Enhanced walking function and quality of life in unicondylar knee replacement patients through continuous nursing intervention: A clinical study

Abstract

BACKGROUND:

The knee joint anatomical structure is susceptible to external forces, which can lead to functional break down, profoundly affecting the quality of life and daily functioning of individuals.

OBJECTIVE:

To investigate the effects of continuous nursing intervention on walking function, quality of life, and treatment satisfaction in patients undergoing unicondylar knee replacement.

METHODS:

This prospective study included 90 patients who underwent unicondylar knee arthroplasty due to unicondylar osteoarthritis. Participants were divided into two groups based on their nursing methods: the control group ( $n=$ 45) and the observation group ( $n=$ 45).

RESULTS:

Three months post-intervention, the observation group demonstrated significant improvements in knee joint range of motion, Hospital for Special Surgery Knee Score score, and Lysholm knee joint score compared to the control group ( $P<$ 0.05). The observation group also had a shorter completion time for the Timed Up and Go test and significantly higher SF-36 scores ( $P<$ 0.05 for both). Additionally, Knee Injury and Osteoarthritis Outcome Score scores in the observation group were significantly higher after three months of intervention ( $P<$ 0.05). And the observation group reported higher satisfaction rates and lower dissatisfaction rates compared to the control group ( $P<$ 0.05).

CONCLUSION:

Early postoperative rehabilitation guidance, regular reviews, and rehabilitation exercise guidance result in better rehabilitation outcomes, enhanced knee joint function, improved walking ability, and overall quality of life for patients undergoing unicondylar knee replacement.

Keywords

Nursing arthroplasty replacement knee quality of life

1. Introduction

In the physiological structure of the human body, the knee joint holds significant importance as one of the most pivotal joints involved in sports activities. Due to its anatomical structure, it is susceptible to external forces, which can lead to functional break down, profoundly affecting the quality of life and daily functioning of individuals. Early knee joint lesions often involve a single compartment, and unicondylar knee joint replacement is a common surgical procedure widely used to treat patients with unicondylar osteoarthritis or unicondylar trauma [1, 2]. The primary goal of this surgery is to relieve pain and improve the quality of life by replacing the damaged part of the knee joint. However, surgery alone is just one part of the entire treatment process, and postoperative rehabilitation and continuous nursing play a vital role in the recovery of patients’ walking function and quality of life [3]. As an essential nursing approach, consecutive nursing intervention is of paramount importance in the rehabilitation after unicondylar knee joint replacement [4, 5]. It not only focuses on the success of the operation but also emphasizes comprehensive care and support for patients post-operation. Continuous nursing intervention provides personalized rehabilitation guidance, regular reviews, and rehabilitation exercise guidance, along with professional psychological and social support to patients [6]. Continuous nursing intervention strategies include early postoperative rehabilitation guidance, regular follow-up to evaluate recovery, continuous rehabilitation exercises, limb rehabilitation care, psychological support, and pressure therapy. This comprehensive nursing model aims to help patients better cope with postoperative challenges and enhance the recovery of their walking ability and overall quality of life. Through personalized rehabilitation guidance and regular reviews, patients are able to gain a better understanding of postoperative precautions, learn correct rehabilitation actions and skills, and minimize the risk of postoperative complications. This approach proves instrumental in accelerating the rehabilitation process and enhancing walking function and activity ability [7, 8]. Additionally, continuous nursing intervention emphasizes on providing patients with psychological and social support to help them cope with postoperative emotional changes, improve social functioning, and enhance overall quality of life [9]. Research has demonstrated that continuous nursing intervention positively impacts the walking ability and quality of life of individuals undergoing unicondylar replacement of the knee joint. Patients typically experience better rehabilitation outcomes and higher satisfaction levels after receiving continuous nursing intervention [10, 11]. However, despite these promising results, the current research on continuous nursing intervention remains relatively limited. There is still a need to further explore the specific intervention content and its efficacy across different patient groups. This nursing model emphasizes the importance of continuity and individualization of care, providing patients with all-encompassing support. At its core, continuous nursing involves establishing a stable and reliable nurse-patient relationship. Nurses closely interact with patients to understand their individual needs and nursing goals, providing ongoing monitoring and support. This comprehensive nursing approach covers various aspects, including disease management, rehabilitation and preventive measures, symptom relief, psychological support, and patient education [12, 13, 14]. Therefore, enhancing precise and effective guidance for continuous care after unicondylar knee replacement surgery is essential to improve rehabilitation outcomes and overall quality of life.

