Did you know that shoulder pain affects millions of people worldwide? Shoulder impingement is a big reason for this.
Shoulder impingement can significantly impact your daily life. The first step in treatment usually focuses on easing pain and improving movement.
We’ll look at the best ways to treat shoulder pain. We’ll see how doctors and therapists work together to help.
Key Takeaways
- Conservative management is the primary approach for treating shoulder impingement.
- A combination of medical and therapeutic strategies is often recommended.
- Early intervention can significantly improve treatment outcomes.
- Personalized treatment plans are key for effective management.
- A multidisciplinary approach may be necessary for optimal recovery.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Definition and Anatomical Considerations
The shoulder joint, also known as the glenohumeral joint, is very complex. It lets us move our arms in many ways. It’s made up of the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone).
The rotator cuff, a group of muscles and tendons, surrounds the shoulder joint. It helps keep the joint stable and lets us move our arms. Shoulder impingement syndrome usually affects the supraspinatus tendon of the rotator cuff. This tendon can get irritated as it goes through the subacromial space.
The subacromial space is the area between the acromion (a bony projection on the scapula) and the humeral head. When the rotator cuff tendons get inflamed or irritated, it can cause pain and make moving the shoulder harder. Knowing how the shoulder joint works is key to diagnosing and treating shoulder impingement syndrome.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Understanding the different types of shoulder impingement is crucial for effective treatment.
| Understanding the different types of shoulder impingement is crucial for effective treatment. | Description | Common Causes |
| Subacromial Impingement | Irritation of rotator cuff tendons beneath the acromion | Repetitive overhead activities, poor posture |
| Internal Impingement | Pinching of the rotator cuff tendons between the humeral head and the glenoid | Throwing motions, swimming, repetitive lifting |
Understanding the different types of shoulder impingement is crucial for effective treatment. By figuring out the specific type, healthcare providers can create a plan that really helps. This plan can address the root causes and help ease the symptoms.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Knowing why shoulder impingement happens is key to treating and preventing it. It occurs when the rotator cuff tendons get irritated or inflamed as they move through the shoulder. This issue can come from both the structure and how the shoulder works.
Structural Factors
Some causes of shoulder impingement are related to the body’s structure. For example, bone spurs can grow on the acromion, making it harder for tendons to pass through. Other structural issues, like osteoarthritis, can also narrow the space for tendons.
Also, the shape of the acromion can affect the risk of shoulder impingement. People with a curved or hooked acromion face a higher risk because of less space for tendons.
Functional Factors
Functional factors also play a big role in shoulder impingement, mainly for those who do a lot of overhead work. Repetitive motion or overuse can cause tendon inflammation. Poor posture can also lead to impingement by changing how the shoulder moves.
Muscle imbalances are another factor. For instance, weak rotator cuff muscles or tight pectoralis major muscles can cause abnormal shoulder movements. This increases the risk of impingement.
Understanding these causes is vital for creating a good treatment plan. It should tackle both the symptoms and the underlying reasons for shoulder impingement.
Recognizing Shoulder Impingement Symptoms
Understanding the different types of shoulder impingement is crucial for effective treatment.
Pain Patterns and Characteristics
Pain from shoulder impingement happens when you lift your arm or move it in certain ways. This pain can be sharp or dull and feels deep in your shoulder. Doing things like reaching high shelves or playing sports like swimming or tennis can make the pain worse.
Range of Motion Limitations
As shoulder impingement gets worse, you might find it harder to move your arm. Simple tasks like getting dressed or combing your hair can become tough. Feeling stiff or tight in your shoulder often goes along with this.
Progression of Symptoms Over Time
If you don’t treat shoulder impingement, symptoms can get worse. At first, pain might only happen when you do certain activities. But as it gets worse, pain can be constant and even happen when you’re resting or at night, making it hard to sleep.
Impact on Daily Activities
Shoulder impingement can significantly impact your daily life.
Shoulder impingement can significantly impact your daily life.
Diagnosing shoulder impingement takes a detailed approach. This includes clinical exams and imaging studies. We’ll walk you through the steps and what to expect.
Clinical Examination Techniques
A detailed clinical exam is key to diagnosing shoulder impingement. We check the shoulder’s range of motion and look for pain points. Tests like the Neer and Hawkins-Kennedy tests help pinpoint the issue.
