Physical Therapy Intervention Strategies Post Ream and Run Hemiarthroplasty Jessica Ottow, Student Physical Therapist Suzanne Ryer, MPT Faculty Mentor
Abstract Background: Treatment of glenohumeral arthritis or chronic shoulder pain in young, active patients can be challenging due to long term consequences associated with functional limitations. Conservative management is common, however, generally only provides short term relief. Surgical options often used are total shoulder arthroplasties (TSA). Risks associated with TSA include delayed failure of the replaced components. Therefore, alternative options such as ream and run hemiarthroplasty are often more appropriate. The R&R hemiarthroplasty procedure allows individuals to return to functional recovery without concern of component failure since; however, there is not a well established physical therapy protocol associated with this procedure. The purpose of this case report is to describe the physical therapy management for a patient following the ream and run hemiarthroplasty shoulder procedure. Case Description: The patient was a 46 year old male who had experienced shoulder pain for 8 years who underwent a ream and run hemiarthroplasty procedure. Status post surgery he had decreased range of motion, strength and functional movement. He was seen in physical therapy over the course of 26 weeks. His plan of care was progressed as tolerated and included techniques for pain management, manual therapy, increasing flexibility, and shoulder and shoulder girdle strengthening. Outcomes: The patient demonstrated improved active range of motion in all planes. His initial DASH scores improved from 92.5/100 to 25.8/100 indicating improvements in shoulder function. He reported improvements in overhead reaching activities, ADLs including showering and decreased shoulder pain. Despite subjective reports the patient was not able to demonstrate full range of motion and continued to have deficits in strength, reaching and other overhead functional activities. Discussion: Early passive range of motion progressing to active assisted and active range of motion in combination with strengthening exercises over a 6 month rehabilitation period resulted in improve range of motion, strength and functional movement following the ream and run hemiarthroplasty. Additional research is necessary in order to improve progression and efficiency compared to the total shoulder arthroplasty protocol.
Background Glenohumeral arthritis is a growing condition with varying sources of etiology including osteoarthritis, secondary degenerative joint disease, rheumatoid arthritis, avascular necrosis, rotator cuff tear arthropathy, and capsulorrhaphy arthropathy. 1 As a result, both elderly and young populations can be affected by the consequences of arthritis. Arthritis is a slow, progressive, mechanical, and biochemical breakdown of the articular cartilage and other joint surfaces, including both the bone and the joint capsule. When the degeneration of the articular surfaces occur, the friction within the joint increases causing breakdown and loss of the load-bearing surfaces, increased pain and loss of normal function. 2 The consequences of arthritis in the glenohumeral joint include pain, decreased shoulder range of motion and loss of strength resulting in loss of normal functional movement. These impairments can be treated a variety of ways depending on the specific diagnosis and severity of the condition. Conservative treatment options include decreasing inflammation, exercises to increase flexibility and strength and activity modification. Surgical options consist of temporary options including arthroscopic debridement and synovectomy; as well as, long term options such as total shoulder arthroplastly. 1 Total shoulder arthroplasty (TSA) is a surgical procedure that involves resurfacing of the glenoid fossa including the placement of a solid polyethylene component. The humeral head is resected and replaced with a metal prosthesis. Advancements in medicine have implemented newer prostheses known as reverse total shoulder replacements, in which the humeral head becomes the concave component and the glenoid fossa becomes the convex or ball component of the joint. The benefit of reverse total shoulder replacements is its design specific to patients with severe rotator cuff deficiencies. 2 There are risks associated with both types of TSA including delayed failure of the replaced components as a result of loosening, fragmentation, asymmetric wearing and instability. 3 Therefore, for individuals with severe cases of arthritis who are young and active, TSA is not the optimal surgical option. The alternative for these patients is a hemiarthroplasty procedure referred to as ream and run (R&R hemiarthroplasty). The focus of the R&R hemiarthroplasty procedure is to increase the stability of the glenohumeral joint and reduce the local contact pressure by establishing a smooth, concentric biological glenoid surface that can remodel with fibrocartilage over it. The R&R hemiarthroplasty procedure involves the replacement of the arthritic humeral head with a metal ball that is fixed within the humerus with a stem component. The glenoid fossa is reamed until the arthritic components of the socket are removed and the desired shape is achieved. During the recovery period a new biological surface is formed on the resurfaced socket. 3 The R&R hemiarthroplasty procedure allows for individuals to achieve similar return to functional recovery as an individual who underwent a TSA with no concern of component failure; however there is a longer recovery period before full return to function. 3 Following the R&R hemiarthroplasty procedure improvements and recovery can continue to be made for up to 1.5 years as reflected in SF-36 questionnaire and DASH scores. 4 Recovery is not only affected by pre-operative states and co-morbidities but is also greatly affected by post-operative guidelines followed subsequent to the R&R hemiarthroplasty procedure. Unfortunately, there is very little literature established regarding the guidelines for physical therapy following an R&R hemiarthroplasty surgery. Research regarding physical therapy guidelines is necessary in order to provide patients with the optimal progression of functional movement in order for them to
