|Year : 2020 | Volume
| Issue : 2 | Page : 121-128
A Comparative Study of Pain Control and Early Rehabilitation after Total Knee Replacement: Local Wound Infiltration versus Epidural Bupivacaine in the Immediate Postoperative Period
M Jonathan Reddy, Shaik Waseem Md. Ahmed, IV Reddy
Department of Orthopaedics, Krishna Institute of Medical Sciences Hospital, Secunderabad, Telangana, India
|Date of Submission||08-Jan-2020|
|Date of Acceptance||18-Mar-2020|
|Date of Web Publication||28-Dec-2020|
Dr. M Jonathan Reddy
Department of Orthopaedics, Krishna Institute of Medical Sciences Hospital, Minister Road, Secunderabad - 500 003, Telangana
Source of Support: None, Conflict of Interest: None
Aim: To study the efficacy and safety of a periarticular analgesic cocktail injection for early rehabilitation after total knee replacements. Patients and Methods: One hundred patients who are included for TKR were posted for unilateral total knee arthroplasty. This prospective randomized controlled study compared pain relief and functional recovery in immediate postoperative patients (initial 72 h) of total knee replacement where one group of patients are given local analgesia and the other group are given epidural analgesia. The patients were randomized into two arms by block randomization. In one arm, the patients received epidural analgesia for 48 h postoperatively. In the other arm, the patients received periarticular injection of an anesthetic cocktail of drugs. Results: The pain relief on the day of surgery (day 1) was significantly better in patients who received pericapsular injection as compared to those who used the epidural injection for postoperative pain relief. The postoperative range of motion and the distance walked in on the day of suture removal (day 14) was marginally better in the epidural group though the difference was not significant. Side effects including nausea, vomiting, pruritus, urinary retention, and respiratory depression were significantly higher in the epidural group as compared to those who received the analgesic cocktail injection. Conclusion: Patients who received epidural infusion for postoperative pain control required more medications as supplements, as evidenced by higher incidence of bolus injections/increased infusion rates/tramadol injections. There were no surgical site infections in either group.
Keywords: Epidural injection, pain scale, total knee arthroplasty
|How to cite this article:|
Reddy M J, Ahmed SW, Reddy I V. A Comparative Study of Pain Control and Early Rehabilitation after Total Knee Replacement: Local Wound Infiltration versus Epidural Bupivacaine in the Immediate Postoperative Period. J Orthop Traumatol Rehabil 2020;12:121-8
|How to cite this URL:|
Reddy M J, Ahmed SW, Reddy I V. A Comparative Study of Pain Control and Early Rehabilitation after Total Knee Replacement: Local Wound Infiltration versus Epidural Bupivacaine in the Immediate Postoperative Period. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Jan 26];12:121-8. Available from: https://www.jotr.in/text.asp?2020/12/2/121/305079
| Introduction|| |
Managing postsurgical pain after total knee arthroplasty (TKA) is challenging but critical to successful surgical outcomes, including patient recovery and rehabilitation and overall satisfaction. Postoperative pain after TKA is a major concern to patients and the best technique to control pain is still controversial.
Clinical practice guidelines recommend multimodal, therapy combining preoperative, intraoperative, and postoperative medications, such as opioids, nonsteroidal anti-inflammatory drugs, gabapentin, pregabalin, and local anesthetics. Adequate pain relief is essential for early mobilization and good functional recovery.
Arun Mullaji in 2009 reviewed the effectiveness of a mixture of opioid, corticosteroid, and a local anesthetic for periarticular injections in patients undergoing bilateral TKR. They injected one of the two knees with the anesthetic cocktail. They reported significantly lower pain scores and better quadriceps recovery on the side that had the periarticular injection of the anesthetic cocktail, as compared to the side that did not have the injection.
Thorsell et al. in their comparative study on TKA patients using local infiltration anesthesia (LIA) technique with ropivacaine, ketorolac, and adrenaline to epidural anesthesia reported earlier mobilization in the group treated with local infiltration technique. They concluded that this technique also offered better patient satisfaction and hence was better for postoperative pain relief than epidural anesthesia.
