Guideline: Physical Therapist Clinical Practice Guideline For The Management of Individuals With Heart Failure
Guideline: Physical Therapist Clinical Practice Guideline For The Management of Individuals With Heart Failure
Guideline: Physical Therapist Clinical Practice Guideline For The Management of Individuals With Heart Failure
Guideline
M.J. Shoemaker, PT, DPT, PhD,
Department of Physical Therapy, Grand Physical Therapist Clinical Practice
Valley State University, 301 Michigan
NE, Suite 200, Grand Rapids, MI 49503
(USA). Dr Shoemaker is a board-
Guideline for the Management of
certified clinical specialist in geriatric
physical therapy. Address all Individuals With Heart Failure
correspondence to Dr Shoemaker at:
[email protected]. Michael J. Shoemaker, Konrad J. Dias, Kristin M. Lefebvre, John D.
K.J. Dias, PT, DPT, PhD, Physical Heick, Sean M. Collins
Therapy Program, Maryville
University of St Louis, St Louis,
The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular
P hysical therapists play a fundamental role in the examination, health care expenditures.7 Increasing attention is being
placed on hospital readmissions for patients with HF due
evaluation, and treatment of patients with heart failure (HF,
formerly congestive heart to the substantial burden it places on patients and
failure and chronic heart failure, or CHF) throughout the payers.7,8
continuum of care. Empirical evidence on the
effectiveness of a variety of rehabilitation treatment Readmission can operationally be defined as simply being
interventions for patients with HF continues to evolve. admitted to the hospital within a specified period following
Physical therapist interventions including education, an index (first, incident) admission. The costs associated
resistance exercise, aerobic exercise, inspiratory muscle with HF readmissions are nearly 31 billion dollars
training, electrical stimulation, and behavior modification annually.9 This total includes the cost of health care
strategies can positively influence functional capacity, services, medications, and missed employment.9 These
strength, and quality of life in patients with HF, and could costs have been rising at an alarming pace, prompting the
particularly myocardial infarction, were thought to be the output).12 With HFpEF, LVEF is unaltered and remains
primary causes of cardiac muscle dysfunction. However, a between 55% and 75%.12 To date, efficacious therapies for
variety of other pathophysiologic causes have more patients with HFpEF are less documented in the literature.
recently become increasingly responsible for Therefore, the reader will note that the key action
cardiomyopathy and subsequent HF, including diseases of statements in the present CPG are primarily directed
the myocardium, pericardium, endocardium, heart valves, towards patients with HFrEF, and limitations in evidence
coronary vessels, as well as from toxins, poorly managed for those with HFpEF are discussed where appropriate.
systemic hypertension, pulmonary and pulmonary and
vascular diseases, and metabolic disorders.11
Classification of Severity of Heart Failure
The subtypes of HF are categorized from both a structural
The American Heart Association/American College of
and functional perspective. Structural HF may include left-
Table 1.
American Heart Association/American College of Cardiology (AHA/ACC) Stages and New York Heart Association (NYHA)
Functional Classes of Heart Failurea
Table 2.
Definitions of Zone Colors Associated With Clinical Manifestations and Physical Therapist Recommendationsa
signs and symptoms are necessary in evaluating a CPGs: the 2013 American College of Cardiology
patient’s response to exercise, signs of exercise guidelines,14 the 2006 Heart Failure Society of America
intolerance, and stability over time. Worsening of guidelines,18 the 2012 European Society of Cardiology
symptoms places the patient at risk of urgent guidelines,19 and the 2011 Canadian Cardiovascular
hospital admission and merits prompt medical Society Heart Failure Management guidelines.20 For this
attention. reason, recognition of decompensation is not a seperate
action statement in this CPG, but rather a fundamental
Recommendations in the present CPG for the physical element of examination that should be performed when
therapist in evaluating the symptomology of acute implementing any of the key action statements in the
decompensation have been developed from four prior document below.
