Physio for Rotator Cuff Tendonitis: Ultimate Best Exercise Guide

Tendonitis is a common problem that affects millions of people. It causes pain and limits how well you can move. Regular exercise is key in managing and treating tendonitis. It keeps joints moving and strengthens the muscles around them.

Exercise brings many health benefits, like living longer and feeling better overall. For tendonitis treatment, certain exercises can help reduce pain and aid in healing. This article will give you a detailed guide on exercises for tendonitis, including physio for rotator cuff tendonitis. We’ll focus on effective tendonitis exercises and treatment options.

Key Takeaways

• Exercise plays a vital role in managing tendonitis.
• Specific exercises can help alleviate symptoms.
• Tendonitis treatment involves a combination of exercises and other therapies.
• Regular exercise can improve overall health and well-being.
• Understanding the best exercises for tendonitis is key for effective management.

Understanding Tendonitis: Causes, Symptoms, and Impact

Tendonitis is a painful condition that affects daily life. It happens when tendons, which connect muscles to bones, get inflamed. This inflammation causes pain, swelling, and makes it hard to move.

What Happens When Tendons Become Inflamed

When tendons get inflamed, it’s called tendonitis. This condition can be very uncomfortable. It can hurt when you move or even when you’re not moving at all.

The tendons in the shoulders, elbows, wrists, hips, knees, and ankles are most often affected. The inflammation is the body’s way of reacting to injury or strain. It leads to swelling and pain.

Common Causes of Tendonitis

Tendonitis often comes from doing the same thing over and over again. This can cause the tendons to get inflamed. Some common causes include:

• Sports activities that involve repetitive motions
• Jobs that require repetitive tasks or heavy lifting
• Sudden injuries or direct blows to tendons
• Aging, as tendons become less flexible over time

Finding out what caused it is important for treatment and preventing it from happening again.

Recognizing Tendonitis Symptoms

It’s important to know the symptoms of tendonitis to get treatment early. Common signs include:

• Pain or tenderness near a joint
• Swelling or redness around the tendon
• A sensation of stiffness, specially in the morning
• A grating or crackling sensation when moving the tendon

These symptoms can make everyday activities hard. Spotting them early can help manage the condition better.

Types of Tendonitis and Their Unique Challenges

Tendonitis can happen in different parts of the body, leading to various conditions. Each one has its own set of challenges. Knowing these differences is key to finding the right treatment.

Upper Body Tendonitis Conditions

Upper body tendonitis often strikes the shoulders, elbows, and wrists. It can cause rotator cuff tendonitis, tennis elbow, and De Quervain’s tenosynovitis. These issues are common in people who do repetitive motions or play sports.

Common Upper Body Tendonitis Conditions:

• Rotator Cuff Tendonitis
• Tennis Elbow (Lateral Epicondylitis)
• Golfer’s Elbow (Medial Epicondylitis)
• De Quervain’s Tenosynovitis

Lower Body Tendonitis Conditions

Lower body tendonitis can hit the hips, knees, and ankles. Conditions like Achilles tendonitis, patellar tendonitis, and peroneal tendonitis can really affect how you move and perform in sports.

Common Lower Body Tendonitis Conditions:

• Achilles Tendonitis
• Patellar Tendonitis
• Peroneal Tendonitis

Condition	Common Activities Causing the Condition	Symptoms
Achilles Tendonitis	Running, jumping	Pain, swelling near the heel
Patellar Tendonitis	Jumping, running	Pain below the kneecap
Peroneal Tendonitis	Ankle rolling, running on uneven surfaces	Pain, swelling on the outer ankle

How Different Types Require Specialized Approaches

Every type of tendonitis needs a treatment plan that’s just right for it. This plan must consider the tendon, how severe it is, and how active the person is. It’s all about finding the best way to help.

Specialized approaches may include:

• Targeted physical therapy exercises
• Modified activity and rest protocols
• Orthotics or supportive devices

The Science Behind Effective Tendonitis Exercises

Tendonitis exercises work by helping the body repair tendons. They are key in treating tendonitis. This is because they improve blood flow, strengthen tendons, and fix damaged tissue.

How Exercise Promotes Tendon Healing

Exercise helps tendons heal by making positive changes in the body. When tendons face controlled stress, the body makes more collagen. This is vital for tendon health.