These tests involve moving the arm in certain ways to see if it hurts. We also check the rotator cuff muscles for strength and tenderness. This helps us figure out if impingement is likely.
Key Clinical Examination Findings:
- Pain when moving the shoulder
- Less range of motion
- Weak rotator cuff muscles
- Tenderness in the affected area
Imaging Studies
Imaging studies are vital for confirming shoulder impingement. X-rays can spot bone issues like spurs. MRI is great for soft tissue like tendons and ligaments.
Ultrasound might also be used to check the rotator cuff. The right imaging study depends on the symptoms and suspected cause.
Differential Diagnosis Considerations
When diagnosing shoulder impingement, we must consider other shoulder pain Conditions like rotator cuff tendinitis and adhesive capsulitis can mimic symptoms. A thorough differential diagnosis helps rule out these alternatives.
We look at the patient’s history, exam results, and imaging to make an accurate diagnosis. This detailed approach helps us create a treatment plan that meets the patient’s needs.
Conservative Management as First-Line Treatment
The first step in treating shoulder impingement is conservative management strategies. These aim to lessen pain and boost function. Starting treatment early is key to avoiding more harm and aiding in healing.
The Importance of Early Intervention
Acting fast is vital in treating shoulder impingement well. Quick action helps avoid more problems and boosts the chance of a good recovery. Early treatment brings many benefits, such as:
- Reduced risk of chronic pain
- Improved range of motion
- Faster recovery times
Goals of First-Line Treatment
The main aims of conservative management are alleviating pain, improving the range of motion, and strengthening the shoulder muscles. A detailed treatment plan is needed to meet these goals, tailored to each person’s needs.
Expected Timeline for Improvement
Most people start seeing improvements in a few weeks after starting treatment. But how fast you get better depends on how bad the condition is and how well you respond to treatment.
The RICE Protocol for Acute Shoulder Impingement
The RICE method is a common treatment for acute shoulder impingement. It stands for Rest, Ice, Compression, and Elevation. This method helps reduce pain and inflammation, speeding up recovery.
Rest: How Much is Appropriate
Rest is the first step in the RICE protocol. It means avoiding activities that make the condition worse. This includes heavy lifting or overhead movements. We advise cutting down on activities that cause pain or discomfort.
Ice Application Techniques and Timing
Ice is key for reducing inflammation. Use an ice pack wrapped in a cloth to avoid skin contact. Apply ice for 15-20 minutes, several times a day, after activities that worsen the condition.
Compression Methods for Shoulder Pain
Compression helps reduce swelling. A compression bandage or sleeve can be effective. Make sure it’s not too tight to cut off circulation. Always check with a healthcare professional for the right application.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Elevating the affected shoulder above the heart level can reduce swelling. Use pillows to support the arm while sleeping or resting.
| Component | Description | Application Tips |
| Rest | Avoid aggravating activities | Minimize heavy lifting or overhead movements |
| Ice | Reduce inflammation | Apply ice for 15-20 minutes, several times a day |
| Compression | Reduce swelling | Use a compression bandage or sleeve, and avoid tightness |
| Elevation | Reduce swelling | Elevate the shoulder above heart level, use pillows for support |
Following the RICE protocol can help manage symptoms of acute shoulder impingement. It’s a step towards starting the recovery process.
Over-the-Counter Pain Management Options
For those with shoulder impingement, OTC meds are a quick fix for pain. They help ease pain and swelling. This makes daily tasks and therapy easier.
NSAIDs for Shoulder Pain
NSAIDs are key for shoulder pain from impingement. They cut down on swelling, a big part of the problem.
Medicines like ibuprofen (Advil, Motrin) and naproxen (Aleve) are good choices. They come in different strengths and are taken by mouth.
Acetaminophen and Other Analgesics
Acetaminophen (Tylenol) is also good for shoulder pain. It doesn’t fight swelling like NSAIDs, but does reduce pain.
It’s important to stick to the right dose of acetaminophen to avoid liver harm.
Topical Pain Relievers
Topical creams, gels, or patches work on the skin over the hurt area. They offer pain relief right where it’s needed, without the whole-body effects of pills.