To help physical therapists determine whether a patient is individuals with HF that are not medically compensated or
sufficiently stable to proceed with an intervention, we have for those who are medically compensated and have no
provided an algorithm to determine whether a patient is participation restrictions and are already physically active.
physical therapists are integral members of the selecting exercise interventions and their associated
interprofessional team assisting with early detection of HF training parameters in that consideration should be given
exacerbation and directing medical follow-up. Physical to self-efficacy, readiness for behavior change, patient
therapists should work within their health care systems to preferences, and individual constraints, which may improve
determine how these or similar algorithms for identification long-term exercise adherence.21–23 Approaches including
of HF exacerbation can be utilized within their specific motivational interviewing, transtheoretical model of
contexts and patient care environments. behavior change, and Bandura’s Social Cognitive Theory
in isolation or in combination may be used.22 Specific
techniques and strategies based in these approaches
Adherence to Exercise-Based Interventions include goal setting, positive feedback, facilitation of
Unlike research on exercise-based interventions in HF, the problem solving, learning by doing, role modeling,
evidence for interventions to improve exercise adherence supportive visits and phone calls, and caregiver
lacks a single meta-analysis due to a broad range of engagement.22–24
interventions and a broad range of measures, most of
which are self-report. This broad range of qualitative A construct related to exercise adherence is the translation
measurement, lack of objective measurement, and lack of of improved exercise capacity and performance into an
unifying conceptual framework precluded the present GDG increase in overall daily physical activity (ie, structured and
from developing a key action statement on exercise incidental physical activity).25 This is believed to be
adherence. However, a few observations about existing important in stopping the negative cycle of inactivity and
literature can be made to help guide clinicians when deconditioning.26 Similar to the literature on exercise
adherence, the research on interventions to improve publications. Abstracts and full text (as necessary) were
overall daily physical activity lacks a consistent objective reviewed by at least 2 members of the GDG, with a third
measurement that allows meta-analysis and precluded the available should disagreement arise (no instances of
present GDG from developing an individual key action disagreement occurred). Meta-analyses, systematic
statement. However, it appears that exercise-based reviews, and clinical practice guidelines were reviewed for
interventions alone are insufficient for translating improved whether they specifically addressed the patients,
exercise capacity into increased overall daily physical interventions, comparisons, and outcomes of interest for
activity and should therefore include the same this CPG. Specifically, whether they: included adult
psychosocial components to intervention delivery as patients with HF during adulthood (acquired not congenital)
previously outlined for interventions to improve exercise and only such patients, whether interventions tested are
adherence.26 Physical therapists should consider interventions utilized by physical therapists, whether
strategies for improving adherence when implementing the reviews were of randomized controlled studies, and
Table 3.
Grades of Recommendation for Action Statements
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in disagreement.
to be within 1 point on the appraisal tool. If there was Role of the Funding Source
Table 4.
Key Action Statementsa
Trust developed by the IOM Committee on Standards for “must” and “may.”29 The use of these action words was
Developing Trustworthy Clinical Practice Guidelines.28 The deliberated by the GDG and is discussed under each key
reader will note the use of the word “should,” “may,” and action statement under the Value Judgements and
“must” as action words in each of the key action Summary of the Evidence subheadings.
statements. Lomotan et al (2010) suggest that “must”
conveys the strongest level of obligation and that guideline This CPG uses literature available prior to January 2018 to
developers rarely use the term, except in cases of a clear create the key action statements. The CPG addresses HF
legal standard or potential for imminent patient harm.29 via 9 action statements. Algorithms were created to make
“Should” is the most common deontic verb, and it conveys this CPG clinically useful and are based on the key action
an intermediate level of obligation between statements and other CPGs (see Figs. 1 and 2).
Action Statement 1: Advocate for central and peripheral alterations and therefore serves as
increased total daily physical activity a useful therapy for patients with HF.
as an essential component of care For the purposes of this paper, we utilize operational
Physical therapists and other health care practitioners definitions for physical activity and exercise provided by
should advocate for a culture of physical activity as an
Thompson and colleagues. Physical activity is defined as
essential component of care in patients with stable heart
any bodily movement produced by skeletal muscles that
failure. (Evidence Quality I; Recommendation Strength: A
results in energy expenditure beyond resting
—Strong).
expenditure.37 Exercise as described by Thompson, is a
subset of physical activity involving structured, repetitive,
Action Statement Profile and purposeful movements in an effort to improve overall
Aggregate evidence quality. Level I. physical fitness.38
role in recommending activity and exercise to improve Role of patient preferences. The role of shared decision
exercise capacity, quality of life and potentially improving making is essential to understanding the patient’s
prognosis and event-free survival. priorities and maximize the utilization of the education
provided.