Spreng et al. compared the efficacy of LIA and epidural anesthesia in TKA patients and reported that epidural anesthesia provided better pain relief in the immediate postoperative period, whereas local infiltration anesthesia provided better pain relief after the initial 24 h. Epidural anesthesia was associated with side effects as hypotension. Local infiltration group were mobilized faster and had showed better knee function and shortened hospital stay.
Sean et al. compared the effect of steroids in the periarticular infiltration solution and reported that the group which received the steroid reported lower pain scores, lesser morphine consumption, and early discharge.
Scott et al. evaluated the effect of local periarticular infiltration on the incidence of heterotopic ossification seen after hip replacement and also on the opioid requirement postoperatively. They reviewed 118 cases without periarticular infiltration and 211 with periarticular infiltration. They inferred that heterotopic ossification was not reduced by the use of periarticular infiltrations, but they reduced the usage of opioids and reduced the length of hospital stay.
Yuenyongviwat et al. in 2012 evaluated the efficacy of bupivacaine alone when used for periarticular injections for pain control in patients undergoing total knee arthroplasty and reported that it provided effective pain control, lesser complications and reduced consumption of morphine.
Tammachote et al. compared the pain control effect of intrathecal morphine and multimodal drug injections in patients undergoing TKA. They found that, 12–16 h postoperatively, the intrathecal group consumed significantly more ketorolac and that the side effects of nausea and vomiting were also more in this group compared to the group treated with multimodal drug injections.
Crowley et al. in 2012 reviewing 843 patients concluded that the studies that compared femoral nerve blocks to placebo or epidural injections failed to show any reduction in the length of hospital stay.
Gibbs et al. reported that though the local anesthetic infiltrations were associated with more pain control, there was no evidence that this modality of treatment reduced the hospital stay.
Wylde et al. in their study determined the effect of local infiltration of a local anesthetic to reduce postoperative pain in osteoarthritis patients undergoing total hip replacement and total knee replacement surgeries and suggested that the chronic pain experienced by the patient postoperatively may be related to acute postoperative pain.
Lamplot et al. in a study of a randomized RCT on multimodal pain management in TKA showed that the multimodal group had lower VAS scores, fewer adverse effects, lower narcotic usage, higher satisfaction scores, and earlier times to physical therapy milestones. They concluded that multimodal pain management protocol decreases narcotic usage, improves pain scores, increases satisfaction, and enhances early recovery.
Spangeh et al. in a study showed that patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks.
Stathellis et al. in a study showed that pericapsular injections combined with an intra-articular catheter provide better pain control, no rebound pain with better function, and might decrease the risk of complications related to motor weakness.
Mont et al. showed that liposomal IA with LB significantly improved postsurgical pain, opioid consumption, and time to first opioid rescue, with more opioid-free patients and no unexpected safety concerns.
Schumer et al. demonstrated that liposomal bupivacaine utilization in total knee replacement did not decrease length of hospital stay. Liposomal bupivacaine will be used as replacement for femoral nerve blocks.
Relief of pain and functional recovery will be monitored postoperatively in both the groups and compared using the standard statistical methods as will be discussed later.
Current study designed to assess the reduction of pain during the immediate postoperative period, and comparing the outcome to the current treatment regimes which are being used to control pain in our setup, i.e., epidural infusion of bupivacaine.
| Patients and Methods|| |
Type of study
It is a prospective randomized controlled study comparing pain relief and functional recovery in immediate postoperative patients (initial 72 h) of total knee replacement where one group of patients are given local analgesia and the other group are given epidural analgesia.
Setting: The study was conducted in the Department of Orthopaedics in Krishna Institute of Medical Sciences, Secunderabad, in unit-1 under Dr. I. V. Reddy. Patients who are booked for TKR were assessed preoperatively in orthopedic outpatient department and explained about the study in detail and were given an information sheet for clarifications. Informed valid consent was taken. Patients were then admitted and were posted for unilateral TKA.