decrease pain and return to normal function in a timely manner. The purpose of this case report is to describe the physical therapy management for a patient following the ream and run hemiarthroplasty shoulder procedure. Case Description History The patient was a 46 year old male who had been experiencing shoulder pain for 8 years before deciding to undergo the ream and run hemiarthroplasty procedure. His past medical history included a C5-6 cervical fusion in 1983 following a neck fracture. The patient reported falling off of a three speed bicycle and landing on his head, resulting in Brown-Sequard syndrome causing loss of motor function and weakness on his entire right side. Over time he continued to report decreased strength in his right shoulder, however, he continued with normal activities and exercise. In 2004 he reported that he tore the cartilage in his right shoulder while doing chair dips. Following this incident he had arthroscopic shoulder cartilage repair. He reported shoulder pain relief following surgery but it did not last for very long. He experienced rapid decline in function, increased pain and further deterioration of the remaining cartilage in his shoulder. He reported that from the time of his previous shoulder surgery and consultation for further surgery he was experiencing increased pain and functional limitations including participating recreational activities, performing any activities involving lifting and reaching overhead, and performing any quick or rapid right shoulder movements. He was able to perform all necessary tasks however, was often distracted by the pain levels. After 8 years of shoulder pain, weakness and a prior shoulder surgery the patient consulted an orthopedic surgeon regarding options to manage his shoulder condition. He underwent an MRI which revealed complete absence of cartilage in his right shoulder. The patient and physician discussed several options and the patient chose the ream and run hemiarthroplasty procedure. His decision was based on his age and the potential for him to no longer have any limitations and not have to undergo another surgical procedure. Following surgery, the patient was referred to physical therapy. An MD protocol regarding therapy for total shoulder replacement was received as general therapy guidelines (Table 1). Physical Therapy Initial Evaluation The patient presented to physical therapy with his right arm in a sling. The patient reported pain on a 0-10 numeric pain scale as 0/10 at best since surgery and 7-8/10 at its worst when performing functional overhead movements. He described the pain in his right shoulder as sharp and deep with an ache over the top. Per MD protocol, the patient was unable to use his right arm for assist in dressing, showering and completing any other reaching activities. A reach assessment was not performed as the patient was in a sling unable to perform the activity at that time. Passive range of motion measurements revealed decreased motion in all planes for the right shoulder (Table 2). Muscle testing was not performed at the time of evaluation per physician protocol. Palpation of the right shoulder revealed increased tightness in the posterior shoulder and levator scapulae. Upon evaluation the patient completed the Disabilities of the Arm, Shoulder and Hand (DASH) outcome assessment form. The DASH is a self report outcome measure questionnaire that allows an individual to assess and measure the physical function and symptoms of the musculoskeletal system of
their upper extremity. It is a useful subjective assessment tool that has an excellent test-retest reliability with an ICC of 0.96 6. The DASH consists of 30 questions that rate symptoms and function on a 0-5 scale where 0 equals does not affect at all and 5 equals affects extremely 5. His DASH score was a 92.5; the scores are scaled from 0-100 where a higher score indicated increased disability and zero indicates no disability. Clinical Impression The findings from the initial physical therapy examination reveal decreased range of motion, strength and functional movement especially for over head motions of the right shoulder following a ream and run hemiarthroplasty. The patient would benefit from skilled physical therapy services in order to appropriately progress and improve range of motion, strength and functional mobility in order to return to activities of daily living and recreation. Intervention Following surgery and physical therapy evaluation, therapy was recommended and initiated 2-3 times per week for 6-8 weeks for manual myofascial techniques, therapeutic exercise and development of an appropriate home exercise program one week following surgery. The orthopedic surgeon s therapy protocol for total shoulder replacement and restrictions were