2. Materials and methods

2.1 General information of patients

From April 2020 to December 2022, a total of 90 patients who underwent unicondylar knee replacement due to unicondylar osteoarthritis or unicondylar trauma were included as the research subjects. The study was approved by the Ethics Committee of The First Hospital of Hebei Medical University (No. 20210669). All enrolled patients provided informed consent before participating.

The sample size for this project was calculated using the following formula: $N=Z^{2}\times{\{}P\times(1-P){\}}/E^{2}$ . $N$ represents the sample size, $Z$ is the z-score corresponding to the desired confidence level (1.96 for 95% confidence and 1.64 for 90% confidence), $E$ is the margin of error, and $P$ is the estimated proportion. Based on this formula, the minimum sample size for quantitative research was determined to be 90 samples.

2.2 Inclusion criteria

Age over 18 years old, regardless of gender.

Patients who underwent unicondylar replacement of knee joint.

Ability to walk independently or with auxiliary tools.

Good compliance.

Willingness to participate in the research, adhering to the research program’s procedures.

2.3 Exclusion criteria

Presence of other serious bone and joint diseases or complications, such as severe osteoporosis and arthritis.

Serious heart and lung diseases, such as severe heart disease and respiratory diseases.

Patients with cognitive impairment or those unable to cooperate with rehabilitation training.

2.4 Nursing interventions for patients

2.4.1 Control group

Patients in the control group received standard care, which included routine postoperative care, wound management, medication management, and basic care to ensure their safety and comfort. These patients did not receive personalized rehabilitation guidance or regular follow-up.

2.4.2 Observation group

Early postoperative rehabilitation guidance: Immediately after surgery, the rehabilitation team provided patients with detailed postoperative rehabilitation guidance. This included instructions on wound care, pain management, and maintaining joint mobility. The guidance also covered the correct use of assistive devices, such as walking aids and knee braces, along with necessary precautions.

Regular reexamination: Patients in the observation group underwent regular reexaminations by the rehabilitation team to evaluate postoperative recovery. These reexaminations included measurements of joint range of motion, muscle strength assessments, and pain evaluations. Based on these assessments, the rehabilitation plans and intervention measures were adjusted accordingly.

Continuous exercise: The rehabilitation team developed personalized rehabilitation exercise plans for patients, including exercises for joint mobility recovery, muscle strength training, and balance training. The team provided guidance on performing these exercises correctly and gradually adjusted the intensity and frequency according to the patient’s condition to promote joint function recovery and enhance muscle strength and balance. Before exercising, the amplitude of the patient’s knee joint flexion and extension was measured and recorded. Exercise equipment was adjusted based on these results to match the patient’s exercise intensity, thereby reducing the risk of injury. Patients were encouraged to maintain sufficient rest periods to sustain continuous exercise. The range of motion for exercise equipment was set based on the initial measured knee joint motion range and incrementally adjusted according to equipment parameters until the knee joint could bend and extend to its maximum angle.

Nursing and rehabilitation: Specifically, this included: (1) Limb rehabilitation care: There were two types of limb rehabilitation care. Passive exercise involved using specialized instruments or caregivers to assist patients in scientifically massaging and engaging in limb activities, such as extending and stretching the tibialis anterior muscle and quadriceps femoris, with no less than 100 stretches per day. Patients exercised their entire body for 30 minutes, twice daily. As patients gained the ability to exercise autonomously, they engaged in simple physical activities, with nursing staff promptly supervising and correcting any improper movements. (2) Psychological care: Nursing staff explained the significance of rehabilitation training to patients, actively communicated with them, effectively evaluated their psychological state, and provided targeted guidance based on their psychological characteristics and personalities. (3) Utilized pneumatic limb circulation to improve the effectiveness of the device. The device adjusted pressure reasonably based on the actual condition of the patient’s affected limb.

Both nursing methods were administered for 6 months. This study adopted a continuity of care strategy involving telephone supervision and guidance to ensure the execution of rehabilitation plans in the continuous care intervention group.