As Dr. Peter Brukner, a sports medicine specialist, notes, “Exercise is essential for tendon health. It keeps tendons strong by boosting collagen and improving blood flow.”

“The goal of exercise in tendonitis rehabilitation is to stimulate the tendon’s natural repair mechanisms without causing further injury.”

Balancing Rest and Activity

It’s important to balance rest and activity when dealing with tendonitis. Rest is needed to avoid more injury, but too much can make tendons stiff and weak. A good balance is to start with gentle exercises that help tendons get stronger.

A study published in the Journal of Orthopaedic & Sports Physical Therapy showed the value of balancing rest and exercise. It found that a well-planned exercise program can greatly improve recovery.

Progressive Loading Principles

Progressive loading is key in treating tendonitis. It means slowly increasing the intensity of exercises to strengthen the tendon. This makes tendons more resilient and less likely to get hurt again.

• Start with low-intensity exercises and gradually increase the load.
• Monitor progress and adjust the exercise program as needed.
• Incorporate a variety of exercises to target different aspects of tendon health.

Understanding and using progressive loading can help improve tendonitis treatment. It leads to better results.

Physio for Rotator Cuff Tendonitis: A Complete Guide

The rotator cuff is a complex structure needing specific exercises for recovery. Physio for rotator cuff tendonitis includes understanding the anatomy, strengthening exercises, improving mobility, and managing recovery.

Anatomy of the Rotator Cuff

The rotator cuff is a group of muscles and tendons around the shoulder joint. It keeps the upper arm bone in place. It has four muscles: the supraspinatus, infraspinatus, teres minor, and subscapularis. Knowing this anatomy is key for a good physio plan.

Effective Strengthening Exercises

Strengthening the rotator cuff muscles is vital for recovery and preventing injuries. Some effective exercises include:

• Internal Rotations: Using a resistance band or light dumbbell, this exercise targets the subscapularis muscle.
• External Rotations: This exercise works the infraspinatus and teres minor muscles, important for shoulder stability.
• Scapular Squeezes: Strengthening the scapular stabilizers improves overall shoulder function.

As “The American Journal of Sports Medicine” states,

“Strengthening the rotator cuff and periscapular muscles is a cornerstone in the rehabilitation of shoulder injuries.”

Mobility and Stretching Techniques

Improving mobility and flexibility is also key in rehabilitation. Techniques include:

• Cross-Body Stretch: Stretches the posterior shoulder and improves flexibility.
• Pendulum Exercises: Gentle movements that help maintain range of motion without straining the rotator cuff.
• Wall Slides: Helps in improving scapular mobility and reducing stiffness.

Recovery Timeline and Progression

The recovery timeline for rotator cuff tendonitis varies. It can take several weeks to a few months to see improvement. A progressive loading program is essential to increase tendon strength.

Progressive Loading Principles: Gradually increasing the intensity of exercises based on the individual’s tolerance and response.

As noted by a study in “The Journal of Orthopaedic and Sports Physical Therapy”,

“Progressive resistance exercises are effective in improving pain and function in patients with rotator cuff tendonopathy.”

Best Exercises for Achilles Tendonitis

Managing Achilles tendonitis needs a mix of exercises and physical therapy. This condition causes pain and inflammation in the Achilles tendon. A full treatment and rehab plan is needed.

Eccentric Heel Drops and Their Benefits

Eccentric heel drops are key for treating Achilles tendonitis. Stand on a step with your heels off the edge, then slowly lower your heels down. Raise back up to start. This strengthens the tendon, helps repair it, and reduces pain.

To do eccentric heel drops well:

• Stand on a step with your heels over the edge.
• Slowly lower your heels down, keeping your knees straight.
• Raise back up to the starting position using your hands or the other leg for support.
• Do 3 sets of 15 reps every day.

Progressive Loading Exercises

Progressive loading exercises are vital for strengthening the Achilles tendon and muscles around it. These workouts get harder as you do them, helping the tendon heal.

Exercise	Repetitions	Sets	Frequency
Calf Raises	15	3	Daily
Single-Leg Heel Raises	10	3	Alternate Days
Resistance Band Calf Exercises	12	3	Daily

Complementary Stretches for Achilles Health

Stretching is key in rehabbing Achilles tendonitis. Good stretches can make you more flexible, reduce stiffness, and ease pain.