utilized as guidelines in order to develop an appropriate therapy program for the patient. The following guidelines and dates were implemented in the plan of care documentation in order to allow for continuity of care between therapists and therapist assistants. Weeks 1-6: PROM progressing to AROM as tolerated, pulleys, no active IR or ext Weeks 6-12: no resisted IR or ext, AAROM and AROM IR and ext, light RROM ER, flexion, abd (isometrics or bands for concentric motions only), no scapular retraction with bands Months 3-12: RROM IR and ext, eccentric strengthening, plyometrics, closed chain exercises The patient was instructed in a home exercise program (Table 3.) on the first day of therapy. The goal of the exercises was to manage pain symptoms, promote range of motion and flexibility of his right shoulder. During the first 6 weeks the focus of therapy included pain management and flexibility. Manual techniques were performed at the beginning of each session including passive range of motion for shoulder flexion, abduction and external rotation. Trigger point release was performed to bilateral levator scapulae, posterior shoulder and subscapularis, as well as light stretching for flexion and extension of the right elbow as needed. The exercises performed included PROM progressing to AAROM and AROM as tolerated by the patient. Care was taken to ensure that the patient did not perform any active shoulder internal rotation or extension. These exercises included utilizing stability balls, stair rails, pulleys and canes in order to progress the range of motion that is available in the patient s right shoulder. Additionally, exercises were included that allowed for shoulder stretching while allowing for strengthening of the rest of the body to keep the patient active as he is recovering from surgery including hip loading interventions. Lastly, interventions were performed in order to maintain strength and flexibility of the right upper extremity since the patient is not using his arm for ADLs and
other functional movements as he did before surgery. The specific exercises incorporated during the first 6 weeks are described further in Table 5. Six weeks following surgery the patient was released from his sling to begin AAROM in all planes, AROM for IR and extension were initiated, and light resistive range of motion and isometrics strengthening. In addition scapular strengthening was performed in order to create scapular stability for a foundation to begin shoulder strengthening. The goals for the weeks 6-12 of physical therapy was to continue to progress range of motion of the right shoulder, begin to increase shoulder strength and develop scapular stability. The specific exercises that were incorporated during weeks 6-12 are described further in the Table 5. Additionally, about 8 weeks following surgery a TENS unit was ordered and issued to the patient for at home use in order to aide in pain management. At the end of 12 weeks therapy was no longer approved by insurance, however, the patient chose to continue therapy for manual services and home exercise instruction under self pay. Therefore, from weeks 12 20 the patient was seen one time per week where he received manual techniques as he was during the prior weeks of therapy. He was also instructed in additional home exercises including the strengthening activities that he had been performing previously during therapy. The specific exercises that were incorporated into the home exercise program from weeks 12-20 are described further in Table 5. Insurance approval for additional therapy services was approved at week 20 and performed through week 26 with the patient being seen 1x per week. The focus of the interventions starting at week 20 were on scapular stabilization and closed chained movements in order to provide a strong base for shoulder movement to build from. The specific exercises that were incorporated into the home exercise program from weeks 20-26 are described further in Table 5. Outcomes Throughout the course of physical therapy various reassessments took place. The focus of each progress note was to reassess the patient s report over pain, ability to reach and perform other ADLs, to reassess range of motion, and to complete a DASH outcome measure survey. A summary of these results is presented in Table 4. The patient s last progress note was written approximately 14 weeks post surgery and revealed that range of motion, pain and function had all improved over the course of therapy. He continued to receive therapy services until approximately 24 weeks post surgery. Throughout those two months the patient battled insurance limitations resulting in alternating receiving full therapy sessions including manual techniques and therapeutic interventions and partial therapy sessions receiving only manual techniques. Although the patient was not able to demonstrate full range of motion and continued to have deficits in strength, reaching and other overhead functional activities he did not return to therapy following his last visit at 24 weeks post surgery as a result of insurance coverage. Therefore, no formal discharge assessment was performed. He attended 43 physical therapy sessions over the course of 6 months following surgery. He had a well established home exercise program that he was performing independently, as well as a good understanding of how to continue to progress the exercises that he was given. The results from the DASH outcome assessment over the course of therapy demonstrated improved function over time. On the initial assessment he rated his disability with a total score of 92.5/100 and his final DASH score was 25.8; demonstrating an improvement in function with an