Study duration: November 2017 to November 2018.
Patients undergoing unilateral TKRAge group 40–80 years.
- Bilateral TKR
- Revision TKR
- Elderly >80 years
- History of arrhythmia/cardiac complications
- Chronic kidney disease
- Those not willing to give consent.
Sample size calculation
The mean (standard deviation [SD]) of the pain scale on a 10 point Likert scale, currently is about 4 (SD = 1.5). Keeping the noninferiority margin at 1.5 with alpha and beta errors at 5% and 20%, respectively, the sample size needed was 12 subjects in each arm.
| Method|| |
New clinically diagnosed cases and controls were recruited for the study. Patients were explained about the study in detail and patient information sheet was given to the patient. Informed valid consent was obtained from patients who were willing to participate in the study. The pro forma for the study was filled in the outpatient department and patient details were obtained. History of diabetes mellitus and rheumatoid arthritis if any was taken. Parameters such as walking distance, aids used, preoperative pain score (using the 11 point Numeric Pain Score for pain), and analgesics used were noted.
Preoperative knee assessment was done using knee society score. Range of movement was measured preoperatively. Extensor lag if any was also noted. X-rays were reviewed and the deformity present documented.
The patients were randomized into two arms by block randomization. In one arm, the patients received epidural analgesia for 48 h postoperatively. In the other arm, the patients received periarticular injection of an anesthetic cocktail of drugs.
All total knee replacement surgeries are carried out in our main operation theatre complex with laminar flow facility. Surgery was performed under (general anesthesia + pericapsular anesthetic cocktail injection or spinal + epidural anesthesia as per the randomization protocol. In all cases, the standard surgical procedure for knee replacement was carried out by the same senior consultant.
Tranexamic acid 10–15 mg/kg – 3 doses was injected intravenously for control of blood loss starting approximately 15 min before tourniquet release. Two further doses at 3 h interval were also given subsequently. This was used for all patients in this study.
A tourniquet was used for all patients, and it was set to a pressure between 300 mm of Hg (Mercury) and 350 mm of Hg depending on the patients' blood pressure (BP) (With pressure equal to the systolic BP of each patient plus 150 mm Hg) before skin incision and deflated before wound closure.
The implant used included posterior stabilized and cruciate retaining knees, from 2 companies – Genesis II (Smith and Nephew, Memphis, TN, USA) and PFC Sigma (DePuy, Johnson and Johnson, Warsaw, IN, USA).
Pericapsular cocktail of anesthetic drugs used for pain control includes:
- Injection ropivacaine 0.75%-1 ampule
- Injection adrenaline ½ CC (0.5 mg of 1:1000)
- Injection morphine ½ CC (5 mg)
- Injection ketorolac 1 ampoule (30 mg)
- Distilled water of 50 ml are mixed as a cocktail.
All the ampules and vials containing the above medications are immersed in sterillium.
And, the contents are transferred into a sterile bowl by one of the member of surgical team using aseptic precautions and are later drawn into a 50 ml syringe by the scrub nurse.
The first 30 ml of the cocktail mixture was injected into the posterior knee capsule and soft tissue around the medial and lateral collateral ligaments before implantation of the actual components. The quadriceps muscle, retinacular tissues, pes anserinus, and suprapatellar and infrapatellar fat pat were then infiltrated with the rest of the cocktail while the cement was setting.
The 2nd arm received analgesia via an epidural line. The epidural infusion was given using an infusion pump with 0.1% Bupivacaine given @4–6 ml/h for the first 48 h postoperatively. The dosage was increase if pain was not controlled. The increase in flow rate was noted, as was any bolus injections for additional pain control.
The common complications encountered in this technique include infections, hematoma, vascular puncture, and nerve injury. The patient will not have weight-bearing capacity on the blocked extremity. This has to be explained to the patient to avoid the risk of falls.