Some good stretches are:

• Standing calf stretch: Stand facing a wall with one hand on the wall for balance. Step one foot back about a foot, keeping your heel on the ground. Bend the front knee and lean forward, stretching the calf.
• Seated calf stretch: Sit on the floor with your legs straight out. Loop a towel around the ball of your foot and gently pull your toes back toward you.

Achilles Tendon Pressure Point Techniques

Pressure point techniques, like self-massage or foam rolling, can ease tension in the Achilles tendon. Applying gentle pressure to certain points can improve blood flow and help with healing.

To use pressure point techniques right:

• Use a foam roller to roll along the Achilles tendon, applying moderate pressure.
• Find tender spots and apply steady pressure for 15-30 seconds.
• Do this several times, focusing on tense areas.

Effective Treatments for Patellar Tendonitis

Managing patellar tendonitis requires a mix of exercises, massage, and changing how you move. This condition, also called jumper’s knee, affects the tendon between the kneecap and shinbone. It causes pain, mainly in athletes who jump a lot.

Quad Strengthening Exercises

Building up the quadriceps muscles is key in treating patellar tendonitis. Quad strengthening exercises lessen the tendon’s stress. This is because they make the knee stronger and more stable.

• Straight Leg Raises: This exercise strengthens the quadriceps without putting excessive strain on the knee joint.
• Squats: Properly performed squats can help strengthen the quadriceps, hamstrings, and glutes, providing knee support.
• Leg Press: The leg press is another effective exercise for strengthening the quadriceps and other leg muscles.

Patellar Tendon Massage Techniques

Massage is a big part of treating patellar tendonitis. Patellar tendon massage techniques ease pain, help healing, and improve tendon function.

1. Transverse Friction Massage: This technique involves applying gentle, sustained pressure across the tendon to stimulate healing.
2. Deep Tissue Massage: Deep tissue massage can help reduce muscle tension around the knee, reducing tendon strain.

Activity Modification Strategies

Changing how you move to lessen tendon stress is vital for recovery. Avoid jumping and other high-impact activities that make the condition worse.

Addressing Patella Pain When Bending

Patella pain when bending is common in patellar tendonitis. To tackle this, use a mix of treatments and exercises. These improve knee bending and strength.

Wrist and Hand Tendonitis: Exercises for Relief

Tendonitis in the wrist and hand can really hurt your daily life. But, the right exercises can help a lot. This condition often comes from doing the same thing over and over again. It causes pain and makes it hard to move your hands.

Understanding the problem and doing the right exercises can help a lot. This way, you can feel better and move your hands more easily.

De Quervain’s Tenosynovitis Exercises

De Quervain’s tenosynovitis is a problem with the tendons on the thumb side of the wrist. To fix this, you need to stretch and strengthen your thumb and wrist.

• Thumb Spreads: Gently spread your thumb away from your index finger, holding for 5 seconds. Repeat 10-15 times.
• Fist Clench: Make a gentle fist with your thumb tucked inside your fingers, then release. Repeat 10-15 times.

Extensor Tendonitis Relief

Extensor tendonitis is when the tendons that straighten your wrist and fingers get hurt. To feel better, try these exercises:

1. Wrist Extension Stretch: Hold your arm straight out with your palm facing down. Use your other hand to gently pull your hand back, stretching your wrist. Hold for 15-30 seconds and repeat 3 times.
2. Finger Bends: Place your hand flat on a table with fingers extended. Slowly bend your fingers down toward your palm, then straighten them again. Repeat 10-15 times.

Wrist Strengthening Progression

Strengthening your wrist is key to getting better and avoiding more problems. Start with these exercises:

Exercise	Description	Repetitions
Wrist Curl	Hold a light weight with your palm facing up. Curl your wrist up, then lower it back down.	10-15
Wrist Extension	Hold a light weight with your palm facing down. Lift your wrist up, then lower it back down.	10-15

How to Get Rid of Tendonitis in Wrist

To get rid of tendonitis in your wrist, you need rest, exercises, and care. An expert says, “Rest is key, but so is keeping your wrist and hand moving gently.”

“The key to recovery is balancing rest with controlled movement to promote healing without causing further irritation.”

Also, remember these tips:

• Avoid activities that make it worse.
• Apply ice to reduce pain and swelling.
• Use ergonomic tools to lessen strain on your wrists.

