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Disability & Rehabilitation
2012
34
17
1473
1480
© 2012 Informa UK, Ltd.
10.3109/09638288.2011.647231
0963-8288
1464-5165
Disability & Rehabilitation, 2012; 34(17): 1473–1480
© 2012 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.647231
16 March 2011
26 November 2011
December 2011
Purpose: Backache and sciatica due to protuberant disc disease
is a major cause of lost working days and health expenditure.
Surgery is a well-established option in the management
flowchart. There is no strong evidence proving that traction for
sciatica is effective. We report a pilot prospective randomized
controlled trial comparing inversion traction and physiotherapy
with standard physiotherapy alone in patients awaiting
lumbar disc surgery. This study sought to study the feasibility
of a randomized controlled trial on the effect of inversion
therapy in patients with single level lumbar discogenic disease,
who had been listed for surgery. Methods: This was a single
centre prospective randomized controlled trial undertaken
at the Regional Neurosciences Centre, Newcastle Upon Tyne,
UK. It was a prospective randomized controlled trial where
patients awaiting surgery for pure lumbar discogenic disease
within the ambit of the prestated inclusion/exclusion criteria
were allocated to either physiotherapy or physiotherapy
and intermittent traction with an inversion device. Post-
treatment assessment made by blinded observers at 6 weeks
for various outcome measures included the Roland Morris
Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36),
Oswestry Disability Index (ODI), Visual Analogue Pain Score
(VAS), magnetic resonance imaging (MRI) appearance and
the need for surgery. Avoidance of surgery was considered a
treatment success. Results: Twenty-six patients were enrolled
and 24 were randomized [13 to inversion + physiotherapy and
11 to physiotherapy alone (control)]. Surgery was avoided
in 10 patients (76.9%) in the inversion group, whereas it was
averted in only two patients (22.2%) in the control group.
Cancellation of the proposed operation was a clinical decision
based on the same criteria by which the patient was listed for
surgery initially. There were no significant differences in the
RMDQ, SF 36, ODI, VAS or MRI results between the two groups.
Conclusion: Intermittent traction with an inversion device
resulted in a significant reduction in the need for surgery. A
larger multicentre prospective randomized controlled trial is
justified in patients with sciatica due to single level lumbar disc
protrusions.
Keywords: Avoidance of surgery, inversion therapy, single
level lumbar discogenic disease, traction
Introduction
Degenerative lumbar disease is a major cause of disability
and health expenditure, especially in the industrialized world
[1,2]. Compression of the nerve roots is oen the cause of
sciatica and, if sustained or severe, can result in neurological
decits. is can be caused by a degenerative disc protrusion
RESEARCH PAPER
Inversion therapy in patients with pure single level lumbar discogenic
disease: a pilot randomized trial
K. S. Manjunath Prasad1, Barbara A. Gregson2, Gerard Hargreaves3, Tiernan Byrnes2, Philip Winburn2 &
A. David Mendelow2
1Department of Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom, 2Department of Neurosurgery,
Regional Neurosciences Centre, Newcastle upon Tyne, United Kingdom, and 3Department of Physiotherapy, University of
Northumbria, Newcastle upon Tyne, United Kingdom
Correspondence: Dr. K.S. Manjunath Prasad, Department of Neurosurgery, James Cook University Hospital, Middlesbrough TS4 3BW,
United Kingdom. Tel: +44 1642 835717. Fax: +44 1642 282770. E-mail: manjunath.prasad@doctors.org.uk
Resolution of impairment and diasability due to radic-•
ulopathy is the aim of any intervention.
Avoidance of surgery meant satisfactory resolution of •
impairment and disability due to radiculopathy. is
happened more oen in the inversion group to the
extent of reaching statistical signicance.
e 12-point improvement in disability by the Oswestry •
Disability Index in the inversion group suggests a role
for this intervention in disability reduction.
Inversion may form part of the conservative rehabilita-•
tion of patients with single level unilateral lumbar disc
protrusion alongside other forms of physiotherapy.
ere is a potential secondary impact in the reduction •
of rehabilitation following surgery.
Implications for Rehabilitation
(Accepted December 2011)
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1474 K.S.M. Prasad et al.
