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Zhang T, Firouzabadi A, Yang D, Liu S, Schmidt H. Age-dependent flexion relaxation phenomenon in chronic low back pain patients. Front Bioeng Biotechnol 2024; 12:1388229. [PMID: 39295844 PMCID: PMC11408191 DOI: 10.3389/fbioe.2024.1388229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/26/2024] [Indexed: 09/21/2024] Open
Abstract
Background The flexion relaxation phenomenon (FRP) is characterized by suddenly reduced paraspinal muscle activity during full flexion. Previous studies showed significant differences in FRP and flexion angles in chronic low back pain (cLBP) patients compared to individuals without back pain (no-BP). However, the relationship between FRP and flexion angles remains insufficiently understood in older populations. Thus, this study investigated the relationship between FRP and flexion angles concerning to the age and presence of cLBP. Methods Forty no-BP subjects (20m/20f; mean age 41.5 years) and thirty-eight cLBP patients (19m/19f; mean age 43.52 years) performed maximum full upper body flexion task. Electromyographic (EMG) measurements were conducted to assess the activity of lumbar erector spinae (ESL), thoracic erector spinae (EST), and multifidus (MF). Lumbar, thoracic, and pelvic angles at the onset (OnsetL/T/P) and offset of the FRP (OffsetL/T/P) and maximum trunk inclination (MaxL/T/P) were calculated. The FRP was evaluated using a flexion relaxation ratio (FRR). Results cLBP patients showed smaller FRR in MF and right ESL compared to no-BP individuals (p < 0.05), while no differences were found in flexion angles between two groups. Subjects over 40 showed smaller FRR in MF and ESL, and smaller flexion angles on OffsetL and MaxL (p < 0.05). Age-related analysis in the cLBP group revealed that patients over 40, compared to younger ones, had smaller FRR in MF and ESL, and smaller values in all thoracic and lumbar flexion angles (p < 0.05). While in no-BP group, significant larger flexion angles in OnsetL and OffsetT (p < 0.05) were observed in participants over 40. Pain-related analysis in the older group revealed that the cLBP patients, compared to no-BP individuals, had smaller FRR in right MF and right ESL, and smaller values in all lumbar and thoracic flexion angles (p < 0.05), while in younger group, there were no significant pain-related differences in FRR, with larger values in all lumbar flexion angles (p < 0.05). Conclusion Our findings indicate a reduction or absence of FRP in cLBP patients compared to no-BP individuals, with age being a significant factor as those over 40 showed smaller FRP and flexion angles compared to younger individuals.
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Affiliation(s)
- Tianwei Zhang
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ali Firouzabadi
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daishui Yang
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sihai Liu
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hendrik Schmidt
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
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Ratajczak M, Waszak M, Śliwicka E, Wendt M, Skrypnik D, Zieliński J, Krutki P. In search of biomarkers for low back pain: can traction therapy effectiveness be prognosed by surface electromyography or blood parameters? Front Physiol 2023; 14:1290409. [PMID: 38143914 PMCID: PMC10739392 DOI: 10.3389/fphys.2023.1290409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/17/2023] [Indexed: 12/26/2023] Open
Abstract
Background: Lumbar traction therapy is a common method to reduce low back pain (LBP) but is not always effective. The search for biomarkers that would prognose the effectiveness of LBP management is one priority for improving patients' quality of life. Objectives: 1) To determine the phenotype of patients benefiting most from lumbar traction therapy. 2) To correlate systemic and electromyographic biomarkers with pain and pain-related disability. Methods: Data on muscle bioelectrical activity (surface electromyography [SEMG]) in the flexion-extension task, the concentrations of twelve systemic biochemical factors, LBP intensity (Visual Analog Scale), the Oswestry Disability Index, and the Roland-Morris Disability Questionnaire (RMDQ) were collected before and 72 h after 20 sessions of lumbar traction therapy. Patients were divided into responders and nonresponders based on the criterion of a 50% reduction in maximal pain. Results: The responders had lower maximal muscle bioactivity in the extension phase on the left side (p < 0.01) and higher flexion-extension ratios on both sides of the body in the SEMG (left: p < 0.05; right: p < 0.01), and higher adipsin, interleukin-2, interleukin-4, and interleukin-10 concentrations (p < 0.05) than nonresponders. Patients with higher interleukin-4 concentrations before therapy achieved greater reductions in maximal pain in the sitting position, bioelectrical muscle activity in flexion, and flexion-relaxation ratio on the left side of the body. Changes in adipsin and interleukin-4 concentrations correlated with changes in LBP intensity (r = 0.68; r = -0.77). Changes in stem cell growth factor and interleukin-17A correlated with changes in RMDQ (R = 0.53) and bioelectrical muscle activity in extension (left: R = -0.67; right: R = -0.76), respectively. Conclusion: Responders to traction therapy had SEMG indices of less favorable muscle activity in the flexion-extension task and elevated indices of inflammation before the study. For the first time, interleukin-4 was indicated as a potential biomarker for prognosing post-therapy changes in pain intensity and muscle activity.