Options include capsaicin creams and lidocaine patches. There are also topical NSAIDs for more targeted pain relief.
Choosing an OTC pain reliever should consider your health history, how bad your pain is, and any other meds you’re on.
| Medication Type | Examples | Primary Use | Notable Side Effects |
| NSAIDs | Ibuprofen, Naproxen | Reduce inflammation and pain | Gastrointestinal issues, kidney strain |
| Acetaminophen | Tylenol | Pain relief | Liver damage (with overdose) |
| Topical Pain Relievers | Capsaicin cream, Lidocaine patches | Localized pain relief | Skin irritation, allergic reactions |
First-Line Physical Therapy Exercises for Shoulder Impingement
When Shoulder impingement can significantly impact your daily life.es is key. Physical therapy can help a lot. It includes a mix of exercises to ease pain and improve movement.
Here are some important exercises to try:
| Exercise | Description | Benefits |
| Shoulder Rolls | Roll your shoulders forward and backward in a circular motion. | Helps loosen tight muscles and improvesthe range of motion. |
| Arm Circles | Hold your arms straight out to the sides and make small circles with your hands. | Strengthen the muscles around the shoulder and improve flexibility. |
| Wall Slides | Stand with your back against a wall and slowly slide your arms up the wall. | Stretches the shoulder muscles and helps reduce pain. |
| Scapular Squeezes | Squeeze your shoulder blades together and hold for a few seconds before releasing. | Strengthens the muscles that support the shoulder joint. |
Remember, it’s important to do these exercises regularly. This will help your shoulder get better faster. Always talk to a physical therapist before starting any new exercises.
These exercises are just the start. Your physical therapist will create a plan that fits your needs. They’ll also help you learn how to do the exercises right.
Posture Correction and Ergonomic Modifications
We know that posture correction and ergonomic modifications are key to easing shoulder pain from impingement syndrome. Making changes in our daily lives can lessen shoulder strain.
Workplace Adjustments
At work, ergonomic changes can greatly help. A well-set-up desk can prevent shoulder problems. Place your computer monitor 20-25 inches away and slightly below eye level.
Ergonomic experts say a good workspace lowers the risk of shoulder issues.
“The workstation should be designed to fit the worker, not the other way around.”
- Adjust your chair so your feet are flat, with knees at or below hip level.
- Keep your keyboard in front, with wrists straight and elbows at 90 degrees.
- Use a document holder to keep papers at eye level, reducing looking down.
Sleeping Positions to Reduce Pain
Our sleep position affects shoulder impingement. Sleeping on the affected side worsens it. Sleeping on your back or the opposite side helps. A supportive pillow is key.
Here are some sleep tips:
- Choose a supportive mattress that keeps its shape.
- Use a pillow that aligns your spine, avoiding too thick or too flat.
- Avoid sleeping with your arm overhead or in a strained position.
Daily Activity Modifications
Changing daily activities is important to avoid making shoulder impingement worse. Be careful with how you do tasks, stretch regularly, and avoid overhead motions.
By making these changes, we can lessen shoulder strain and aid in healing. Posture correction and ergonomic modifications are essential in treating shoulder impingement.
Activity Modification Strategies
Modifying activities is key in treating shoulder impingement. Making smart changes to daily routines can help ease shoulder pain. This approach aids in recovery.
Avoiding Painful Overhead Activities
Overhead activities often worsen shoulder impingement. It’s wise to cut down or stop tasks that make you lift your arms over your shoulders. If your job or hobby requires this, look for ways to put less strain on your shoulders.
Sports-Specific Modifications
For athletes, sports that involve overhead movements can be tough. Swimmers, tennis players, and baseball players might need to change their moves. Getting help from a coach or trainer to adjust can help avoid more injuries.
Gradual Return to Normal Activities
Going back to normal activities slowly is important after symptoms lessen. Gradually increase the intensity and range of movements. This lets your shoulder get stronger and adapt. Patience is key to avoiding injury again.
Setting Realistic Expectations
Recovering from shoulder impingement means setting realistic goals. Knowing it might take weeks to months to fully recover helps stay on track. We help patients set reachable goals and adjust plans as needed.
Using these strategies can help manage shoulder impingement. It reduces pain and improves life quality.