improvement in score of 66.7 points. An improvement of at least 10 points indicates an important change 5. He continued to report that he was unable to participate in full recreational activities, severe difficulty with overhead activities including washing his hair and back and moderate weakness and stiffness in his arm. Discussion The purpose of this case report was to describe the physical therapy management for a patient following the ream and run hemiarthroplasty shoulder procedure. As a result of the varying options for shoulder replacement surgery and the rarity of the use of the ream and run hemiarthroplasty procedure, previous research regarding the physical therapy management including interventions and progression is lacking and general guidelines for total shoulder arthroplasty are generally used as a reference to develop an appropriate plan of care. The individual in this case report was able to show improvements utilizing the guidelines and progression of exercises explained in this case report through his course of therapy. The large majority of research regarding the ream and run hemiarthroplasty procedure discusses and compares this procedure to a total shoulder arthroplasty. Many of the studies conclude and report optimistic outcomes with very few complications associated with the ream and run hemiarthroplasty as compared the total shoulder arthroplasty procedure. A retrospective study by Sperling et al 7 compared 138 cases of 50 year old or less patients who had underwent either the TSA or hemiarthroplasty procedure and found no differences between the outcomes of the procedures. They both provided improved overall physical function and provided patients with long term pain relief. Another study reported that following the R&R hemiarthroplasty procedure improvements and recovery can continue to be made for up to 1.5 years as reflected in SF-36 questionnaire and DASH scores. 4 Finally, a case report similar to this one the patient received physical therapy for 14 weeks post surgery and was followed through his one and two year follow-up with his physician. The patient demonstrated improved range of motion for both IR and ER at discharge. Subjective outcome measures including the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) also indicated improvements in physical function at discharge and the 1 st and 2 nd year follow-up. 8 The patient in this case report demonstrated similar findings to previous research showing improvements in range of motion, pain management and functional strength and movement following a specific physical therapy plan of care. Unfortunately, the patient experienced complications with insurance limitations and was unable to fully participate in physical therapy sessions over the course of the 6 months that he was seen. From weeks 12-19 the patient only received manual techniques based on a self pay basis which limited the appropriate assessment and progression of strengthening interventions. Additionally, as a result of his insurance limitations no formal discharge was performed since the patient choose not to come back after performing several self pay sessions. Despite these limitations the patient was an active participant in a progressive home exercise program and did choose to participate in self pay sessions where he could receive manual therapy techniques that addressed deficits in range of motion and areas of tightness and pain. Even though the patient was able to make great improvements it is difficult to determine if the changes were due to the physical therapy protocol that was developed or as a result of
something he was doing when not in therapy as the patient commonly reported attempting to work out in the gym and return to functional activities. An additional limitation of this case report is that the physician protocol used was associated with a total shoulder arthroplasty rather than a hemiarthroplasty. The protocol utilized very cautious progression of interventions which resulted in prolonged immobility limiting ability to progress therapy causing increased tightness and need to address manual techniques rather than AROM and strengthening necessary to optimize function. However, the patient was able to reach long term outcomes for return for function that were consistent with previous research which indicated improvements and recovery can continue to be made for up to 1.5 years as reflected in SF-36 questionnaire and DASH scores. 4 This case report presents a thorough postoperative rehabilitation program which yielded good results improving range of motion, decreasing pain reports and improved function as demonstrated by the DASH scores. In order to provide comprehensive results regarding physical therapy protocols following ream and run hemiarthroplasty further research should be conducted regarding protocols for total shoulder arthroplasty compared to revised protocols for hemiarthroplasty. The value of additional research is important because despite the long term outcomes that are achieved following either procedure the prognosis for the hemiarthroplasty is longer than total shoulder arthroplasty. During prolonged rehabilitation insurance complications can occur and therapy services may not be available for long term care. Therefore, it is crucial that physical therapy be able to progress patients following R&R hemiarthroplasty safely and efficiently.