2.5 Evaluation of knee joint function before and after intervention: Assessment of knee joint mobility, Hospital for Special Surgery Knee Score (HSS), Lysholm Knee Score, and Timed Up and Go (TUG) test

Postoperative rehabilitation methods: After anesthesia and awakening, rehabilitation focused on quadriceps muscle strength training and patellar displacement exercises to prevent joint adhesion. Patients were encouraged to bear weight and walk on the ground as early as the first day after surgery. Maintaining a normal gait was emphasized to ensure coordination between the knee and hip joints. Additional rehabilitation exercises included straight leg lifts and ankle pump exercises.

Comparison of knee joint range of motion: The knee joint range of motion was compared between the two groups of patients preoperatively and at 3 and 6 months postoperatively. Patients sat by the bed with straightened calves, flat on the bed surface, toes pointing upward. Measurements included back extension (20^∘–30^∘), plantar flexion (40^∘–50^∘), varus (30^∘), eversion (30^∘–35^∘), and flexion (135^∘–150^∘).

Hospital for Special Surgery Knee Score (HSS): The HSS was used to evaluate knee joint function recovery, with scores ranging from 0 to 100. Scores $\geqslant$ 86 indicate excellent function, 70–85 are considered good, 60–69 moderate, and $\leqslant$ 59 poor.

The Lysholm Knee Joint Score was utilized to assess the knee joint function of both patient groups before and after treatment. This scale comprises 8 modules, covering aspects such as limp, pain, swelling, support, and instability. Scores range from 0 to 100, with higher scores indicating better knee function. Scores below 70 indicate a significant decrease in knee function.

The Timed Up and Go (TUG) Test was employed to evaluate patients’ walking function before and after intervention. During the test, patients wore their usual shoes and sat on a chair with armrests (seat height approximately 45 cm, armrest height around 20 cm). If using a walking aid (e.g., cane or walker), patients held it in hand. A colored strip, visible line, or marker was placed 3 meters away on the ground. Upon the tester’s “start” command, patients stood up, walked to the marker at their normal pace, turned around, returned to the chair, and sat down again without assistance. The time taken (in seconds) to complete the task was recorded, along with any risk of falling observed during the test. Patients were allowed 1–2 practice attempts before formal testing to ensure they understood the procedure completely.

2.6 Quality of life assessment

For evaluating patients’ quality of life, the SF-36 and Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaires were employed. The SF-36 assesses physical function, mental health, and social function in a healthy state. Each dimension is scored from 0 to 100, with higher scores indicating better quality of life in that dimension. On the other hand, KOOS is a questionnaire designed to evaluate symptoms, pain, physical function, and quality of life in patients with knee joint injury and osteoarthritis. Similarly, higher scores in each the dimension reflect better quality of life and milder symptoms.

2.7 Satisfaction questionnaire

To comprehensively evaluate patients’ satisfaction with knee joint treatment and nursing, a questionnaire was administered. The scoring criteria were as follows: 1 $=$ very dissatisfied, 2 $=$ dissatisfied, 3 $=$ satisfied, and 4 $=$ very satisfied. The specific survey items included: satisfaction with treatment results (scored 1–4), satisfaction with pain relief after treatment (scored 1–4), satisfaction with functional recovery after treatment (scored 1–4), satisfaction with improvement of quality of life after treatment (scored 1–4), satisfaction with professional level and service of medical staff (scored 1–4), and satisfaction with the management of complications and adverse reactions during treatment (scored 1–4).The satisfaction survey was administered upon completion of six months of rehabilitation exercise by the patients.

2.8 Statistical analysis

Data analysis was conducted using SPSS statistical software version 21.0. Measurement data are presented as mean $\pm$ standard deviation and analyzed using the $t$ -test. Counting data were presented as percentages and analyzed using the chi-square test. The experimental data of the two groups before and after intervention were compared using paired $t$ -tests.