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Affiliation(s)
- Marzena Ratajczak
- Department of Medical Biology, Poznan University of Physical Education, Poznan, Poland
| | - Małgorzata Waszak
- Department of Medical Biology, Poznan University of Physical Education, Poznan, Poland
| | - Ewa Śliwicka
- Department of Physiology and Biochemistry, Poznan University of Physical Education, Poznan, Poland
| | - Michał Wendt
- Department of Medical Biology, Poznan University of Physical Education, Poznan, Poland
| | - Damian Skrypnik
- Department of Treatment of Obesity, Metabolic Disorders and Clinical Dietetics, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Zieliński
- Department of Athletics, Strength and Conditioning, Poznan University of Physical Education, Poznan, Poland
| | - Piotr Krutki
- Department of Medical Biology, Poznan University of Physical Education, Poznan, Poland
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Mackey S, Howarth SJ, Frey M, De Carvalho D. An investigation of the flexion relaxation ratio in adults with and without a history of self-reported low back pain and transient sitting-induced pain. J Electromyogr Kinesiol 2022; 67:102719. [PMID: 36334404 DOI: 10.1016/j.jelekin.2022.102719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 10/10/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
It is unknown whether the presence of sitting-induced pain or a clinical history of low back pain (LBP) changes spine function outcomes such as the flexion relaxation ratio (FRR). The purpose of this investigation was to determine whether sitting-induced pain or a history of non-specific LBP results in a different FRR. Forty-seven participants were instrumented with surface electromyography over erector spinae at L1, and accelerometers at L1 and S2. Standing maximum lumbar flexion trials were taken preceding and following a 1-hour sitting trial. Pain ratings during sitting and history of LBP were used to group participants for analysis. FRR values taken after the sitting exposures were compared between those that did and did not develop pain during sitting. Baseline FRR values were compared participants with and without a history of LBP. No significant differences in FRR were found for either pain groups (p = 0.11) or clinical history (p = 0.85). Lack of differences may be due to participants not currently experiencing a clinical episode of pain when the ratio was measured and/or because 1-hour sitting exposure was not long enough to induce pain modulation. The findings suggest that neither sitting-induced pain development or clinical history need to be controlled to prevent confounding of FRR.
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Affiliation(s)
- Sarah Mackey
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Samuel J Howarth
- Division of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Mona Frey
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Diana De Carvalho
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada.
