Mobile health technologies for the monitoring of menstrual cycle: A systematic review of online stores in Brazil.

AIM: To perform a systematic review of available mHealth apps for menstrual cycle monitoring in Brazil. METHODS: A search for menstrual cycle mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on October 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). RESULTS: Our review identified 2400 potentially relevant mHealth apps, of which 56 were eligible for inclusion. The majority of the apps offered tools to track menstruation symptoms (63%) and educational content for users (32%). The mean ( ±SD) MARS app quality score for the 28 evaluated apps in Android was 3.5 ± 0.6 on a 0-5 scale. For the 28 evaluated apps in iOS, the mean app quality score was 3.8 ± 0.4. Most of the included apps, for both systems, scored average for credibility, user interface, and engagement. CONCLUSION: The majority of available tools in Brazil are of moderate quality and limited functionality for menstrual cycle monitoring. This study highlights the top three mHealth apps available on each online store for individuals seeking menstrual cycle monitoring options.

The effects of cryotherapy on pain and function in individuals with knee osteoarthritis: a systematic review of randomized controlled trials.

OBJECTIVE: To investigate the effectiveness of cryotherapy on pain and physical function in knee osteoarthritis. DATA SOURCES: An electronic search was performed up to February 2019 on PubMed/MEDLINE, EMBASE, CINAHL, Lilacs, Cochrane, Web of Science, Ibecs, and Scielo databases with keywords knee osteoarthritis and cryotherapy. METHODS: Two authors independently performed the study selection. All languages and publication dates were considered. The PEDro scale was used to assess the methodological quality of the studies, and the body of evidence was analyzed and synthesized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The clinical relevance of the included studies was evaluated using the criteria proposed in the Cochrane Handbook for Systematic Reviews of Interventions. RESULTS: Of the five studies, 202 subjects were included. All studies included participants with established knee osteoarthritis. The mean PEDro score was 4.20/10, and meta-analysis was not possible due to heterogeneity among the studies. The mean clinical relevance was 3/5. Only two studies were considered for analysis based on the GRADE approach, and low level of evidence was synthesized regarding the effectiveness of cryotherapy for pain management, knee stiffness, knee range of motion, and physical function. Application techniques, frequency, and duration did not affect outcomes. CONCLUSIONS: There were insufficient primary studies to draw any conclusions about the effectiveness of cryotherapy on pain and physical function on individuals with knee osteoarthritis.

Comparison between the effects of 4 different electrical stimulation current waveforms on isometric knee extension torque and perceived discomfort in healthy women.

INTRODUCTION: We studied the effects of different neuromuscular electrical stimulation (NMES) currents, 2 kHz-frequency alternating currents (KACs, Russian and Aussie) and 2 pulsed currents (PCs), on isometric knee extension torque and discomfort level, both in isolation and combined, with maximum voluntary contraction (MVC). METHODS: Twenty-one women (age 21.6 ± 2.5 years) were studied. We evaluated torque evoked by NMES or NMES combined with maximum voluntary contraction of the quadriceps muscle of healthy women. Discomfort level was measured using a visual analog pain scale. RESULTS: Despite comparable levels of discomfort, evoked torque was lower for Russian current compared with the other modalities (Russian 50.8%, Aussie 71.7%, PC500 76.9%, and PC200 70.1%; P < 0.001). There was no advantage in combining NMES with MVC compared with isolated NMES. CONCLUSIONS: The Aussie and PC approaches proved superior to Russian current for inducing isometric knee extension torque. This information is important in guiding decision making with regard to NMES protocols for muscle strengthening.

Photobiomodulation does not provide incremental benefits to patients with knee osteoarthritis who receive a strengthening exercises program: a randomized controlled trial.