The Role of Shoulder Braces and Supports
For those with shoulder impingement, shoulder braces and supports can be a big help. They add stability and protection, easing pain and aiding in healing. We’ll look at the various types of supports, how to use them, and their benefits and drawbacks.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Understanding the different types of shoulder impingement is crucial for effective treatment.
- Soft braces or sleeves that offer gentle support and compression.
- Rigid or semi-rigid braces that provide more substantial support and stability.
- Sling supports that immobilize the shoulder to some extent, allowing for rest and recovery.
Proper Application and Usage Guidelines
To get the most out of shoulder braces and supports, using them correctly is key. This means:
- Ensuring a proper fit to avoid discomfort or restricted movement.
- Following the manufacturer’s instructions for application and wear.
- Gradually increasing wear time as needed and under the guidance of a healthcare professional.
Benefits and Limitations of Support Devices
Shoulder braces and supports have many advantages, including:
- Pain Relief: They reduce movement and support the shoulder, easing pain from impingement.
- Stability: They stabilize the shoulder joint, helping it heal better.
But, there are also some downsides to consider:
- Dependence: Relying too much on these devices can weaken shoulder muscles if not used wisely.
- Comfort: Some people might find certain braces uncomfortable or too restrictive.
When to Consider Corticosteroid Injections
If shoulder impingement symptoms don’t get better with simple treatments, doctors might suggest corticosteroid injections. These injections can help by reducing inflammation and pain. They are a good option when other treatments don’t work well.
Injection Procedure and Process
The injection process involves putting corticosteroid medication into the shoulder area. It’s done under ultrasound to make sure it’s in the right spot. The whole thing is quick and might feel a bit uncomfortable.
Expected Benefits and Timeframe
Corticosteroid injections can greatly lessen shoulder pain and swelling. You might start feeling better in a few days to a week. The best results usually happen within 1-2 weeks after the shot.
Potential Risks and Side Effects
Even though they’re safe, corticosteroid injections can cause some side effects. These might include temporary pain increase, skin thinning, and weakened tendons. Though rare, serious issues like infection or nerve damage can also happen.
Limitations on Frequency and Number
To avoid risks, doctors usually limit how often and how many injections you can get. Most say no more than 3-4 injections a year, with at least 3 months between them. Whether to get more injections depends on how you react and if you have any side effects.
Here’s a quick rundown on corticosteroid injections for shoulder impingement:
| Aspect | Description | Considerations |
| Procedure | Administering corticosteroids under ultrasound guidance | Minor discomfort, quick process |
| Benefits | Reduced inflammation and pain, improved mobility | Noticeable within days to a week |
| Risks | Temporary flare-up, skin thinning, tendon weakening | Rare serious complications like infection or nerve damage |
| Limitations | Limited to 3-4 injections per year | Minimum 3 months between injections |
Alternative First-Line Treatments for Shoulder Impingement
For those with shoulder impingement, there are alternative treatments that can help. These options can work alongside traditional methods to aid in recovery.
Acupuncture and Dry Needling
Acupuncture and dry needling are methods that use body points to heal and ease pain. Acupuncture involves thin needles in specific body points to balance and heal. Dry needling targets muscle trigger points to ease tension and pain.
Both methods can help with shoulder pain from impingement. They stimulate healing, reduce inflammation, and improve movement.
Massage Therapy Techniques
Massage therapy is also helpful for shoulder impingement. Techniques like deep tissue massage and trigger point therapy can relax muscles and improve flexibility.
Regular massages boost blood flow, aiding in healing and pain reduction. It’s important to find a licensed therapist who can customize the massage for you.
Heat Therapy Applications
Heat therapy is a simple yet effective way to manage shoulder pain. It increases blood flow, reduces stiffness, and relaxes muscles. This is great before physical activities or exercises.
There are many ways to use heat therapy, like warm compresses or heating pads. Always follow safety guidelines to avoid burns.