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Fan Y, Liu F, Li M, Ruan X, Wu M, Su K, Gao J, Feng X. Observation of curative effect on meridian theory-based extracorporeal shock wave therapy for non-specific low back pain: study protocol for a randomized controlled trial. J Orthop Surg Res 2022; 17:265. [PMID: 35562830 PMCID: PMC9107249 DOI: 10.1186/s13018-022-03146-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-specific low back pain (NLBP) is a major global socioeconomic burden, and the prevalence of NLBP is still on the rise. At present, there is no ideal drug to cure this disease. This may be the reason why patients often use complementary therapies. Among them, extracorporeal shock wave therapy (ESWT) has gradually received more attention and has become the main treatment method for NLBP. The purpose of this study is to provide scientific evidence for the effect and safety of meridian theory-based ESWT on NLBP. Objective This study aims to evaluate the effect and safety of meridian theory-based ESWT on NLBP. This study will also provide more high-quality experimental evidence for the clinical application of meridian theory-based ESWT for the treatment of NLBP in future. Methods The study design is a single-blind, multi-center, randomized controlled trial. 66 patients with NLBP, aged 18 to 60 years, will be randomly divided into two groups: the experimental group (N = 33), which will receive meridian theory-based ESWT application, and the control group (N = 33) which will receive conventional ESWT treatment. These two applications will be carried out twice a week for two weeks. The primary outcome will be the Visual Analog Scale (VAS), and the secondary outcomes will be Oswestry Disability Index (ODI), Surface Electromyography (sEMG), and Patient Health Questionnaire-15 (PHQ-15). All outcomes will be evaluated at baseline and after the intervention (7 days, 14 days). Discussion Results of this trial will contribute to providing rigorous clinical evidence for the efficacy and security of meridian theory-based ESWT for NLBP. Trial registration: Chinese Clinical Trial Registry, ChiCTR2100051049. Registered on 10 September 2021, http://www.chictr.org.cn/showproj.aspx?proj=46316.
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Affiliation(s)
- Yongfu Fan
- Henan University of Chinese Medicine, Zhengzhou, 450000, China
| | - Feilai Liu
- Rehabilitation Center, The First Affiliated Hospital of Henan University of Chinese Medicine, 19# Renmin Road, Jinshui District, Zhengzhou, 450000, Henan Province, China
| | - Mengna Li
- Institute of Pain Medicine and Special Environmental Medicine, Nantong University, Nantong, 226019, China
| | - Xiaodi Ruan
- Henan University of Chinese Medicine, Zhengzhou, 450000, China
| | - Mingli Wu
- Rehabilitation Center, The First Affiliated Hospital of Henan University of Chinese Medicine, 19# Renmin Road, Jinshui District, Zhengzhou, 450000, Henan Province, China
| | - Kaiqi Su
- Rehabilitation Center, The First Affiliated Hospital of Henan University of Chinese Medicine, 19# Renmin Road, Jinshui District, Zhengzhou, 450000, Henan Province, China
| | - Jing Gao
- Rehabilitation Center, The First Affiliated Hospital of Henan University of Chinese Medicine, 19# Renmin Road, Jinshui District, Zhengzhou, 450000, Henan Province, China
| | - Xiaodong Feng
- Henan University of Chinese Medicine, Zhengzhou, 450000, China. .,Rehabilitation Center, The First Affiliated Hospital of Henan University of Chinese Medicine, 19# Renmin Road, Jinshui District, Zhengzhou, 450000, Henan Province, China.
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Zheng YL, Hu HY, Liu XC, Su X, Chen PJ, Wang XQ. The Effects of Whole-Body Vibration Exercise on Anticipatory Delay of Core Muscles in Patients with Nonspecific Low Back Pain. Pain Res Manag 2021; 2021:9274964. [PMID: 34394778 PMCID: PMC8357519 DOI: 10.1155/2021/9274964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022]
Abstract
Objective The objective of this study is to determine the effect of whole-body vibration (WBV) exercise on the anticipatory delay of core muscles in nonspecific low back pain (NSLBP) patients. Methods Forty participants with NSLBP were randomly divided into the WBV group and the control group. The sEMG signals of deltoid, erector spines (ES), multifidus (MF), rectus abdominis (RA), and transversus abdominus/internal oblique muscles (TrA/IO) were recorded before and after the intervention in the weight-shifting task. The relative activation time of each muscle was calculated. Results In the WBV group, the relative activation time of bilateral MF and bilateral TrA/IO was significantly reduced on shoulder flexion (right MF: P=0.014; left MF: P=0.011; right TrA/IO: P=0.008; left TrA/IO: P=0.026). As for shoulder abduction, except for the left TrA/IO and the left RA, the relative activation time of other muscles was significantly reduced (right ES: P=0.001; left ES: P < 0.001; right MF: P=0.001; left MF: P=0.009; right TrA/IO: P < 0.001; right RA: P=0.001). In the control group, there was no significant difference in the relative activation time of each muscle before and after the intervention (P > 0.05). Conclusions WBV exercise can effectively alleviate the anticipatory delay of core muscles in NSLBP patients, but the long-term effects still need further study. This trial is registered with ChiCTR-TRC-13003708.