BACKGROUND: There is lack of agreement in the literature about the effectiveness of photobiomodulation (PBM) for reducing pain-related symptoms in patients with knee osteoarthritis (OA). OBJECTIVE: To evaluate whether PBM, when combined to exercises, provides incremental therapeutic benefits for pain, physical function, and quality of life (QoL) in patients with knee OA. METHODS: A six-month double-blind placebo-controlled randomized trial was conducted. Patients with knee OA were randomly assigned to one of three treatment groups: Exercise, Exercise plus Active PBM, or Exercise plus Placebo PBM. Treatment was provided over an eight-week period, three times per week. The primary outcomes were pain at rest and upon movement, assessed by a visual analogue scale (VAS). WOMAC global score, QoL, and a core-set of performance-based tests were measured as secondary outcomes. All outcomes were collected at baseline, immediately after treatment, and after three- and six-month post-treatment. RESULTS: 127 participants were allocated as follows: Exercise, N = 41; Exercise plus Active PBM, N = 44; and Exercise plus Placebo PBM, N = 42. There was no between-groups difference in improvement in pain, physical function, and QoL for all follow-up times. However, all groups presented significant, clinically relevant improvements in pain, physical function, and QoL immediately and three months after treatment compared with baseline measures. CONCLUSION: Patients with knee OA who received a strengthening exercises program did not experience incremental benefits regarding pain, physical function, or QoL when adding PBM to their therapeutic exercises.

Mobile health technologies for the management of spine disorders: A systematic review of mHealth applications in Brazil.

BACKGROUND: Spine disorders are conditions that affect a growing number of individuals, and mobile health (mHealth) applications (apps) offer potential to assist the self-management of these conditions. OBJECTIVES: To perform a systematic review of the availability of mHealth apps for patients with spine disorders at Brazilian online stores and evaluate the apps in terms of engagement, user interface, experience, and quality of the information. DESIGN: Systematic review. METHOD: A search for spine disorders mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 2021. Only smartphone apps in Brazilian Portuguese directed at spine disorders that provided information about education, counseling, exercise, or monitoring of patient health were included. The quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). RESULTS: Of the 2775 mHealth apps found, 10 were eligible for inclusion. All apps offered exercise programs. Three apps also offered tools to track patient-reported symptoms, nutritional orientation, or educational content in addition to the exercise program. Using MARS, the apps scored poorly in terms of quality, with an overall mean score ±standard deviation of 2.75 ± 0.63 on a scale of 1-5 points. Most apps scored poorly for credibility, user interface, and engagement. CONCLUSIONS: The mHealth apps for spine disorders currently available in Brazil are of poor quality and limited functionality. Effective collaboration between industry and researchers is needed to develop better user-centered mHealth apps that can empower patients with these conditions.

Effect of compression by elastic bandages on pain and function in individuals with knee osteoarthritis: protocol of a randomised controlled clinical trial.

INTRODUCTION: Although compression is used to control pain in knee osteoarthritis (KOA), its clinical application is poorly supported, and there is a lack of scientific evidence to support its clinical use. As a low-cost and accessible protocol, compression using elastic bands could be a non-pharmacological intervention to reduce pain and improve physical function in individuals with KOA. This study aims to evaluate the effects of compression on pain and function in individuals with KOA. METHODS AND ANALYSIS: A randomised controlled clinical trial will be conducted. Individuals with KOA (n=90; both sexes; between 40 and 75 years old) will be allocated to three groups (n=30/group): compression (compression by the elastic bandage on the affected knee, once a day for 20 min, on four consecutive days); sham (same protocol, but the elastic band is placed around the affected knee without compression) and control (no intervention). The individuals in the three groups will be evaluated 1 day before the first intervention, 1 day after the last intervention, and at the 12th and 24th weeks after the end of the intervention. Pain intensity by the Visual Analogue Scale and pain scale from Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) will be the primary outcomes. The secondary variables will be physical function assessed by the WOMAC questionnaire and physical tests (step test; 30 s sit and stand test; 40 m accelerated walk test). The Global Rating of Change Scale (GRC) will also be applied to quantify the volunteers' perceived change. ETHICS AND DISSEMINATION: The project was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (3955692). The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04724902.

Therapeutic ultrasound for knee osteoarthritis: A systematic review and meta-analysis with grade quality assessment.