Table 1. Total Shoulder Replacement Therapy Protocol Weeks 1-6 Weeks 6-12 Months 3-12 Sling for 6 weeks Begin AAROM-AROM IR and ext Begin resisted IR/ext: isometricslight bands-weights PROM-AAROM-AROM as tolerated No active IR/extension for 6wks ROM goal Week 1: 90 FF/20 ER at side; ABD max 75 without rotation ROM goal Week 2: 120 FF/40 ER at side; ABD max 75 without rotation No resisted IR/ext until 12 wks Grip strength ok Canes/pulleys ok for PROM Heat before PT, ice after PT Goals: Increase ROM as tolerated Begin light resisted ER/FF/ABD; isometric/bands, concentric only No resisted IR/ext until 12 wks No scapular retraction with bands Advance strengthening as tolerated; 10 reps/1 set per exercise rotator cuff/deltoid/scapular stabilizers Increase ROM to full Begin eccentric motions, plyometrics, and closed chain exercises at 12wks Table 2. Range of Motion Passive Motion Right (Degrees) Left (Degrees) Shoulder Flexion 35 176 Shoulder Abduction 45 146 Shoulder Internal Rotation 40 (arm at side) 64 Shoulder External Rotation -25 (arm at side) 87 Elbow Extension -15 0 Table 3. Home Exercise Program Exercise Codman s PROM shoulder flexion on stability ball Cane PROM shoulder ER, ABD Grip/Wrist/Elbow AROM Description Flexion, Horizontal ABD, Circles cw and ccw x2 min each direction as tolerated by patient 2x10 reps stretch as tolerated by patient Seated, 1x10 reps stretch as tolerated by patient AROM for wrist flexion/ext; AROM for elbow flex/ext/supination/pronation; AROM for finger flex/ext; gentle ball squeezes all as tolerated by patient several times per day
Table 4. Progress Note Documentation Progress Note Date Initial Evaluation Week 6 Week 8 Week 14 Pain History Current: 0/10 Best: 0/10 Worst: 7-8/10 Current: 1/10 Best: 0/10 Worst: 10/10 Current: 2/10 Best: 0/10 Worst: 10/10 Current: 0/10 Best: 0/10 Worst: 5/10 Functional Activity Reaching: Unable to perform Reaching: Unable to perform Reaching: Unable to perform Shaking hands: Increases pain Reaching: Able to reach 70 Shaking hands: No limitation Range of motion DASH score Misc./Subjective Flexion: 35 Abduction: 45 IR: 40 (at side) ER: -25 (at side) Elbow ext: -15 Flexion: 122 Abduction: 100 IR: 55 (at side) ER: 30 (at side) Elbow ext: 0 Flexion:126 Abduction: 105 IR: 55 (at side) ER: 37 (at side) Elbow ext: 0 Flexion: 142 Abduction: 105 IR: 54 (at side) ER: 48 (at side) Elbow ext: 0 Score: 92.5 Score: 65.8 Score: 54.2 Score: No DASH performed Week 21 * Score: 31.7 Week 23 * Score: 29.2 Week 26 * Score: 25.8 * Indicates DASH score was the only part of reassessment as advocation to receive insurance reimbursement. -Initial Evaluation information -Patient summary form indicates extreme difficulty with all ADLs -MD reports out of sling tomorrow -Performing HEP regularly -Moving shoulder getting easier -Not working -Subluxation out of sling -TENS helping -No pain with shaving for 1 st time -Not working - subluxation without sling -Believes strength is increasing
Table 5. Rehabilitation Interventions Interventions weeks 1-6 *Performed as part of HEP, as well as, in clinic in order to monitor patient progression and tolerance to exercise Exercise Description Home exercise program Described in Intervention section Table 3. - Codman s exercise - *PROM shoulder flexion on stability ball - *Cane PROM shoulder ER, ABD - Grip, Wrist, *Elbow AROM Manual Techniques - Manual techniques are performed as tolerated by patient, as well as, as needed by how patient presents to therapy that day Pulleys Seated scapular retraction Bicep curls Sink squat Lateral lunge Stair rail slide into flexion Interventions weeks 6-12 - PROM R shoulder flexion, ABD and ER - Trigger point release levator scapulae and posterior shoulder - Light stretching elbow flexion and extension -Strain counter strain pec minor stretch - Cross friction massage rotator cuff tendons Performed in scaption and flexion x2 min each direction X10 repetitions, 1-3 second hold Seated; X10 repetitions, 1lb Right, 5lb Left Stand facing stable surface, hold stable surface, squat until gentle stretch felt in shoulder; x10 reps Lunge until gentle stretch felt in shoulder; x10 reps Right hand on towel on stair rail slide arm up until stretch is felt; 10second hold at end range; x10 reps Home exercise program - Codman s exercise - *PROM shoulder flexion on stability ball - *Cane PROM shoulder ER, ABD - Grip, Wrist, *Elbow AROM Manual Techniques: - Manual techniques are performed as tolerated by patient, as well as, as needed by how patient Described in Intervention section Table 3. - Same as week 1-6 - Scapular range of motion