Disability & Rehabilitation
or by other processes like spondylolisthesis, spinal stenosis
and arthritis of the spinal joints. Sciatica can be described as
pain radiating down the leg(s) along the distribution of the
sciatic nerve and is usually a sequel to mechanical compres-
sion or inammation of the lumbosacral nerve roots [1].
e natural history of lumbar discogenic disease is well
known. It is usually a benign self-limiting condition. Sciatica
due to disc disease resolves without surgery in 1–12 months
in the majority of patients [3]. Over a period of time, the
protruded disc fragment decreases in size as the normal route
of “nutrition” is impeded and the hydration is reduced. e
relationship between the bulging disc and the adjacent nerve
is not only very close, but the inammatory changes in the
root cause further reduction in the space for the nerve. With
restriction of movement and activity coupled with reduction
in disc size, the inammation is also reduced and symptoms
are sometimes alleviated. If this does not happen, a variety of
interventions are available [4].
General Practitioners in Maastricht have reported that
there was no dierence in the outcomes when patients with
lumbar discogenic backache were managed either with bed
rest or no bed rest [5]. ese results were conrmed in a later
Cochrane review [6]. ere is no evidence that one or the
other type of conservative therapy is superior, including no
treatment for patients with lumbosacral radicular syndrome
[7]. ere is no evidence for optimal sequencing of therapies
or their ecacy in the treatment of sciatica [8].
Surgery for sciatica due to disc herniation is well estab-
lished [9], but costs more than a hundred million pounds per
year in the United Kingdom alone. Surgery has been shown
to reduce the time to recovery by about 50% but is associated
with a complication rate of 1–3% [3]. e biggest challenge
faced by clinicians in the management of these patients there-
fore is to optimize the use and timing of surgical intervention.
Avoiding surgery (and that too within a reasonable waiting
period as a signicant outcome measure) has not been clearly
addressed by earlier trials. e SPORT trial failed to show a
benet from surgery perhaps because of a high cross-over rate
(30%) from conservative treatment to surgery [10].
Traction is a well-known treatment for lumbar discogenic
disease used commonly in North America [11] and to a lesser
extent in parts of Europe [12]. Traction may work by separa-
tion of vertebral bodies, distraction and gliding of facet joints,
widening of the intervertebral foramen, straightening of the
spinal curves and stretching of the spinal musculature [13].
By distracting the vertebral bodies, negative pressure could
probably withdraw the protruding fragment back into the disc
space. e futility of traction (continuous or intermittent) as
a single treatment for low back pain [14] or radiculopathy [7]
is highlighted in some systematic reviews while research is
not infallible in denitively proving that there is “no eect”
or “no dierence” between two treatments [15]. Traction is
more likely to work if there is radicular involvement [16–19]
manifesting as sciatica [16,17].
Type of traction and traction dosage could inuence eec-
tiveness in sciatica. Traction can be continuous or intermittent
and can be manual, mechanical or motorized. Traction forces
of less than 20% of the body weight have been described as
placebo [20], whereas others claim that this can also be useful
[16,21]. e importance of intradiscal pressure especially in
relation to posture is well known [22]. Nachemson et al. [22]
showed that a traction load of 60% of the body weight is suf-
cient to reduce the residual pressure of 25% caused by stand-
ing to zero. In “Inversion” or “Backswing”, a tilt table is used
and the weight of the entire upper half of the patient’s body
assisted by gravity acts as the traction. e traction forces here
are likely to be more consistent and tailored to each patient
than conventional traction.
e primary aim of the present study was to assess the e-
cacy of traction using an inversion device in alleviating symp-
toms due to lumbar disc protrusion and avoiding the need for
surgery in patients with acute disc prorusions that had been
oered microdiscectomy.
Methods
Patients
Recruitment and randomization were undertaken at the
Regional Neurosciences Unit, Newcastle upon Tyne between
February 2003 and September 2006. Approval from the
Newcastle Local Research ethics committee was obtained in
2003. Patients eligible for inclusion were aged between 18 and
45 years (both inclusive), within 6 months of the rst episode
of symptoms caused by a single level unilateral lumbar disc
protrusion causing the appropriate nerve root impingement
and in whom a decision to operate was made. Patients were
not considered eligible if there were any red ag features,
increasing neurological decits, signicant cardio-respiratory
disorder, pregnancy, weight more than 20% of ideal norms
for height and age or more than 140 kg. Magnetic resonance
imaging (MRI) evidence of a large sequestrated disc fragment
was also an exclusion criterion.