By doing these exercises and following these tips, you can manage and reduce wrist and hand tendonitis.

Addressing Foot and Ankle Tendonitis

Dealing with foot and ankle tendonitis needs a mix of stretching and strengthening. This condition can really hurt your ability to move and do everyday things. So, finding the right way to manage it is very important.

Peroneal Tendonitis Treatment

Treatment for peroneal tendonitis includes rest, physical therapy, and sometimes special shoes. Good treatment starts with knowing why it happens, like too much use or bad foot shape.

• Rest and ice to reduce inflammation
• Physical therapy to strengthen the peroneal muscles
• Orthotics to correct foot mechanics

How to Stretch Peroneus Longus

Stretching the peroneus longus helps keep it flexible and less tight. Here’s how to do it:

1. Stand with your feet shoulder-width apart.
2. Cross the affected leg over the other.
3. Gently pull the foot towards you with your hand.

Regular stretching helps stop more irritation and helps it heal.

Foot Intrinsic Muscle Strengthening

It’s important to strengthen the foot’s intrinsic muscles. This helps support the arch and lessens tendon strain. Toe curls and marble pickups are great exercises for this.

• Toe curls: Curl your toes under and then release.
• Marble pickups: Pick up marbles with your toes.

How to Get Rid of Tendonitis in Foot

To get rid of tendonitis in the foot, you need a full plan. This includes rest, physical therapy, and sometimes doctor visits. Early treatment is the best way to avoid long-term tendonitis.

By using these methods and sticking to a regular exercise plan, you can handle foot and ankle tendonitis well. This helps prevent it from coming back.

Elbow Tendonitis: Tennis and Golfer’s Elbow Solutions

Elbow tendonitis includes tennis elbow and golfer’s elbow. These conditions cause pain and swelling in the elbow tendons. They often happen from too much strain or overuse.

Eccentric Exercises for Lateral Epicondylitis

Eccentric exercises are great for tennis elbow. They make the tendon stretch slowly while it’s under tension. This helps it heal and get stronger. A simple yet effective eccentric exercise for tennis elbow is the wrist extension exercise using a light weight.

Medial Epicondylitis Strengthening

Golfer’s elbow needs special strengthening exercises. These exercises work on the forearm muscles attached to the medial epicondyle. Wrist flexion exercises with a light dumbbell can help strengthen the tendons and reduce pain.

Addressing Bicep Muscle Pain Near Elbow

Bicep muscle pain near the elbow might be from tendonitis or strains. Gentle stretching and strengthening can help. It’s essential to identify the underlying cause of the pain to develop an effective treatment plan.

Upper Bicep Pain Management

Managing upper bicep pain involves rest, physical therapy, and avoiding activities that make it worse. Physical therapy may include exercises to strengthen the bicep and surrounding muscles, improving overall elbow function.

By focusing on the causes of elbow tendonitis and using specific exercises, people can ease their pain. It’s important to talk to a healthcare professional to find the right treatment.

The Role of Massage in Tendonitis Recovery

Massage techniques are now seen as a key part of tendonitis recovery. They help improve blood flow and lessen pain. This makes massage a great addition to traditional treatments like exercise and physical therapy.

Benefits of Massage for Tendonitis

Massage is very helpful in managing tendonitis. It boosts blood flow to the injured area. This brings oxygen and nutrients needed for healing. It also reduces pain and swelling, making it easier to move.

Key Benefits:

• Enhanced blood flow for tendon repair
• Reduced pain and inflammation
• Improved tendon function and mobility

Dragon Tendon Massage Techniques

Dragon tendon massage focuses on tendons and the tissue around them. It uses special strokes and pressures to help them heal and relax.

Technique Application: A trained therapist uses deep tissue and friction strokes. These are chosen based on the person’s specific needs.

Deep Tissue Massage for Tendonitis

Deep tissue massage is great for tendonitis because it works on the deeper muscle and tendon layers. It helps to clear out scar tissue and adhesions. This promotes healthier tendon function.

Massage Technique	Benefits for Tendonitis
Deep Tissue Massage	Breaks up adhesions, promotes tendon health
Dragon Tendon Massage	Stimulates healing, relaxes tendons
Self-Massage	Enhances self-management, reduces pain

Self-Massage Tools and Techniques

Self-massage is a powerful tool for managing tendonitis. Using tools like foam rollers or massage balls, people can target specific areas. This helps to reduce pain and improve tendon health.