Ultrasound and Electrical Stimulation
Ultrasound and electrical stimulation are also used for shoulder impingement. Ultrasound therapy uses sound waves to heal deep tissues and reduce inflammation. Electrical stimulation stimulates muscle contractions, improves circulation, and eases pain.
| Therapy | Benefits | Application |
| Acupuncture | Pain relief, reduced inflammation | Thin needles inserted into specific body points |
| Dry Needling | Relieves muscle tension, pain relief | Targeting trigger points within muscles |
| Massage Therapy | Improved flexibility, reduced muscle tension | Various massage techniques are applied by a therapist |
| Heat Therapy | Increased blood flow, reduced stiffness | Applying heat using compresses, pads, or showers |
| Ultrasound Therapy | Deep tissue healing, reduced inflammation | High-frequency sound waves are applied to the affected area |
| Electrical Stimulation | Improved circulation, reduced pain | Electrical currents stimulate muscle contractions |
These alternative therapies can be part of a complete treatment plan for shoulder impingement. Always talk to healthcare professionals to find the best treatment for you.
Creating an Effective Treatment Plan
Creating a good treatment plan is a team effort. We work with healthcare providers to make a plan that meets each patient’s needs and goals.
Working with Healthcare Providers
It’s important to work together with healthcare providers. We talk with our patients to understand their condition and treatment options. Then, we create a plan that fits their lifestyle and goals.
Key aspects of working with healthcare providers include:
- Initial consultation to discuss symptoms and treatment goals
- Regular follow-ups to monitor progress and adjust the treatment plan
- Open communication to address any concerns or questions
Tracking Progress and Symptoms
It’s key to track how well the treatment is working. We use different tools and methods to keep an eye on patient progress. This helps us make any needed changes.
| Tracking Method | Description | Frequency |
| Patient-reported outcomes | Standardized questionnaires to assess pain and function | Initial, 6 weeks, 12 weeks |
| Range of motion assessments | Measurement of shoulder mobility | Initial, 6 weeks, 12 weeks |
| Strength testing | Assessment of shoulder strength | Initial, 12 weeks |
Adjusting Treatment as Needed
As we track progress, we might need to change the treatment plan. This could mean changing exercises, pain management, or adding new therapies.
Adjustments to the treatment plan are made based on:
- Patient feedback and reported symptoms
- Clinical assessment findings
- Progress towards recovery goals
Setting Recovery Goals
Setting realistic goals is important for staying motivated. We help our patients set goals that match their treatment plan.
By working with healthcare providers, tracking progress, adjusting the plan as needed, and setting goals, we can make a treatment plan for shoulder impingement. This plan helps patients recover well and improves their quality of life.
When First-Line Treatments Fail: Next Steps
If shoulder impingement symptoms don’t get better with initial treatments, we look at other options. We work with patients to understand their condition better. Then, we decide on the best next steps together.
Advanced Physical Therapy Approaches
Advanced physical therapy might be suggested if the first steps don’t work. This could include special exercises, manual therapy, or other methods. These aim to improve shoulder function and lessen pain.
We also think about using ultrasound or electrical stimulation to help with healing. These methods can be very helpful for those who didn’t get better with usual physical therapy.
Additional Imaging and Testing
More tests might be needed if symptoms keep coming back. This could include MRI or CT scans.
These tests help us understand the condition better. They can show issues that weren’t seen before.
| Diagnostic Test | Purpose | Benefits |
| MRI | Detailed imaging of soft tissues | Identifies tendon or ligament damage |
| CT Scan | Detailed imaging of bone structures | Helps identify bone spurs or fractures |
| Ultrasound | Dynamic imaging of tendons and ligaments | Assesses tendon or ligament movement |
Referral to Orthopedic Specialists
When more specialized care is needed, we refer patients to orthopedic specialists. These experts can offer further evaluation and treatment options not available through primary care.
Orthopedic specialists can provide advanced treatments. These are tailored to the patient’s needs, aiming for the best results.
Considering Surgical Consultation
If all else fails and symptoms are severe, surgery might be suggested. We talk to patients about the benefits and risks of surgery. This ensures they know all their options.
Surgery can range from simple arthroscopic procedures to more complex operations. It depends on the cause of the shoulder impingement.
By teaming up with orthopedic specialists and other healthcare professionals, we ensure our patients get the best care. This helps them achieve the best possible outcomes.
Understanding the different types of shoulder impingement is crucial for effective treatment.