BACKGROUND: Therapeutic ultrasound (US) is a widely used intervention in physical therapy to manage pain and to aid in the healing of soft tissue. OBJECTIVE: This systematic review aimed to determine the effects of therapeutic US on knee osteoarthritis (KOA) symptoms. METHODS: PubMed, MEDLINE, EMBASE, Google Scholar, and the Cochrane databases were searched from inception to April 2019. Randomized controlled trials (RCTs) involving adults with symptomatic KOA that compared therapeutic US with a sham or other control were included. The methodological quality of the trials was assessed at the study level using the Cochrane Risk of Bias tool. The quality of evidence at the outcome level- and overall- was assessed using GRADE methodology. Meta-analyses were conducted using random effects models, and heterogeneity was assessed using the I2 statistic. RESULTS: Four studies (N = 234 participants) were eligible for inclusion in our primary analyses assessing therapeutic US versus sham. The methodological quality of the included RCTs ranged from moderate to very low. Treatment with therapeutic US resulted in small, statistically significant benefits for pain (approximate 9.6% improvement on a 0-100 visual analog scale [95% confidence interval: 2, 17.4%]) and self-reported measures of function (approximate 12.8% improvement on a 0-100 visual analog scale [0.4, 25.2%]). The overall quality of the evidence was very low. No adverse events were reported in any of the included studies. CONCLUSIONS: The use of therapeutic US may provide additional benefits to physical therapy regimens in terms of symptom relief in individuals with KOA. However, it is not possible to make any meaningful recommendations for clinical practice due to the small number of applicable RCTs and the low methodological quality of the RCTs deemed eligible for this study.

Knee osteoarthritis: key treatments and implications for physical therapy.

BACKGROUND: Knee osteoarthritis (OA) is a chronic progressive disease that imparts a substantial socioeconomic burden to society and healthcare systems. The prevalence of knee OA has dramatically risen in recent decades due to consistent increases in life expectancy and obesity worldwide. Patient education, physical exercise, and weight loss (for overweight or obese individuals) constitute the first-line knee OA treatment approach. However, less than 40% of patients with knee OA receive this kind of intervention. There is an unmet need for healthcare professionals treating individuals with knee OA to understand the current recommended treatment strategies to provide effective rehabilitation. OBJECTIVE: To guide physical therapists in their clinical decision making by summarizing the safest and most efficacious treatment options currently available, and by delineating the most traditional outcome measures used in clinical research for knee OA. CONCLUSION: There is a need for healthcare providers to abandon low-quality and ineffective treatments and educate themselves and their patients about the current best evidence-based practices for knee OA.

Mobile health technologies for the management of urinary incontinence: A systematic review of online stores in Brazil.

BACKGROUND: Urinary incontinence (UI) is a serious condition for which often times insufficient non-surgical treatment options are provided or sought. Mobile health (mHealth) applications (apps) offer potential to assist with the self-management of UI. OBJECTIVE: To perform a systematic review of available mHealth apps for UI in Brazil. METHODS: A search for UI mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 4 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). RESULTS: Of the 1111 mHealth apps found, 12 were eligible for inclusion. Four offered exclusively exercise programs, six offered exercise and educational content, and two offered tools to track patient-reported symptoms. The included apps scored poorly on the MARS quality scale, with a mean ±â€¯standard deviation score of 2.7 ±â€¯0.6 on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement. CONCLUSION: Although there is growing interest in the development of mHealth technologies to support patients with UI, currently available tools in Brazil are of poor quality and limited functionality. Effective collaboration between industry and research is needed to develop new user-centered mHealth apps that can empower patients with UI.

Mobile health technologies for the management of rheumatic diseases: a systematic review of online stores in Brazil.

Rheumatic diseases are serious conditions with a low uptake of conservative treatments. Mobile health (mHealth) applications (apps) offer potential to assist the self-management of rheumatic diseases. Our goal was to perform a systematic review of available mHealth apps for rheumatic diseases in Brazil. We focused on the most prevalent rheumatic diseases: osteoarthritis, rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, osteoporosis, and axial spondylarthritis. Google Play Store and AppStore in Brazil were queried by two independent reviewers on September 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Of the 3173 mHealth apps found, five were eligible for inclusion. Two for fibromyalgia and two for axial spondylarthritis offered exercise, educational content, and tools to track patient-reported symptoms; and one for osteoporosis offered educational content and tracking tools only. The included apps scored moderately on the MARS quality scale, with a mean score (SD) of 3.1 (0.7) on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement. There is growing interest in the development of mHealth technologies to support rheumatic diseases patients. Although the majority of the included apps came from non-profit organizations, they are still of poor quality and limited functionality. This study is a call for to the development of new user-centered mHealth apps that can empower rheumatic diseases patients in Brazil, especially in the area of osteoarthritis, rheumatoid arthritis, and lupus, since no apps were found.