Action Statement 2: Educate on and
facilitate components of chronic Exclusions. None.
(Evidence Quality I; Recommendation Strength: Readmission rates have been reported to be as high as 20%
A—Strong) within 30 days and up to 50% by 6 months for patients with a
diagnosis of HF.46 Reports from a cross-sectional chart-review
Action Statement Profile investigation on 435 patients admitted to an urban university
hospital with complaints of shortness of breath or fatigue and
Aggregate evidence quality. Level I. evidence of HF indicated non-compliance with medications
and diet as the most common identifiable abnormalities
Benefits: associated with clinical deterioration
• Significant reduction in all-cause hospital readmissions prior to admission.47 Education on self-management of HF
(RR = 0.59, CI = 0.44–0.80 P < .00143; 45 RR = 0.73, CI = has been found to not only decrease hospital readmission
44
0.57–0.93 ; RR = 0.87, CI = 0.79–0.95 ) for patients with heart failure, but also all-cause
• Significant reduction in heart failure
43
readmissions (RR = readmissions and possibly decreased mortality in this
0.44, CI = 0.27–0.71, P < .001 ; RR = 0.70, CI =
0.61–0.8145; RR = 0.66, CI = 0.52–0.8344) population.43,48–50 However, there are important caveats to
this body of evidence, including definition of and lack of
consistency in patient education interventions, variability in
Risks, harm, cost. None. the delivery of interventions (in isolation vs. as part of a
specialized team approach) and the effect on mortality.44,51
Benefit–harm assessment. Preponderance of benefit. Furthermore, it appears that patient education
on self-monitoring alone (and not other chronic disease
Value judgments. The GDG utilized “must” in the key self-management techniques) for acute decompensation
action statement based on the overwhelming is ineffective for reducing hospitalization compared with
preponderance of evidence indicating the benefits of implantable wireless pulmonary artery pressure
patient education on reducing hospital readmissions. monitors.52
The extent to which a physical therapist performs
components of medication reconciliation is expected to Several systematic reviews have focused exclusively
depend on practice setting and level of clinical on self-care strategies and disease management programs
experience. and have documented positive outcomes in patients with HF.
Jovicic et al43 completed a systematic review of
6 randomized controlled trials involving self-management
Intentional vagueness. Although existing research has interventions for 857 patients, 18 years of
not studied use of chronic disease self-management
age or older and diagnosed with HF. The authors reported
interventions in patients with HF when performed that self-management significantly decreased all-cause
exclusively by physical therapists, the GDG believed that hospital readmissions by 41% (RR = 0.59, CI = 0.44–0.80;
such interventions were appropriate to be performed by P < .001), decreased HF readmissions by 66% (RR =
physical therapists, especially in the context of the 0.44, CI = 0.27–0.71; P < .001) with no change in HF-
interprofessional team. related mortality with cost savings of $1300–$7515 per
patient per year.43
Holland published a systematic review of 30 randomized is high in fresh vegetables, fruits, low-fat dairy products,
controlled trials involving patients 56 to 86 years of age and whole grains, poultry, fish, and nuts and is low in sweets,
NYHA Classification II to IV.53 Common elements within the sugar-sweetened beverages, and red meats. Further,
education included one-to-one education concerning HF, this diet reduces consumption of saturated fat, total fat, and
medications, diet, exercise advice, symptom monitoring, and cholesterol while increasing dietary potassium,
self-management across a number of visits. Patients also magnesium, calcium, protein, and fiber. Adopting a dietary
received phone calls at a rate of 1.4 calls per month on plan based on DASH guidelines has been shown to reduce
average and had access to remote monitoring. The results systolic BP readings by 8 to 14 mmHg.56 Dietary guidelines
indicate a reduction in all-cause hospital readmissions by with an adherence to sodium restrictions is also useful in
13% (RR = 0.87, CI = 0.79–0.95), and reduced all-cause preventing HF exacerbations. A Cochrane Database
mortality by 20% (RR = systematic review in 2013 indicates a 2- to 8-mmHg drop in
0.79, CI = 0.69–0.92). Additionally, HF admission systolic BP with the utilization of this dietary sodium
can have a role in this process, and is currently Value judgments. The guideline developers have utilized
a required standard of practice in home health settings. “must” in the key action statement based on the
overwhelming preponderance of evidence, but clinicians
Several systematic reviews and CPGs support the use of should recognize that “must” is applicable only for patients
educational interventions in HF. Although physical who are consistent with the populations studied.