To stop shoulder impingement from coming back, we need a full plan. This plan includes long-term exercises, changing how we do activities, and regular checks. Shoulder impingement can really mess up our daily lives. But by taking early steps, we can keep our shoulders healthy.
Long-Term Exercise Programs
Staying active with exercises is key to avoiding shoulder impingement again. These exercises should include:
- Range of motion exercises to keep our shoulders flexible and not stiff.
- Strengthening exercises to make our shoulder muscles strong.
- Stretching techniques to boost flexibility and cut down muscle tightness.
It’s smart to talk to a doctor to get an exercise plan that fits you.
Activity and Sport Modifications
Changing how we do activities and sports can also help. This might mean:
- Staying away from or changing overhead activities that make the problem worse.
- Changing sports techniques to put less stress on the shoulder.
- Slowly going back to normal activities to avoid sudden stress on the shoulder.
By making these changes, we can lower the chance of it happening again and keep our shoulders healthy.
Regular Assessment and Maintenance
Regular checks are important to catch problems early. This means:
- Seeing healthcare providers regularly.
- Watching for early signs of shoulder impingement coming back.
- Changing exercise plans and activity levels if needed.
By being proactive, we can keep our shoulders in top shape and avoid problems.
Conclusion
Shoulder impingement can significantly impact your daily life.
Early treatment is key, and a good plan includes several steps. This includes trying conservative methods, physical therapy, and making lifestyle changes. Knowing the causes and symptoms helps people get the right treatment early on. This can prevent serious damage later.
With the right treatment, you can manage shoulder impingement well. This means less pain and a better life. It’s important to work with healthcare experts to get a treatment plan that’s just right for you. This way, you can get the best results.
FAQ
Understanding the different types of shoulder impingement is crucial for effective treatment.
Shoulder impingement syndrome happens when the rotator cuff tendons get irritated or inflamed. This is because they pass through the shoulder joint. It leads to pain and limited movement.
What are the common causes of shoulder impingement?
Causes include repetitive strain and poor posture. Anatomical abnormalities and activities that involve overhead movements also play a role.
What are the typical symptoms of shoulder impingement?
Symptoms include pain when moving the arm and a limited range of motion. Pain gets worse with activities that involve lifting the arm.
Understanding the different types of shoulder impingement is crucial for effective treatment.
Diagnosis starts with a clinical exam. Imaging studies like X-rays or MRI might be used to check the rotator cuff and shoulder joint.
What is the first-line treatment for shoulder impingement?
The first treatment is usually conservative. This includes the RICE protocol, physical therapy, and over-the-counter pain relief.
What is the RICE protocol, and how is it applied?
The RICE protocol helps reduce pain and inflammation. It involves avoiding activities that make it worse, using ice, compression, and elevating the shoulder.
What over-the-counter pain management options are available for shoulder impingement?
Options include NSAIDs like ibuprofen and acetaminophen. Topical pain relievers are also available to manage pain and inflammation.
What role does physical therapy play in treating shoulder impingement?
Physical therapy includes exercises to improve the range of motion and strengthen the rotator cuff. It aims to reduce pain and improve function.
How can posture correction and ergonomic modifications help?
Correcting posture and making ergonomic adjustments can reduce shoulder strain. This helps alleviate pain and prevent further irritation.
When are corticosteroid injections considered for shoulder impingement?
Corticosteroid injections are considered when other treatments don’t work. They help reduce inflammation and pain.
What alternative treatments are available for shoulder impingement?
Alternative treatments include acupuncture, dry needling, and massage therapy. Heat therapy and modalities like ultrasound are also options.
How can the recurrence of shoulder impingement be prevented?
Prevention involves a long-term exercise program and modifying activities. Regular assessment is key to ensuring shoulder health.
What are the next steps if first-line treatments for shoulder impingement are not effective?
Next steps may include advanced physical therapy or additional imaging. Referral to orthopedic specialists or surgical consultation might be considered.
How important is it to work with healthcare providers to manage shoulder impingement?
Working closely with healthcare providers is essential. They help develop a personalized treatment plan and track progress to manage the condition effectively.
References
- Garving, C., Jakob, S., Bauer, I., Nadjar, R., & Brunner, U. (2017). Impingement syndrome of the shoulder. Deutsches Ärzteblatt International, 114(45), 765–776.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5729108/
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