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Affiliation(s)
- Yi-Li Zheng
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Hao-Yu Hu
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China
| | - Xiao-Chen Liu
- Department of Rehabilitation Medicine, Shanghai East Hospital, Shanghai, China
| | - Xuan Su
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Pei-Jie Chen
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Xue-Qiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China
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Vanhauter N, Van Erck A, Anciaux M, Pollefliet A, Joos E. Isometric and isokinetic muscle strength measurements of the lumbar flexors and extensors with BioniX Sim3 Pro in patients with chronic low back pain: A pilot study. J Back Musculoskelet Rehabil 2021; 34:381-388. [PMID: 33492281 DOI: 10.3233/bmr-200225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The World Health Organization states that low back pain is the leading cause for disability worldwide. Patients with chronic low back pain (CLBP) show important decreases in lumbar strength and can now be assessed by using the new isokinetic dynamometer BioniX Sim3 Pro which offers very detailed measurements. OBJECTIVE To compare lumbar flexion and extension strength values, as well as extension-flexion ratio (EFR) based on isokinetic velocity and gender, for patients with CLBP on the BioniX Sim3 Pro. METHODS A retrospective analysis was performed on data from 20 men and 22 women with CLBP. Maximum torque in flexion and extension was measured isometrically and isokinetically. Statistical analysis was performed on these parameters. RESULTS EFR shows a downward trend with increasing speed of measurement (isometric to isokinetic 30∘/s and isokinetic 30∘/s to isokinetic 90∘/s, respectively): in men from 1.21 to 1.04 (p< 0.001) and from 1.04 to 0.93 (p= 0.207). In women, EFR decreased from 1.41 to 1.13 (p< 0.001) and from 1.13 to 1.00 (p= 0.144). CONCLUSIONS Patients with CLBP have a decreased strength in lumbar extension and flexion compared to the age-corrected normal values of Bionix Sim3 Pro. With increasing speed of testing protocol, a decrease in EFR is observed in this population.
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Affiliation(s)
- N Vanhauter
- Physical Medicine and Rehabilitation, UZ Brussel, Brussels, Belgium
| | - A Van Erck
- Physical Medicine and Rehabilitation, AZ Jan Palfijn, Ghent, Belgium
| | - M Anciaux
- Physical Medicine and Rehabilitation, AZ Jan Palfijn, Ghent, Belgium
| | - A Pollefliet
- Physical Medicine and Rehabilitation, AZ Jan Palfijn, Ghent, Belgium
| | - E Joos
- Physical Medicine and Rehabilitation, UZ Brussel, Brussels, Belgium
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Cimarras-Otal C, Marcen-Cinca N, Rabal-Pelay J, Lacrcel-Tejero B, Alczar-Crevilln A, Villalba-Ruete J, Bataller-Cervero AV. Adapted exercises versus general exercise recommendations on chronic low back pain in industrial workers: A randomized control pilot study. Work 2021; 67:733-740. [PMID: 33164978 DOI: 10.3233/wor-203322] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Exercise has been demonstrated as effective for the treatment of low back pain (LBP) in workers. OBJECTIVE The purpose of this study was to investigate whether an exercise program adapted to the characteristics of the workplace is a useful supplement to general exercise recommendations in assembly line workers with chronic LBP. METHODS Workers were randomly assigned to intervention group-adapted exercises plus general exercise recommendations (n = 10), and control group-general exercise recommendations (n = 8). Both received 8-week exercise program through a mobile application (APP) to manage the intervention. Outcome was based on lumbar disability (Oswestry Disability Index), interference and lumbar pain intensity (Brief Pain Inventory), and kinematic parameters. RESULTS Significant differences were obtained for the intervention group in the "pain interference" variable, in the "mood" and "enjoyment" sub-variables, as well as in "flexion angle" variable. For the control group, significant differences occurred in the "pain intensity" variable. Adapted exercise plus general recommendations seems more effective than the general recommendations for the improvement of lumbar flexion. CONCLUSIONS An adapted exercise program for assembly line workers with chronic LBP could be an effective treatment. Future studies with a larger sample size and with an exhaustive control of the exercise adherence are required to confirm the findings of this pilot study.