Patient-specific reference values for objective physical function tests: data from the Osteoarthritis Initiative.

INTRODUCTION/OBJECTIVE: We aimed to establish sex-specific reference values of objective physical function tests among individuals with or at risk for knee osteoarthritis (KOA) across subsets of age, radiographic KOA severity, and body mass index (BMI). METHOD: We included Osteoarthritis Initiative participants with data for objective physical function tests, sex, age, BMI, and radiographic KOA severity (Kellgren-Lawrence [KL] grade) at baseline. Objective physical function was quantified with 20-m walk speed, chair-stand speed, 400-m walk time, and knee extension and flexion strength. We created participant characteristic subsets for sex, age, KL grade, and BMI. Reference values were created as percentiles from minimum to maximum in 10% increments for each combination of participant characteristic subsets. Previously established clinically important differences for 20-m walk speed and knee extension strength were used to highlight clinically relevant differences. RESULTS: Objective physical function reference values tables and an interactive reference value table were created across all combinations of sex, age, KL grade, and BMI among 3860 individuals with or at risk for KOA. Clinically relevant differences exist for 20-m walk speed and knee extension strength between males and females across age groups, KL grades, and BMI categories. CONCLUSIONS: Establishing an individual's relative level of objective physical function by comparing their performance to individuals with similar sex, age, KL grade, or BMI may help improve interpretation of physical function performance. The interactive reference value table will provide clinicians and researchers a clinically accessible avenue to use these reference values.Key Points• Since greater age, radiographic knee osteoarthritis severity, and body mass index are all associated with worse objective physical function, reference values should consider the complex inter-play among these patient characteristics.• This study provides objective physical function reference values among subsets of individuals across the spectrum of sex, age groups, radiographic knee osteoarthritis severity, and body mass index categories.• These reference values offer a more patient-centered approach for interpreting an individual's relative level of objective physical function by comparing them to a more homogeneous group of individuals with similar participant characteristics.• We have provided a clinically accessible interactive table that will enable clinicians and researchers to input their patient's data to quickly and efficiently determine a patient's relative objective physical function compared to individual's with similar characteristics.

Short-term cryotherapy did not substantially reduce pain and had unclear effects on physical function and quality of life in people with knee osteoarthritis: a randomised trial.

OBJECTIVE: Does short-term cryotherapy improve pain, function and quality of life in people with knee osteoarthritis (OA)? DESIGN: Randomised controlled trial with concealed allocation, blinded assessment of some outcomes, and intention-to-treat analysis. PARTICIPANTS: People living in the community with knee OA. INTERVENTIONS: The experimental group received cryotherapy, delivered as packs of crushed ice applied to the knee with mild compression. The control group received the same regimen but with sham packs filled with sand. The interventions were applied once a day for 4 consecutive days. OUTCOME MEASURES: Participants were assessed at baseline and on the day after the 4-day intervention period. The primary outcome was pain intensity according to a visual analogue scale. Secondary outcomes were baseline to post-intervention changes according to the Western Ontario and McMaster Universities Osteoarthritis, Knee injury and Osteoarthritis Outcome; Timed Up and Go test; and 30-Second Chair to Stand test. RESULTS: Sixty participants were randomised into the experimental group (n = 30) or the control group (n = 30). Twenty-nine participants from each group completed the trial. The mean between-group difference in change in pain severity was -0.8 cm (95% CI -1.6 to 0.1), where negative values favour the experimental group. This result did not reach the nominated smallest worthwhile effect of 1.75 cm. The secondary outcomes had less-precise estimates, with confidence intervals that spanned worthwhile, trivial and mildly harmful effects. CONCLUSION: Short-term cryotherapy was not superior to a sham intervention in terms of relieving pain or improving function and quality of life in people with knee OA. Although cryotherapy is considered to be a widely used resource in clinical practice, this study does not suggest that it has an important short-term effect, when compared with a sham control, as a non-pharmacological treatment for people with knee osteoarthritis. REGISTRATION: NCT02725047.