Written informed consent according to the prescription
of the local research ethics committee was obtained in every
patient.
Procedures
Sealed serially marked envelopes were used for randomiza-
tion by the treating physiotherapist. All patients were given a
standard regime of physiotherapy. One group had traction with
standardized access and time on the inversion table for a period
of 4 weeks whereas the other group did not have this. All patients
were assessed by blinded observers aer 6 weeks. e outcome
measures used were Roland Morris Disability Questionnaire
(RMDQ), Short Form 36 (SF 36), Oswestry Disability Index
(ODI), Visual Analogue Pain Score (VAS), MRI appearance
and need for surgery. An MRI done 6 weeks aer the random-
ized treatment was commenced and the pre randomization
and post-treatment MRI scans were compared. If the second
MRI was worse, a score of −1 was given while it was 0 for an
unchanged appearance. If the second MRI was better, but com-
pression persisted, a score of +1 was given while total relief of
compression earned +2. Patients who went on to have surgery
were considered as treatment failures. In all patients, surgery
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Inversion therapy in lumbar discogenic disease 1475
© Informa UK, Ltd.
was initially considered the best option; but because of the wait-
ing lists in the unit, a nal decision about surgery was made by
the treating surgeon preoperatively. e treating neurosurgeon
was blinded to the allocation to inversion or not.
e treatment protocol for both groups of patients
included physiotherapy. Best practice physiotherapy remains
to be established for radiculopathy [23–25]. Each patient was
assessed for impairment and clinical ndings and treated with
a combination of education and advice [26], specic exercise
for movement control [27] exercises for reduction of derange-
ment [23] and manual therapy techniques [24,25]. Distraction
techniques were not used with this group. In addition to phys-
iotherapy, the inversion therapy group received mechanical
inversion three times a week for 4 weeks. Each session com-
prised up to six 2-minute inversions within the tolerance of
the patient. Guvenol et al. [28] inverted patients 10 minutes
daily for 10 days, however poor tolerance due to anxiety was
reported with this dose. Static inversion is reported to pro-
duce feelings of congestion and to avoid this Goldman et al.
[29] suggest short periods within patient tolerance.
e patient completed outcome measures used in the
study were SF 36, RMDQ, ODI and VAS. All four question-
naires have been used in the low back pain population. e
RMDQ and ODI are recognized disease-specic measures
of patient perception of disability [30]. e RMDQ [31] is a
patient completed questionnaire developed from the Sickness
Impact Prole. e 24-item scale covers a range of functional
activities with higher scores representing worse dysfunction.
e ODI [32] measures perceived disability in 10 activities
of daily living. e scale produces a score out of 100% with
a higher score representing increasing disability. e SF 36
[33] is a generic measure of eight dimensions of health status
divided between physical and mental health. A score of 100%
denotes the best health status possible. A VAS is a measure-
ment instrument that measures a characteristic or attitude
across a continuum of values.
Statistical analysis
Statistical analyses were conducted using SPSS 140 and
WinPepi 6.3. Data were compared using Fisher Exact test,
t-tests and Mann–Whitney U tests as appropriate.
Results
Twenty-six patients were recruited but two patients did not
attend the physiotherapy department, and so 24 patients were
randomized. Of these, all baseline and follow-up data were
missing for one patient and one patient did not fulll the inclu-
sion criteria. us 22 patients were eligible for assessment. Of
these, 13 patients were randomized to inversion while 11 were
allocated to the group without inversion. e trial prole is
shown as a ow chart in Figure 1 and details of all patients’
age, sex and level of disc involved is given in Table I.
Surgery
Surgical intervention was avoided in 10 patients (76.9%)
among the inversion group, while it was avoided in only two
patients (22.2%) among the no inversion group. Cancellation
of the proposed operation was a clinical decision-based on
the same criteria by which the patient was listed for surgery
initially. is is statistically signicant (Figures 2 and 3).