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Affiliation(s)
- Cristina Cimarras-Otal
- Universidad San Jorge, Autovía A-23 Zaragoza-Huesca Km 299, 50830, Villanueva de Gállego, Spain
| | - Noel Marcen-Cinca
- Universidad San Jorge, Autovía A-23 Zaragoza-Huesca Km 299, 50830, Villanueva de Gállego, Spain
| | - Juan Rabal-Pelay
- Universidad San Jorge, Autovía A-23 Zaragoza-Huesca Km 299, 50830, Villanueva de Gállego, Spain
| | | | | | - JosAntonio Villalba-Ruete
- BSH Electrodomésticos España S.A., Pol. Industrial Otallana, Avenida La Industria, 50016, Zaragoza, Spain
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Neuromuscular activation analysis of the trunk muscles during hippotherapy sessions. J Bodyw Mov Ther 2020; 24:235-241. [DOI: 10.1016/j.jbmt.2020.02.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/18/2019] [Accepted: 02/26/2020] [Indexed: 11/20/2022]
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Sao CH, Chan-Tiopianco M, Chung KC, Chen YJ, Horng HC, Lee WL, Wang PH. Pain after laparoscopic surgery: Focus on shoulder-tip pain after gynecological laparoscopic surgery. J Chin Med Assoc 2019; 82:819-826. [PMID: 31517775 DOI: 10.1097/jcma.0000000000000190] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Laparoscopy, one of minimally invasive procedures, is a commonly used procedure in diagnosis and management of various kinds of clinical problems, including gynecologic organ-related diseases. Compared with conventional exploratory laparotomy, the benefits of laparoscopic surgery include reduction of surgical wound, decreasing in postoperative pain, shortening hospital stay, rapid recovery, and a better cosmetic result. However, there are still up to 80% of patients after laparoscopic surgery complaining of high levels of pain and needing pain relief. Postlaparoscopic pain can be separated into distinct causes, such as surgical trauma- or incision wound-associated inflammatory change, and pneumoperitoneum (carbon dioxide [CO2])-related morphological and biochemical changes of peritoneum and diaphragm. The latter is secondary to irritation, stretching, and foreign body stimulation, leading to phrenic neuropraxia and subsequent shoulder-tip pain (STP). STP is the most typical unpleasant experience of patients after laparoscopic surgery. There are at least 11 strategies available to attempt to decrease postlaparoscopic STP, including (1) the use of an alternative insufflating gas in place of CO2, (2) the use of low-pressure pneumoperitoneum in place of standard-pressure pneumoperitoneum, (3) the use of warmed or warmed and humidified CO2, (4) gasless laparoscopy, (5) subdiaphragmatic intraperitoneal anesthesia, (6) local intraperitoneal anesthesia, (7) actively expelling out of gas, (8) intraperitoneal drainage, (9) fluid instillation, (10) pulmonary recruitment maneuvers, and (11) others and combination. The present article is limited in discussing postlaparoscopic STP. We extensively review published articles to provide a better strategy to reduce postlaparoscopic STP.
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Affiliation(s)
- Chih-Hsuan Sao
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | | | - Kai-Cheng Chung
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Jen Chen
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Huann-Cheng Horng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wen-Ling Lee
- Department of Medicine, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
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