therapist services have not been explicitly included in
prior research, physical therapists, as members of the Intentional vagueness. Only aerobic exercise training
interprofessional team, must include education on self- parameter ranges are provided in the present guideline as
care behaviors as part of the overall care in an effort to there has been a lack of standard parameters used across
reduce hospitalizations and maximize outcomes in studies. Setting of exercise training is not specified though
patients with HF. home-based training programs are significantly less
studied. The only modes of exercise that have been
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extensively studied have been cycle ergometry, treadmill
Action Statement 3: Prescribe walking, or dancing. However, other modes of aerobic
aerobic exercise training training would be appropriate, especially when adapting
Physical therapists must prescribe aerobic exercise the exercise prescription to individual patient preferences.
training for patients with stable, NYHA Class II to III HF
using the following parameters: Role of patient preferences. Given that intervention
durations in included studies frequently exceeded
Time: 20 to 60 minutes.
3 months, and that continued adherence is required to
Intensity: 50% to 90% of peak VO2 or peak work. maintain training effects, selection of training parameters
should consider self-efficacy, readiness for behavior
Frequency: 3 to 5 times per week.
change, patient preferences, and individual constraints.
Duration: at least 8 to 12 weeks.
Exclusions. The use of aerobic exercise training has not
Mode: treadmill or cycle ergometer or dancing.
been studied in patients who are unstable/acutely
(Evidence Quality I; Recommendation Strength: decompensated, who have significant musculoskeletal or
A—Strong) pulmonary comorbidities, or who are in an inpatient
setting or who have significant comorbidity. Therefore,
clinical judgment must be used in the decision to include
Action Statement Profile
aerobic exercise training in these populations.
Aggregate evidence quality. Level I.
Summary of Evidence
Class IV HF who meet the criteria for clinical stability may for this potentially important variable with regard to
not be found in routine clinical practice. Specifically with specificity of training and whether walking-based training
regard to HFpEF, 4 separate meta-analyses with significant modes result in better functional or HRQL outcomes given
overlap of the same 8 studies concluded that the benefits that walking is a component of many functional activities.
of exercise training were similar to that of those with
HFrEF, though only 5 of the 8 studies included aerobic With regard to combined aerobic and resistance exercise
exercise training alone (the others included NMES, IMT, or training, the research that directly examines the addition
combined aerobic and resistance training).67,81–83 One study of resistance/strength training is limited, and does not
identified an improved E/e’ ratio (a measure of atrial appear to offer additional benefit to peak VO2. This is
pressure associated with diastolic dysfunction) following discussed in greater detail in the combined aerobic and
aerobic training as a possible mechanism for the resistance exercise training key action statement.
improvements in exercise tolerance and cardiac function.85
Given that intervention durations in included studies Intentional vagueness. There is no consensus for
frequently exceeded 3 months, and that continued adherence screening of patients for eligibility to participate in high-
is required to maintain training effect,96 strategies to enhance intensity training, including the need for baseline
adherence to exercise should be considered. In the HF- CPET.
ACTION trial,97 exercise adherence, measured by number of
minutes per exercise per week, decreased from a median of Role of patient preferences. Adherence is thought to be
95 minutes per week by the 4- to 6-month follow-up to 74
higher with shorter, higher intensity, interval-based
minutes per week at 10- to
sessions.59,76
12-month follow-up (full adherence was defined as
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>120 minutes per week). A subgroup analysis by Cooper
et al98 revealed that, although perceived social support was Exclusions. Patients for whom high intensity and high
not associated with clinical outcomes, it was associated heart rates might be contraindicated (eg, some
with exercise adherence. Characteristics of patients with types/settings of ICDs, history of exercise-related adverse
low adherence (<90 minutes per week) included those events, suboptimally treated coronary artery disease).
who were female, younger, black, NYHA Class III to IV,
and had lower baseline exercise capacity and HRQL.