Adding massage to a treatment plan can greatly help those with tendonitis. It can make a big difference in their recovery.

Specialized Massage Techniques for Different Tendons

Understanding the specific needs of different tendons is key to effective massage for tendonitis. Each tendon needs a unique approach for healing and relief.

Massage for Achilles Tendonitis

Massage for Achilles tendonitis aims to reduce inflammation and aid in healing. It uses deep tissue and friction massage to break up adhesions.

Shoulder tendonitis massage techniques also aim to reduce inflammation, but in a different way.

Tendonitis Type	Massage Technique	Benefits
Achilles Tendonitis	Deep Tissue Massage	Reduces inflammation, promotes healing
Shoulder Tendonitis	Friction Massage	Breaks up adhesions, improves mobility
Wrist Tendonitis	Cross-Friction Massage	Enhances tendon strength, reduces pain

Shoulder Tendonitis Massage Approaches

For shoulder tendonitis, friction massage is used to improve mobility and reduce pain. It helps break up adhesions and increases blood flow.

Wrist Tendonitis Massage Methods

Wrist tendonitis benefits from cross-friction massage, which strengthens the tendon and reduces pain. This method involves applying massage perpendicular to the tendon’s direction.

Using the Armaid Massager and Other Tools

Tools like the Armaid massager are very effective for tendonitis. They apply the right pressure and technique. These devices make self-massage easy and help keep tendons healthy.

Heat vs. Ice: Optimal Application for Tendonitis

The debate on heat vs. ice for tendonitis has been ongoing. But knowing the best way to use them can really help. Heat and ice each have their own benefits, depending on the stage of tendonitis treatment.

When to Use Heat for Tendonitis

Heat therapy is best in the later stages of tendonitis recovery or for long-term tendonitis. It boosts blood flow, aids in healing, and relaxes muscles.

• Increased Blood Flow: Heat widens blood vessels, boosting blood flow and healing.
• Muscle Relaxation: Heat relaxes muscles around the tendon, easing stiffness and pain.

How Long to Apply Heat for Tendonitis

The time to use heat varies, but usually, it’s 15-20 minutes at a time, several times a day.

1. Make sure the heat isn’t too hot to avoid burns.
2. Place a towel or cloth between the heat source and your skin.

Does Ice Help with Tendonitis?

Ice is great during tendonitis’s early stages. It reduces inflammation and pain by narrowing blood vessels.

• Pain Relief: Ice numbs pain, giving quick relief.
• Reduced Inflammation: Cold therapy cuts down swelling and inflammation.

Topical Treatments: Does Icy Hot Help with Tendonitis?

Topical treatments like Icy Hot can offer relief by creating a warm or cold feeling on the skin. This distracts from the pain.

Icy Hot and similar products can help with temporary pain relief. But, use them as directed and along with other treatments like physical therapy and exercise.

Progressive Loading: The Key to Tendon Rehabilitation

Progressive loading is key in tendonitis rehab. It helps tendons get stronger over time. This method slowly increases the stress on tendons through exercises, aiding in healing and making them more resilient.

Understanding Tendon Adaptation

Tendons can adapt to demands placed on them. When they face progressive loading, they change at a cellular level. This leads to increased strength and flexibility, which is vital for tendon healing.

Tendon adaptation occurs in several stages:

• Initial response to loading, where tendons react to the stress
• Cellular changes, involving the activation of various cell types
• Matrix remodeling, where the tendon structure is reorganized
• Strengthening, resulting in improved tendon function

Creating a Progressive Exercise Plan

Creating a progressive exercise plan is complex. First, you must assess the tendon’s current state. Then, you tailor the plan to gradually increase the load on the tendon.

Exercise Phase	Loading Level	Repetitions
Initial Phase	Low	10-15
Progression Phase	Moderate	15-20
Advanced Phase	High	20-25

Monitoring Progress and Adjusting Load

It’s important to regularly check on progress in tendon rehab. Look at pain levels, tendon function, and overall recovery. Adjust the exercise plan as needed to keep moving forward and ensure the best recovery.

Key indicators for adjusting the load include:

• Increased pain or discomfort
• Plateau in progress or improvement
• Changes in tendon function or strength

Understanding tendon adaptation, creating a progressive exercise plan, and monitoring progress are key. They help individuals effectively rehab tendonitis and achieve lasting recovery.