Avoidance of surgery thus has to be considered as a treatment
success.
MRI
Post-treatment MRI scans were available for 21 patients. One
patient who had surgery before the treatment was completed
because of worsening symptoms. e majority of the patients
in both groups (53.8% for the inversion group and 54.5% for
the control group) had unchanged images. e number of
patients in whom a change was seen either for the better or
worse was not statistically signicantly dierent and the same
was true when the two groups were compared (Figure 4).
Roland Morris Disability Questionnaire
is was available for 12 subjects in the inversion group and
7 patients in the other group. Table II displays the median
and range of Roland Morris scores at baseline and follow-up
for each group and change over time. A higher score implies
the disability is greater and a negative change score implies
improvement over time. ere are no statistically signicant
dierences between the two treatments.
SF 36
is was available for 12 subjects in the inversion group and
7 patients in the other group. Table III displays the mean and
standard deviation of each component of SF 36 at baseline
and the change over time between baseline and follow-up.
e higher the score at baseline, the better the health status
and the more positive the change over time the greater the
improvement. e change in health measure ranges from 1
to 5 and a score of 1 indicates that the patient feels they are
much better now than they were a year ago whereas a score
of 5 indicates that they are much worse now. A negative
value for change in health status implies improvement and
a positive value implies the patient is reporting being worse.
Comparisons between the two treatment groups have been
made using the t-test.
Patients in both groups show a poor health status on most
components at baseline. ese values are similar to those
reported in other studies. ere is little dierence between
the two groups. On average, the patients improve over time
but again there is no dierence between the two groups in
the degree by which they improve although this study is not
powered to be able to show a dierence.
Oswestry Disability Index
is was available for eight subjects in the inversion group and
three patients in the other group. Table IV displays the median
and range of Oswestry scores at baseline and follow-up for
each group and the change in score. A higher score at baseline
or follow-up implies a greater disability. A negative change in
score implies an improvement over time. ere is no dier-
ence in score at baseline but patients in the inversion therapy
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1476 K.S.M. Prasad et al.
Disability & Rehabilitation
group tend to have less disability at follow-up and the change
in score between baseline and follow-up almost reaches sta-
tistical signicance (using Mann–Whitney U test). Patients in
the inversion therapy group have a median improvement of
12 percentage points while those in the physiotherapy group
have a median improvement of 0 percentage points.
Visual Analogue Pain Score (VAS)
ough the VAS was available for 12 patients in the inversion
group before and aer treatment, one in each of the before
and aer cohort groups was not available at the other time
point and therefore the mean and median was calculated for
11 subjects. In the control group, data were available for seven
patients, before and aer treatment. A negative change over a
period of time indicates improvement. Figure 5 gives details
of the VAS before and aer treatment in the two groups. e
change was not statistically signicant in either group. In the
control group, the median VAS changed from 2.8 to 3.0 (t-test
p = 0.697) and for the inversion group it changed from 3.2 to
0.9 (t-test p = 0.078).
Discussion
Our pilot trial has shown that intermittent extreme traction
with an inversion device has resulted in a signicant reduc-
tion in the number of patients requiring surgery for radicular
symptoms due to lumbar disc protrusion.
Traction for sciatica
Some systematic reviews have highlighted the ineective-
ness of traction in low back pain [14] and radiculopathic
pain like sciatica [7], whereas a number of other reports have
Figure 1. Trial prole.
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Inversion therapy in lumbar discogenic disease 1477
© Informa UK, Ltd.
contradicted this, especially when used for disability and pain
due to radiculopathy [16–19].
is study was therefore undertaken in patients listed and
waiting for an operation to relieve root compression due to
lumbar disc disease.
Type of traction
Inversion or Backswing is a form of traction where the patient
is strapped at the ankles in a tilt table. e patient is then
gradually tilted to a head down position. is results in a
form of extreme traction where the traction force is created
by the weight of the upper half of the patients’ body and grav-
ity. is brings in a sort of standardization as the traction is
dependent on the patient’s own body weight. Inversion is used
as intermittent traction with each patient having standardized
access and time with the device spread over a specied period
of time. Our study looked at the specic subset of patients
with radicular symptoms with the traction group receiving
intermittent inversion.