Neuromuscular electrical stimulation in critically ill traumatic brain injury patients attenuates muscle atrophy, neurophysiological disorders, and weakness: a randomized controlled trial.

BACKGROUND: Critically ill traumatic brain injury (TBI) patients experience extensive muscle damage during their stay in the intensive care unit. Neuromuscular electrical stimulation (NMES) has been considered a promising treatment to reduce the functional and clinical impacts of this. However, the time needed for NMES to produce effects over the muscles is still unclear. This study primarily aimed to assess the time needed and effects of an NMES protocol on muscle architecture, neuromuscular electrophysiological disorder (NED), and muscle strength, and secondarily, to evaluate the effects on plasma systemic inflammation, catabolic responses, and clinical outcomes. METHODS: We performed a randomized clinical trial in critically ill TBI patients. The control group received only conventional physiotherapy, while the NMES group additionally underwent daily NMES for 14 days in the lower limb muscles. Participants were assessed at baseline and on days 3, 7, and 14 of their stay in the intensive care unit. The primary outcomes were assessed with muscle ultrasound, neuromuscular electrophysiology, and evoked peak force, and the secondary outcomes with plasma cytokines, matrix metalloproteinases, and clinical outcomes. RESULTS: Sixty participants were randomized, and twenty completed the trial from each group. After 14 days, the control group presented a significant reduction in muscle thickness of tibialis anterior and rectus femoris, mean of - 0.33 mm (- 14%) and - 0.49 mm (- 21%), p < 0.0001, respectively, while muscle thickness was preserved in the NMES group. The control group presented a higher incidence of NED: 47% vs. 0% in the NMES group, p < 0.0001, risk ratio of 16, and the NMES group demonstrated an increase in the evoked peak force (2.34 kg/f, p < 0.0001), in contrast to the control group (- 1.55 kg/f, p < 0.0001). The time needed for the NMES protocol to prevent muscle architecture disorders and treat weakness was at least 7 days, and 14 days to treat NED. The secondary outcomes exhibited less precise results, with confidence intervals that spanned worthwhile or trivial effects. CONCLUSIONS: NMES applied daily for fourteen consecutive days reduced muscle atrophy, the incidence of NED, and muscle weakness in critically ill TBI patients. At least 7 days of NMES were required to elicit the first significant results. TRIAL REGISTRATION: The trial was registered at ensaiosclinicos.gov.br under protocol RBR-8kdrbz on 17 January 2016.

The effects of neuromuscular electrical stimulation on strength, pain, and function in individuals with knee osteoarthritis: a systematic review with meta-analysis / Efeitos da estimulação elétrica neuromuscular na força, dor e função em indivíduos com osteoartrite de joelho: uma revisão sistemática com meta-análise / Efectos de la electroestimulación neuromuscular sobre la fuerza, el dolor y la función en personas con osteoartritis de la rodilla: una revisión sistemática con metaanálisis

ABSTRACT We aimed to investigate the effects of neuromuscular electrical stimulation on muscle strength, pain relief, and improvement in function in patients with knee osteoarthritis. Databases were searched from December 2017 to July 2020 and included PubMed, Embase, LILACS, and the Cochrane Central Register of Controlled Trials. A manual search was also performed by checking the reference lists of eligible articles. The PRISMA guidelines were followed. The studies selected compared NMES with an exercise program on isometric muscle strength as a primary outcome. The secondary outcomes were pain and function. The quality of the studies was assessed using the Risk of Bias assessment and PEDro scale, and the overall quality of the evidence was assessed using the GRADE approach. Eight studies were included in this systematic review. A total of 571 patients were analyzed. Neuromuscular electrical stimulation associated with exercise promoted an increase in isometric strength of the quadriceps muscle compared to the active control group, demonstrating heterogeneity and statistical difference (95% CI=1.16 to 5.10, I2=97%, p=0.002; very low-certainty evidence). NMES associated with exercise did not improve physical function (95% CI=−0.37 to 0.59, I2=0%, p=0.67; low-certainty evidence) and showed controversial results for pain compared to an active control group (qualitative assessment). In conclusion, NMES induces an increase in muscle strength in patients with osteoarthritis compared to an active control group. No differences were found for physical function and pain outcomes. Further research is needed due to the uncertain level of evidence.