Summary of Evidence
2 to 3 days per week. The studies examined in the that initially the physical therapist is conservative in
systematic reviews also tended to be longer in duration, addressing the progression of strength in patients with HF.
with some studies lasting up to 6 months in duration. The
mode of exercise varied widely from study to study within Although Valsalva can occur with higher weight loads,
the separate systematic reviews. Modes included anything evidence towards the negative effect of the Valsalva is
from traditional to wrist and ankle weights to hydraulic and weak and conscious cuing on the part of the physical
pneumatic resistance. However, studies often just referred therapist to avoid the Valsalva maneuver can increase the
to progressive resistive exercise (PRE) and did not define a patient’s safety during the task. The increase in core
mode of exercise. In addition, bouts of exercise alternated stability using the Valsalva maneuver when lifting can also
between high intensity intervals and continuous bouts of 8 be accomplished, without increased atrial pressure, using
to 10 reps of a single exercise. forced exhalation during lifting.108 The clinician should also
consider repetition to failure. If a patient is easily able to
Value judgments. Because only a few studies, using benefits of exercise training were similar to that of those
small samples sizes, have empirically compared combined with HFrEF, though only 2 of the 8 studies included
resistance and aerobic training to aerobic training alone, combined aerobic and resistance exercise training (the
the developers were unable to recommend this action others included only aerobic exercise, neuromuscular
statement at a higher level. electric stimulation, or inspiratory muscle
training).67,81–83,113 No study reported any adverse events,
Intentional vagueness. Presence of baseline muscular regardless of the exercise training mode.
strength impairment.
Therefore, the amount of time a patient is willing to
Role of patient preferences. Total exercise training time dedicate to exercise training must be considered when
should be considered. determining the duration of the aerobic and resistance
training components of a combined intervention.
Risk, harm, cost. No documented risks or harms, though dyspnea, poor quality of life, and poor prognosis.121–124 As
consideration should be given to those individuals at risk summarized below, the effects of IMT on a number of
for vocal fold dysfunction and pneumothorax, as well as important clinical outcomes has prompted some to propose
those with markedly elevated left ventricular end diastolic IMT as an alternative intervention for those who are unable
volumes. Device cost can vary. Patient time to complete an or unwilling to participate in a more traditional rehabilitation
intervention, especially with lower training intensities and program.117,125
longer durations or when combined with other
interventions, should be considered. With regard to effect of IMT alone on clinical outcomes
based on reported weighted mean differences, meaningful
Benefit–harm assessment. Preponderance of benefit.
improvements in SMIP exercise tolerance and HRQL117
have consistently been demonstrated.
Action Statement Profile
improvement, such as those with severe COPD with inspiratory muscle weakness as an adjunct to aerobic
hyperinflation or neuromuscular conditions that result in exercise training using the following parameters:
irreversible inspiratory muscle weakness. With regard to
Time: 30 min/day.
clinical setting, only outpatient and home-based programs
have been studied, so the evidence is unable to inform Intensity: >30% maximal inspiratory pressure (PIMax or
decisions regarding the use of IMT in other settings and MIP).
the timing of initiating IMT as a patient progresses through Frequency: 5 to 7 days/wk.
the continuum of care. Thus extrapolation to patients with
understudied characteristics and settings, although not Duration: at least 8 to 12 weeks.
inappropriate, should be performed with caution. (Evidence Quality: II, Recommendation Strength:
B–Moderate)
With regard to safety, no adverse events related IMT have
dyspnea, poor quality of life, and poor prognosis. As 700 ms and for small lower extremity muscles 0.5 to
summarized in the preceding key action statement, IMT as 0.7 ms, 20–30% of MVIC, intensity to muscle
a single intervention results in meaningful improvements in contraction.
MIP, exercise tolerance, and quality of life have • Frequency: 5 to 7 days/week.
consistently been demonstrated. However, it is also • Duration: at least 5 to 10 weeks.
important to address the use of IMT combined with aerobic
exercise training. (Evidence Quality I; Recommendation Strength:
A—Strong)
Based on the 3 studies 135–137 included in the meta-analysis by
Neto et al, the addition of IMT to an aerobic exercise program
resulted in additional improvements in MIP Action Statement Profile
(12.9–23.5 cmH2O, pooled effect of 20.89 cmH2O), and Aggregate evidence quality. Level I.