Sheeld [34] surmised that the benecial eects from
adapting the tilt table for traction resulted from stretching
of paraspinal muscles, ligaments and intervertebral discs.
Another study showed that gravity assisted traction was more
eective than other forms of traction [35]. Studying the eects
of gravity assisted traction on intervertebral dimensions of
the lumbar spine, it has been shown that this form of traction
produced signicant intervertebral separation between the
lumbar vertebrae [36,37].
Decline in electromyographic (EMG) activity (which is
thought to be an indicator of muscle pain) was consistently
demonstrated with the use of the inversion device [37,38].
Traction dosage
Using gravity and the weight of the patient’s own body, a con-
sistent and reproducible traction can be administered. ese
factors inuence the traction dosage as well.
Traction of less than 25% of body weight has been
described as low dose or sham traction [39]. A traction
load of 60% body weight was found to cause a reduction
of the residual intradiscal pressure of 25% standing body
weight to zero [22]. Inversion devices can easily achieve this.
Table I. Patient details.
SINo Age Sex Level Treatment Scan outcome Surgery
1 33 M L5-S1 Inversion 1 0
2 40 M L4-5 Control 0 1
3 29 M L5-S1 Inversion 1 0
4 28 M L4-5 Inversion 0 1
5 34 M L4-5 Control 2 1
6 25 M L5-S1 Inversion 1 1
7 38 F L4-5 Control 0 0
8 36 F L4-5 Inversion 0 0
9 34 M L5-S1 Inversion 0 1
10 38 F L4-5 Inversion 0 0
11 38 F L5-S1 Control 0 1
12 43 M L4-5 Inversion −1 0
13 41 F L5-S1 Control 1 0
14 44 F L5-S1 Inversion 2 0
15 28 F L5-S1 Control 0 0
16 43 F L5-S1 Control 0 1
17 31 M L5-S1 Control OPERATED 1
18 35 F L5-S1 Control 0 1
19 31 F L5-S1 Inversion −1 0
20 40 F L4-5 Inversion 0 0
21 32 M L5-S1 Inversion 0 0
22 43 M L5-S1 Control 0 1
23 35 F L5-S1 Inversion 0 0
24 31 F L5-S1 Control 0 1
Figure 2. Avoidance of surgery.
Figure 3. Duration of Avoidance of surgery.
Figure 4. MRI scan outcome.
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1478 K.S.M. Prasad et al.
Disability & Rehabilitation
Administration of consistent and eective traction dosage
could thus be achieved by using inversion as an intervention
in this study.
Possible effects
e most striking feature in this study was the statistically
signicant higher rate of avoidance of surgery in the inversion
group. e other domain where the change due to inversion
was noteworthy was in the ODI. A 12 point improvement
was seen in this scale, suggesting a useful role for inversion in
reducing disability. is almost reached statistical signicance
when compared with the “no inversion” group. Fritz and
Irrgang [40] used a modied ODI and found that an improve-
ment of 6 points or more made a clinical dierence.
Surgery only addresses neural compression by disc
material, but this is seen in a number of asymptomatic
individuals as well. Pain and disability in lumbar disco-
genic disease might be due to mechanical, inammatory
and immunological causes and not just due to compression
[41]. Sheeld [34] surmised that the benecial eects due to
inversion resulted from stretching of paraspinal muscles, lig-
aments and intervertebral discs whereas other studies have
demonstrated decline in EMG activity (which is thought to
be an indicator of muscle pain) with the use of the inver-
sion device [37,38]. ese observations might explain the
signicant benets due to inversion as assessed by ODI and
avoidance of surgery even though the appearance on MRI
was not congruent.
Changes in practice
Some surgeons in this centre now oer inversion therapy as
standard initial treatment to patients awaiting surgery for
pure single level lumbar discogenic sciatica within the ambit
of the inclusion/exclusion criteria used in this trial.
Adverse effects
No serious adverse eect was noted in either group in this
trial. is was noted from a process of reporting adverse
events by exception. e available literature shows that there
is no clear reporting of adverse events with traction in general
and inversion in particular [14].