RESUMO O objetivo deste estudo foi investigar os efeitos da estimulação elétrica neuromuscular (EENM) na força muscular, alívio da dor e melhora da função em pacientes com osteoartrite de joelho. Realizou-se uma pesquisa em diferentes bases de dados, como PubMed, Embase, LILACS e o Cochrane Central Register of Controlled Trials, no período de dezembro de 2017 até julho de 2020. Procedeu-se a uma busca manual com o intuito de verificar as listas de referências dos artigos elegíveis. As diretrizes PRISMA foram seguidas. Os estudos selecionados comparavam a estimulação elétrica neuromuscular com um programa de exercícios de força muscular isométrica como desfecho primário. Os resultados secundários foram dor e função. A qualidade dos estudos foi avaliada usando avaliação de risco de viés e a escala PEDro e a qualidade geral das evidências foi avaliada usando a abordagem GRADE. Oito estudos foram incluídos nesta revisão sistemática com um total de 571 pacientes analisados. A EENM associada ao exercício promoveu o aumento da força isométrica do músculo quadríceps em relação ao grupo controle ativo, demonstrando heterogeneidade e diferença estatística (IC 95%=1,16 a 5,10, I2=97%, p=0,002; evidência de muito baixa certeza), mas não melhorou a função física (IC 95%=−0,37 a 0,59, I2=0%, p=0,67; evidência de baixa certeza) e mostrou resultados controversos para dor em comparação ao grupo de controle ativo (avaliação qualitativa). Conclui-se que a EENM induz o aumento da força muscular em pacientes com osteoartrite, porém não foram encontradas diferenças nos resultados de funcionalidade e dor em comparação com o grupo de controle ativo. Devido à incerteza das evidências, são necessárias mais pesquisas sobre o assunto.

RESUMEN El objetivo de este estudio fue analizar los efectos de la electroestimulación neuromuscular (NMES) sobre la fuerza muscular, el alivio del dolor y la mejora de la función en pacientes con osteoartritis de la rodilla. Se realizó una búsqueda en las bases de datos PubMed, Embase, LILACS y Cochrane Central Register of Controlled Trials, en el periodo de diciembre de 2017 y julio de 2020. Se llevó a cabo una búsqueda manual para verificar las listas de referencias de los artículos elegibles. Se aplicó las pautas PRISMA. Los estudios seleccionados compararon la electroestimulación neuromuscular con un programa de ejercicio de fuerza muscular isométrica como resultado primario. Los resultados secundarios fueron el dolor y la función. La calidad de los estudios se evaluó mediante la evaluación del riesgo de sesgo y la escala PEDro, y la calidad general de la evidencia se estimó con el uso del sistema GRADE. Ocho estudios con un total de 571 pacientes compusieron esta revisión sistemática. La EENM asociada con el ejercicio aumentó la fuerza isométrica del músculo cuádriceps en comparación con el grupo control activo, demostrando una heterogeneidad y diferencia estadística (IC 95%=1,16 a 5,10, I2=97%, p=0,002; evidencia con muy baja seguridad), pero no mejoró la función física (IC 95%=−0,37 a 0,59, I2=0%, p=0,67; evidencia con baja seguridad) y mostró resultados controvertidos para el dolor en comparación con el grupo control activo (evaluación cualitativa). Se concluyó que la EENM indujo un aumento de la fuerza muscular en pacientes con osteoartritis, pero no se encontraron diferencias en los resultados de función y dolor en comparación con el grupo control activo. Debido a la incertidumbre de la evidencia, se necesitan más estudios sobre el tema.