3. Results

3.1 General data analysis

Table 1
General data analysis

Parameter	Control group	Observation group	$T$ value/ $\chi^{2}$ value	$P$ value
Gender (male: female)	8:37	14:31	4.120	0.851
Age (years)	61.38 $\pm$ 5.23	63.17 $\pm$ 4.33	2.674	0.535
BMI (kg/m²)	22.55 $\pm$ 2.05	21.94 $\pm$ 1.93	1.993	0.101
VAS score	6.25 $\pm$ 3.51	7.49 $\pm$ 3.26	3.206	0.824
Knee flexion angle (degree)	114.26 $\pm$ 25.38	109.66 $\pm$ 27.49	4.511	0.375
Operation duration (hours)	2.13 $\pm$ 0.54	2.26 $\pm$ 0.49	1.062	0.142
Length of stay (days)	7.38 $\pm$ 2.57	8.42 $\pm$ 2.96	2.675	0.229

Subjects were randomly divided into a control group ( $n=$ 45) and an observation group ( $n=$ 45). The control group received standard nursing without special intervention measures, while the observation group received continuous nursing intervention, including early postoperative rehabilitation guidance, regular reviews, and rehabilitation exercise guidance. The patients’ ages ranged from 55 to 75 years, with an average age of 62.68 $\pm$ 5.26 years. Among them, there were 22 males and 68 females. In the control group, there were 23 males and 22 females, with an average age of 61.38 $\pm$ 5.23 years. The average BMI was 22.55 $\pm$ 2.05 kg/m², and the preoperative VAS score was 6.25 $\pm$ 3.51. The maximum flexion angle was 114.26 $\pm$ 25.38 degrees, and the operation time averaged 2.13 $\pm$ 0.54 hours. The average length of hospital stay was 7.38 days. In the observation group, there were 29 males and 16 females, with an average age of 63.17 $\pm$ 4.33 years. The average BMI was 21.94 $\pm$ 1.93 kg/m², and the preoperative VAS score was 7.49 $\pm$ 3.26. The maximum flexion angle was 109.66 $\pm$ 27.49 degrees, and the operation time averaged 2.26 $\pm$ 0.49 hours. Additionally, the average length of hospital stay was 8.42 $\pm$ 2.96 days. There were no significant differences in the general characteristics between the two groups ( $P>$ 0.05) (Table 1).

3.2 Knee joint mobility, HSS, Lysholm knee joint score, and TUG test

Table 2
Knee joint mobility, HSS, Lysholm knee joint score, and TUG test score for patients ( $\bar{x}\pm s$ , $n=$ 45)

Groups	Knee joint mobility			HSS
	Before intervention	After three months of intervention	After six months of intervention	Before intervention	After three months of intervention	After six months of intervention
Control group	48.26 $\pm$ 10.23	100.39 $\pm$ 25.66	112.32 $\pm$ 30.65	64.36 $\pm$ 8.24	75.63 $\pm$ 6.58	83.69 $\pm$ 7.53
Observation group	49.01 $\pm$ 11.15	119.85 $\pm$ 26.02	125.71 $\pm$ 33.62	68.71 $\pm$ 7.71	91.44 $\pm$ 8.35	112.02 $\pm$ 11.75
$T$ value	1.526	6.851	8.254	3.209	11.634	16.236
$P$ value	0.285	0.001	0.001	0.114	0.001	0.001
Groups	Lysholm knee joint score			TUG test
	Before intervention	After three months of intervention	After six months of intervention	Before intervention	After three months of intervention	After six months of intervention
Control group	52.69 $\pm$ 6.98	73.38 $\pm$ 7.26	82.52 $\pm$ 9.01	16.32 $\pm$ 5.49	12.67 $\pm$ 3.88	10.29 $\pm$ 5.18
Observation group	53.37 $\pm$ 7.22	87.52 $\pm$ 9.12	95.21 $\pm$ 10.86	17.44 $\pm$ 4.61	7.35 $\pm$ 3.15	5.21 $\pm$ 1.25
$T$ value	1.023	8.962	12.036	2.118	12.524	7.258
$P$ value	0.527	0.001	0.001	0.335	0.001	0.001

Before the intervention, there were no significant differences in knee joint range of motion, HSS score, and Lysholm knee joint score between the two groups of patients ( $P>$ 0.05). However, three months after the intervention, the observation group showed significant improvements in knee joint range of motion, HSS score, and Lysholm knee joint score compared to the control group ( $P<$ 0.05). Additionally, there was no significant difference in the completion time of the TUG test between the two groups before the intervention ( $P>$ 0.05). After three months of intervention, the observation group demonstrated a significantly shorter completion time in the TUG test compared to the control group ( $P<$ 0.05) (Table 2).