Economic impact
Again, the costs of treatment with traction or the price of any
adverse event thereof is not clearly seen in the available lit-
erature. Looking at costs for intermittent inversion, costs for
lumbar disc surgery and the demonstrated reduction in the
number of operations from our own data, savings in excess
of a hundred million pounds per year can be expected if we
assume that around 15,000 operations are done in the UK
every year for lumbar discogenic disease.
Further research
e available literature does not provide evidence of e-
cacy from traction. However, traction as a single treatment
Table IV. Oswestry disability index.
Inversion +
physiotherapy
N = S
Physiotherapy
N = 3 Signicance
Baseline oswestry 50 (22–78) 48 (38–56) 0.644
Follow-up oswestry 31 (14–74) 54 (32–56) 0.298
Change in oswestry −12 (−26 to 0) 0 (−6 to 6) 0.064
Figure 5. Visual analogue score.
Table III. SF 36 scores.
Inversion +
physiotherapy
N = 12
Physiotherapy
N = 7 Signicance
Baseline
SF 36 physical function 43.5 (27.5) 35.7 (20.1) 0.521
SF 36 role − physical 17.3 (37.3) 32.1 (47.2) 0.449
SF 36 bodily pain 29.8 (23.7) 26.3 (9.3) 0.710
SF 36 general health 59.0 (13.2) 71.7 (12.4) 0.065
SF 36 vitality 39.2 (12.7) 44.3 (6.7) 0.344
SF 36 social function 44.2 (22.0) 53.6 (25.7) 0.404
SF 36 role − emotional 46.2 (46.2) 42.9 (53.5) 0.887
SF 36 mental health 54.1 (19.3) 61.7 (22.0) 0.436
SF 36 change in health 4.3 (0.8) 3.3 (1.0) 0.032
Change
SF 36 physical function 9.2 (15.3) 8.2 (18.3) 0.901
SF 36 role − physical 10.4 (24.9) 7.1 (31.3) 0.804
SF 36 bodily pain 12.5 (24.6) 15.6 (15.5) 0.771
SF 36 general health 2.8 (15.1) 0.0 (13.4) 0.705
SF 36 vitality 11.3 (16.0) 0.5 (12.9) 0.148
SF 36 social function 15.6 (28.3) 2.5 (30.6) 0.824
SF 36 role − emotional 13.9 (54.0) 23.8 (41.8) 0.682
SF 36 mental health 10.0 (14.6) −2.3 (14.2) 0.092
SF 36 change in health −0.7 (0.9) 0.2 (1.3) 0.151
Table II. Roland Morris disability questionnaire assessment.
Inversion +
physiotherapy
N = 12
Physiotherapy
N = 7 Signicance
Baseline Roland Morris 12.5 (1–20) 10 (1–19) 0.475
Follow-up Roland Morris 7.5 (0–20) 11 (2–21) 0.552
Change ill Roland Morris −1 (−13 to 4) −1 (−5 to 8) 0.441
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Inversion therapy in lumbar discogenic disease 1479
© Informa UK, Ltd.
for low back pain also cannot be recommended at present
[7,14]. Heterogeneity of patient populations in terms of type
and duration of symptoms, non standardization of traction,
variations in duration of follow-up and outcome measures
used and lack of power are all contributory factors for lack
of strong evidence regarding the use of traction [42,43]. is
should encourage researchers to organize trials of high quality
incorporating these points.
Conclusion
Our hypothesis was that inversion therapy would reduce the
need for a surgical procedure in subjects with sciatica due to
single level disc protrusion. e results of this study do sup-
port this; surgery was avoided in 77% in the inversion group
while it was averted in only 22% in the non inversion group.
Avoidance of surgery did not prejudice other outcome mea-
sures and vice versa. e study demonstrated the feasibility
of a randomized controlled trial of the impact of an inversion
device on various outcome measures in single level disco-
genic disease. Previous trials of traction have not reported on
avoidance of surgery as an outcome measure and this trial has
addressed that issue. e economic impact is very signicant
and a larger multicentre prospective randomized control trial
is justied.
Declaration of Interest: e work was partially supported by
a grant from the Jacobson Charitable Trust.
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