patients with stroke. These training programs should occur in therapeutic climates with: 1) structured activities which are tailored to patients needs, 2) explicitly formulated goals, 3) (mostly) hands-off nursing care (using mainly verbal instructions), 4) a supportive climate created by the multidisciplinary team, and 5) interaction with other patients. All activities have the focus on discharge of the patient to an independent or assisted living situation. Although it is likely that intervention and training programs may improve various outcomes of patients with stroke, the effects of such programs would need to be investigated, preferably using randomized clinical trials, which may offer information about their effectiveness on various patient outcomes.

Key Practice Points
  • Stroke patients in Skilled Nursing Facilities spend more than half of the day on therapeutic activities. Patients with a better functional status spend more time on therapeutic activities.
  • Nurses are challenged with how to activate patients and engage them in purposeful task-oriented rehabilitation in daily activities.
  • Nurses need to emphasize the importance of more time for training of patients with worse functional status.
  • Poor functional recovery has psychological and social consequences and ultimately consequences for discharge from the SNF to an independent or assisted living situation after stroke.
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Conclusion

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

Stroke patients spend more than half of the day on therapeutic activities. Patients with a better functional status spend more time on therapeutic activities. Nurses are challenged with how to activate patients and engage them in purposeful task-oriented rehabilitation in daily activities. Nurses need to emphasize the importance of more time for training of patients with worse functional status. This poor functional recovery has psychological and social consequences and ultimately consequences for discharge from the SNF to an independent or assisted living situation after stroke.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References

We thank the patients who participated in the study, the nurses, other healthcare professionals and the management of the Skilled Nursing Facilities. We also thank the research assistants Anita Koetsier, Nieke van Oosten and Wendy van de Wege of the University of Applied Sciences Zeeland, Vlissingen, the Netherlands.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest: No conflict of interest has been declared by the authors.

References

  1. Top of page
  2. Abstract
  3. Background
  4. The study
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgments
  9. References
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