3.3 SF-36 score for patients

Table 3
SF-36 score for patients ( $\bar{{x}}\pm s$ , $n=$ 45)

Groups	Before intervention	After three months of intervention	After six months of intervention
Control group	45.37 $\pm$ 6.59	72.85 $\pm$ 6.37	88.92 $\pm$ 10.25
Observation group	47.44 $\pm$ 5.27	85.36 $\pm$ 7.99	96.71 $\pm$ 9.56
$T$ value	3.108	9.522	12.351
$P$ value	0.421	0.001	0.001

Before the intervention, no significant differences were found in the SF-36 scores between the two groups ( $P>$ 0.05). However, after three months of intervention, the SF-36 score in the observation group were significantly higher than in the control group ( $P<$ 0.05) (Table 3).

3.4 KOOS score for patients

Table 4
KOOS score for patients ( $\bar{x}\pm s$ , $n=$ 45)

Groups	Before intervention	After three months of intervention	After six months of intervention
Control group	56.22 $\pm$ 5.49	81.62 $\pm$ 7.72	98.60 $\pm$ 10.68
Observation group	55.34 $\pm$ 6.71	93.58 $\pm$ 5.03	115.56 $\pm$ 15.27
$T$ value	3.118	13.725	16.173
$P$ value	0.477	0.001	0.001

The KOOS was utilized to evaluate the quality of life related to knee joint injury. Before the intervention, the KOOS scores did not differ between the two groups ( $P>$ 0.05), whereas they were significantly higher in the observation group compared to the control group after three months of intervention ( $P<$ 0.05) (Table 4).

3.5 Patient satisfaction survey

Table 5
Patient satisfaction survey ( $n=$ 45)

Group	Very satisfied	Satisfied	Dissatisfied	Very dissatisfied
Control group ( $n=$ 45)	14 (31.11%)	9 (20.00%)	8 (17.77%)	10 (22.22%)
Observation group ( $n=$ 45)	21 (46.66%)	15 (33.33%)	5 (11.11%)	4 (8.88%)
$\chi^{2}$ value	9.492	13.671	2.044	15.249
$P$ value	0.001	0.001	0.001	0.001

The patients’ overall satisfaction was evaluated through a questionnaire. The observation group showed higher rates of “very satisfied” and “satisfied” responses compared to the control group ( $P<$ 0.05). Additionally, the observation group had significantly lower rates of overall dissatisfaction compared to the control group ( $P<$ 0.05) (Table 5).

4. Discussion

Unicondylar knee replacement is a common surgical operation used to treat knee joint injury caused by unicondylar osteoarthritis or unicondylar trauma. In this procedure, only the damaged part of the knee joint, usually the medial or lateral condyle, is replaced (the condyle is one of the bony protrusions of the knee joint). Continuous nursing refers to ongoing, comprehensive, and coordinated nursing intervention for patients throughout the medical process, with the goal of improving their health status and quality of life [15, 16].

The impact of continuous nursing intervention of patients undergoing knee unicondylar replacement is both positive and significant. Earlier research has indicated that continuous nursing intervention plays a crucial role in the rehabilitation process of these patients, encompassing early postoperative rehabilitation guidance, regular reviews, and rehabilitation exercise guidance [17, 18]. Continuous nursing intervention accelerates the rehabilitation process of patients. Early postoperative rehabilitation guidance is instrumental in helping patients comprehend postoperative precautions, rehabilitation timelines, and rehabilitation goals, thereby enhancing their understanding and willingness to cooperate with the rehabilitation process [19]. Regular reviews and follow-ups enable timely monitoring of patients’ rehabilitation progress, facilitating the identification and resolution of any issues that may arise during the rehabilitation process. This allows for the adjustment of rehabilitation plans, ensuring a smooth and effective rehabilitation progress [20]. Moreover, continuous nursing intervention significantly contributes to improving patients’ walking ability [21, 22]. The rehabilitation exercise instruction, which includes joint range exercises, muscle strength training, and balance training, effectively enhances patient’s muscle strength and joint stability, leading to improved gait and walking ability [23]. Through continuous rehabilitation guidance and supervision, patient’s joint mobility and walking ability gradually recover, ultimately advancing the independence and quality of daily life. During the habilitation process, patients may encounter various psychological and social challenges, such as mood fluctuations and social obstacles. Continuous nursing intervention provides essential psychological support and education to help patients cope with these issues, maintain a positive attitude, and preserve good social functioning, thereby enhancing their quality of life and well-being. An integral aspect of continuous nursing intervention is the cultivation of patients’ self-management skills [24]. Through education and guidance, patients acquire self-rehabilitation techniques, including the correct use of assistive devices, rational drug management, and pain control. By empowering patients with these self-management abilities, they become more actively engaged in their rehabilitation process and better equipped to manage their own progress. This, in turn, facilities improved rehabilitation outcomes and long-term maintenance of their ability. Clinical studies have consistently demonstrated the positive impact of continuous nursing intervention on functional recovery and quality of life in patients who underwent unicondylar knee replacement. The findings revealed that patients who received continuous nursing intervention experienced notable enhancements in terms of activity ability, pain relief, and life satisfaction during their postoperative rehabilitation period. Similar research in the field of orthopedics also reported positive results, indicating that continuous nursing intervention effectively reduces patients’ pain, improves joint function, and enhances their self-management capabilities [25].