Exclusions. Patients with implanted ICDs/pacemakers are generally underrepresented in this literature. However,
were excluded from all randomized trials. However, the GDG feels that NMES may be a feasible alternative
several case series studies on patients (total of 11 patients to whole body exercise for those patients with Class
with bipolar sensing pacemakers and 6 patients with ICDs) IV HF.
demonstrated that there were not any adverse effects from
NMES.144–146 The GDG did not find literature regarding the Few studies clearly stated the instructions provided to
use of NMES in HF patients with a high risk of venous patients as to what, if any, activity should be performed
thromboembolism and/or thrombophlebitis. during NMES treatment. One study specifically instructed
patients to be ambulatory while receiving NMES. Fall risk,
baseline level of inactivity, and exercise tolerance should
Summary of Evidence be considered when providing patient instructions for
When considering options for the patient with HF, NMES patients who receive NMES during gait. The GDG
• Of all of the exercise-related options, which are the physical therapy; Erin Haling, PT, DPT, certified safe patient handling
clinician, certified ergonomics assessment specialist I, II, III; June
most effective in particular subgroups of patients with Hanks, PT, PhD; John Imundi, PT, DPT; Kerry Lammers, PT, DPT,
HF in decreasing readmissions, increasing function and
increasing quality of life? board-certified clinical specialist in cardiovascular and pulmonary
physical therapy; Andrea Mendes, PT, DPT; Kristen Peterson, PT,
• What are appropriate interventions and exercise DPT; Julie Ronnebaum, PT, DPT, PhD, board-certified clinical
dosing/parameters for:
specialist in geriatric physical therapy; Richard Severin, PT, DPT,
◦ Patients soon after (within days) of acute board-certified clinical specialist in cardiovascular and pulmonary
exacerbation? physical therapy; Jonathan Wood, PT, DPT, board-certified clinical
◦ Patients in acute care, inpatient rehab, subacute specialist in neurologic physical therapy. External reviewers: Jason L.
rehab, or home health early post-acute care? Rengo, MSc, certified cardiac rehabilitation professional, Fellow of the
◦ Patients undergoing upward titration of cardiac American Association of Cardiovascular and Pulmonary Rehabilitation;
remodeling agents and not yet on a stable, optimal Ellen Hillegass, PT, EdD, FAPTA, board-certified clinical specialist in
pharmacologic regimen? cardiovascular and pulmonary physical therapy; Carl Fairburn, PT,
DPT; Suzanne Greenwalt, PT, DPT, board-certified clinical specialist in
• Are there variations in response or outcomes cardiovascular and pulmonary physical therapy, board-certified clinical
specialist in geriatric physical therapy; Michael Puthoff, PT, PhD;
associated with common comorbidities?
• What is the influence of combining or staging Wayne Brewer PT, MPH, PhD, board-certified clinical specialist in
orthopedic physical therapy, certified strength and conditioning
interventions (such as starting with E-Stim and specialist; Anne K. Swisher PT, PhD, FAPTA, board-certified clinical
progressing to aerobic training)?
specialist in cardiovascular and pulmonary physical therapy; Lawrence
• What is the influence of resistance training in specific Cahalin, PT, PhD, board-certified clinical specialist in cardiovascular
instances of muscle weakness (eg, targeted and pulmonary physical therapy. Grand Valley State University
therapeutic exercise)? graduate assistants:
• What particular presentations of movement dysfunction Kelly Gotberg, PT, DPT; Sarah Veldman, SPT; Kelsey
in patients with HF may warrant particular combinations
of interventions? Berry, SPT.
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Appendix 1.
Key Words for Literature Search
Additional evidence selection criteria will include: Health retrospective studies, case series/case reports; and
care settings: Across the spectrum from critical care to excluded any cross sectional design studies.
outpatient (including home care). Publication status: Only published full papers were
Timeframe: No limit. included (Not unpublished manuscripts or abstracts of
Study design: We included practice guidelines, systematic conference proceedings).
reviews with or without meta-analysis; RCTs, prospective Language: Our search and inclusion included English
comparison studies, prospective non comparison studies, language publications
Appendix 2.
Flow Chart of Article Selection