Physical Therapy Approaches for Tendonitis

Physical therapy is key in treating tendonitis. It uses various techniques for different tendons. This approach helps each patient recover better.

Professional PT Techniques for Different Tendons

Physical therapists use different methods for each tendon. For example, shoulder tendonitis needs a unique approach compared to wrist or ankle tendonitis.

Tendon-specific techniques include:

• Eccentric exercises to strengthen tendons
• Manual therapy to improve tendon gliding
• Modalities such as ultrasound or electrical stimulation to promote healing

Physical Therapy for Peroneal Tendonitis

Peroneal tendonitis affects the outside of the ankle. Physical therapy for it includes:

• Strengthening exercises for the peroneal muscles
• Stretching to improve ankle mobility
• Proprioceptive training to enhance balance and reduce strain on the tendons

Tendinitis of Wrist Physical Therapy

Wrist tendonitis often comes from repetitive strain or overuse. Physical therapy for it may include:

• Eccentric exercises to strengthen the wrist tendons
• Wrist extension stretches to improve flexibility
• Ergonomic adjustments to reduce strain during daily activities

Tendonitis Location	Common PT Techniques	Goals
Shoulder	Eccentric strengthening, mobility exercises	Improve strength, reduce pain
Wrist	Wrist extensions, ergonomic adjustments	Enhance flexibility, reduce strain
Ankle	Peroneal strengthening, proprioceptive training	Improve balance, strengthen tendons

When to Consider Professional Treatment

If tendonitis pain or limited mobility persists, seek professional physical therapy. A physical therapist can create a treatment plan tailored for you.

Early treatment can prevent further injury and speed up recovery.

Preventing Tendonitis Recurrence: Maintenance Exercises

To prevent tendonitis from coming back, you need to do more than just treat it once. You must keep up with maintenance exercises, change how you do activities, and adjust your equipment. Knowing how these steps help can lower your risk of getting tendonitis again.

Long-term Strengthening Strategies

Keeping your tendons strong is key to avoiding tendonitis. Even after the pain goes away, keep doing exercises that strengthen your tendons and muscles. Eccentric exercises, like eccentric heel drops for Achilles tendonitis, are very helpful.

Staying consistent with your strengthening routine is important. Slowly increase the difficulty of your exercises to keep challenging your tendons and building strength.

Activity Modification Techniques

Changing how you do activities is also important. Find and change activities that put too much stress on your tendons. For example, change your throwing technique in sports or how you do repetitive tasks at work.

Proper warm-up and cool-down routines are also key. They get your tendons ready for activity and help them recover, lowering injury risk. Doing low-impact activities like swimming or cycling can also keep you fit without hurting your tendons.

Equipment and Ergonomic Considerations

Using the right equipment and setting up your workspace ergonomically is vital. Make sure your equipment fits right and doesn’t put too much strain on your tendons. For example, adjust bike handlebars to ease wrist strain or use ergonomic handles on tools.

As

“Proper ergonomics is not just about comfort; it’s about preventing injuries that can lead to long-term issues.”

This shows why it’s important to focus on setting up your equipment and workspace to support tendon health.

Regularly check and update your equipment and work practices to spot and fix risks early. This proactive approach can greatly lower your chance of getting tendonitis again.

Conclusion: Creating Your Personalized Tendonitis Recovery Plan

Creating a personalized tendonitis recovery plan is key to healing well and avoiding future injuries. Knowing the causes, symptoms, and types of tendonitis helps tailor a plan for your needs.

A good recovery plan includes exercises, physical therapy, and lifestyle changes. Exercises that gradually increase in intensity and strengthening are important. They help the tendons heal and regain function.

Working with healthcare professionals is vital for a personalized plan. They can suggest the best exercises, adjust activities, and add equipment and ergonomic tips for long-term recovery.

Being proactive in your recovery helps you regain strength, lessen pain, and improve function. A plan made just for you lets you confidently return to your usual activities. This reduces the chance of getting tendonitis again.

FAQ

References

Dimitrios, S. (2015). Exercise for tendinopathy. International Journal of Sports Physical Therapy, 10(2), 286-295.https://pmc.ncbi.nlm.nih.gov/articles/PMC4482821/