In this study, we examined the influence of continuous nursing intervention on the walking function and quality of life of patients who underwent unicondylar replacement of the knee joint. Two groups of patients were subjected to different postoperative nursing interventions. The control group received routine nursing care, while the observation group received continuous nursing intervention, which included early postoperative rehabilitation guidance, regular reviews, and rehabilitation exercise guidance. These interventions aimed to provide personalized rehabilitation guidance and monitoring to promote the rehabilitation process of patients. Our results depicted that after three months of intervention, the observation group showed notable improvements in knee joint function and walking ability, higher HSS scores, and shorter TUG test times compared to the control group. This indicates that continuous nursing intervention significantly enhances patients’ walking function, shortens the time required to complete daily activities, and facilitates a better return to normal life. Additionally, the SF-36 rating scale was utilized to assess the quality of life of patients. The results found that the observation group exhibited higher quality of life scores compared to the control group after three months of intervention. The SF-36 score assesses various aspects of quality of life, including physiological function, mental health, and social function, among others. As a result, continuous nursing intervention can advance patients’ overall quality of life and enhance their psychological and social well-being. Additionally, the study applied the KOOS rating scale to evaluate the quality of life related to knee joint injury, showing that after three months of intervention, the observation group had higher KOOS scores compared to the control group. The KOOS score mainly covers pain, symptoms, daily activities, exercise, and quality of life. Continuous nursing intervention is able to relieve patients’ pain symptoms, improve their daily activities and physical capabilities, thereby improving their quality of life related to knee joint injury. Moreover, the results of the comprehensive satisfaction survey indicated that the rates of overall satisfaction, including both “very satisfied” and “satisfied”, were significantly higher in the observation group compared to the control group, while lower dissatisfaction rates were found in the observation group compared to the control group. This demonstrates that continuous nursing intervention can increase overall patient satisfaction and enhance their contentment with the treatment outcome.

This study has several limitations. For instance, the sample size is relatively small and lacks geographical diversity. Additionally, the observation period is relatively short, and therefore, the long-term effects of treatment have not been fully evaluated.

5. Conclusion

In conclusion, continuous nursing intervention positively influences the walking function and quality of life of patients undergoing unicondylar replacement of the knee joint. Through early postoperative rehabilitation guidance, regular reviews, and rehabilitation exercise guidance, patients achieve better rehabilitation outcomes and improved knee joint function, walking ability, and overall quality of life. This study holds significant guiding value for nursing and rehabilitation after unicondylar knee replacement and provides valuable references for clinical practice.

Author contributions

CHZ and HW contributed to the conception and design of the study; JGW, XLJ, HJZ and FZ performed the experiments, collected and analyzed data; YL and YLL wrote the manuscript; YP revised the manuscript. All authors reviewed and approved the final version of the manuscript.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki of the World Medical Association and approved by the Ethics Committee of The First Hospital of Hebei Medical University (No. 20210669).

Funding

No funding was received for this study.

Informed consent

Informed consent was obtained from all study subjects before enrollment.

Footnotes

Acknowledgments

The authors are grateful to all staff professionals and participants.

Conflict of interest

The authors declare that they have no competing interests.

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