presents to therapy that day Codman s exercises Pulleys Isometric strengthening at wall for shoulder flexion, ABD and ER High table planks Planks on stability ball Planks on bosu with cw and ccw circles Rotator cuff strengthening flexion, ext, ER, IR Wall walk ups Bicep curls Tricep kick backs Scapular clock Latissimus Dorsi stretch TENS unit Interventions weeks 12-20 Horizontal D1/D2 patterns ; x2 min each direction as tolerated by patient Performed in scaption, flexion and IR; x2 min ea direction X10 reps in each direction Maintain up to 30seconds x2-3 reps Maintain up to 30 seconds x2-3 reps Plank on flat surface of bosu, scapular movement to perform small circles of bosu; x10 ea direction, x2 reps Standing, resistance band, x10 reps Walk hand up wall; flexion, scaption, ER; x10 ea direction Standing; x10 repetitions; 10lb bilaterally Standing; x10 repetitions; 10lb bilaterally Sidelying; cw and ccw; x1 min each direction 2x30sec holds Shoulder settings on unit; pulse width 260, pulse rate 80-100Hz; as necessary for pain throughout the day Exercise Home exercise program - Codman s exercise - *PROM shoulder flexion on stability ball - *Cane PROM shoulder ER, ABD - Grip, Wrist, *Elbow AROM Manual Techniques - Manual techniques are performed as tolerated by patient, as well as, as needed by how patient presents to therapy that day Additional Home Exercises Interventions weeks 20-26 Description Described in Intervention section Table 3. - Same as week 6-12 - High table planks - Rotator cuff strengthening flexion, ext, ER, IR - Wall walk ups - Bicep curls - Tricep kick backs
Exercise Home exercise program - Codman s exercise - *PROM shoulder flexion on stability ball - *Cane PROM shoulder ER, ABD - Grip, Wrist, *Elbow AROM - High table planks - Rotator cuff strengthening flexion, ext, ER, IR - Wall walk ups - Bicep curls - Tricep kick backs Manual Techniques - Manual techniques are performed as tolerated by patient, as well as, as needed by how patient presents to therapy that day Simultaneous (sim) shoulder ER Prone on elbows sim shoulder ER Shoulder ext Prone mid trap and low trap raises Planks and reverse planks on TRX Wall push ups TRX low rows Seated ER eccentric control Description Described in Intervention section Table 3. - Same as week 12-20 - Trigger point release pec minor - Seated scapular mobilizations; grade III - Inferior and posterior capsule mobilizations; grade II and III Standing; green tband; x10 reps Prone on elbows; green tband; x10 reps Standing; green tband; x10 reps Prone; x10 reps ea 4x30 sec holds each x10 reps x10 reps Seated; elbow on foam roller so it is perpendicular to the body; slowly lower into IR to activate eccentric control of ERs; x10 reps 4 pt horizontal ADD stretch 4 pt; bring arm in across body until stretch is felt; 2x30 sec hold Pec minor stretch Doorway stretch; 2x30 sec holds Push/Pull with cable cross Level 4 (20lbs); x10 ea Lat pull down Cable cross; level 2 (10lbs); x10 References 1. Parsons I, Weldon E, Titelman R, Smith K. Glenohumeral arthritis and its management. Physical Medicine & Rehabilitation Clinics Of North America [serial online]. May 2004;15(2):447-474. Available from: CINAHL Plus with Full Text, Ipswich, MA. 2. Millett P, Gobezie R, Boykin R. Shoulder osteoarthritis: diagnosis and management. American Family Physician [serial online]. September 2008;78(5):605-611. Available from: CINAHL Plus with Full Text, Ipswich, MA.
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