Dosage of epidural infusion given in the postoperative period was noted as well as any changes in the flow rates and any extra tramadol/epidural bolus for breakthrough pain relief if any were also documented. For those who got pericapsular injections, the extra boluses of Tramadol were noted for breakthrough pain.
Postoperative physiotherapy schedule
All patients were encouraged to perform foot pump exercises in bed and encouraged to do straight leg raise (SLR) from the day 1 of the surgery.
Days to do active SLR in the supine position and lag on supine were documented. On the 2nd day, they were encouraged to sit with the legs out of the bed, and do active quadriceps strengthening.
Amount of knee flexion possible and the lag on extension when sitting from the second postoperative day were also documented.
Later, all were encouraged to walk with a walker after the drain was removed. They were started on active and passive range of movement exercises by sitting at bedside.
Number of days taken to walk 50 m was documented.
The distance walked in 6 min with a walker was recorded on the 14th postoperative day. Perioperative complications if any were also documented.
The data were analyzed using a repeated-measure ANOVA to compare the amount of morphine consumption, neuropathic pain scale for pain, range of movement, and postoperative functional rehabilitation capability.
| Results|| |
A total of 100 patients were included in the study. One of the patients was excluded due to protocol deviation (the epidural pump got pulled away hence pain was controlled with injection tramadol 50 mg given).
None discontinued from the study. All consented for the study.
Diagnosis: They comprised 21 osteoarthritis, four rheumatoid arthritis and one gouty arthritis. Osteo arthritis formed the major part of the control study group forming (81% of the study). The other arthritis knees studied were rheumatoid and gouty arthritis.
Type of analgesia
In the patients, 49 had epidural infiltration and 50 had analgesic cocktail. Analgesic cocktail was given in osteoarthritic knees and no other knees.
There were 43 males and 56 females with females forming 57% of the study population. Of this 22 males and 27 females had epidural. Twenty-one males and 29 females had pericapsular injection of the cocktail [Table 1].
Middle aged people formed most of the study group. The mean age of the study population was 58 years. The mean age of those patients who received epidural infiltration was 56 years and that of the analgesic cocktail was 59 years. The lowest age group studied being 41 years and the oldest being 71 years.
The chief presenting complaint of all the patients in the study group was pain and deformity though the duration was variable. Other symptoms were difficulty in doing activities of daily living, stiffness and locking. The duration of deformity and pain were variable.
Left knees were seen more commonly affected than the right. Sixty-eight knees of the 99 knees studied were left and the rest were right. Of the studied, 32 left knees and 17 right knees were given epidural infiltration and 36 left and 14 right knees had analgesic cocktail.
The prevalence of diabetes in this study population was 34%. Thirty-four out of 99 patients had diabetes. Eighteen out of 34 had epidural and the rest analgesic cocktail with no statistical significance (P = 0.093).
The mean walking distance of the study group before surgery was 609 m in total. The mean walking distance for the epidural group was 413 m and of the analgesic cocktail group 777 m. Walking distance in comparison was much more affected among the epidural group than the cocktail group indicating a severe disease process but was not significant statistically (P = 0.649).
Forty-two percent of the study population used some kind of support for ambulation before surgery. Among the epidural group 50% did not use any aid for walking. One of the patients was wheel chair bound and another used the support of two people while taking steps. The rest used a walking stick for support. Among the analgesic cocktail group 27 out of 50 did not use any aid. The rest 23 used a walking stick. On analysis both the groups were equal on aid usage and there wasn't any statistical significance (P = 0.629).
Preoperative pain score
Average preoperative pain score of the epidural group was 6.25 compared to 5.4 in the analgesic cocktail. The maximum pain experienced by the epidural group was ten and of the analgesic cocktail was nine. The minimum pain score was two and zero. There was no significant statistical difference in the preoperative pain scores between the two groups on analysis (P = 0.494) [Figure 1] and [Figure 2].
50% of epidural group used pain killers for pain control as a daily basis for activities of daily living while 36% in the analgesic cocktail group. The rest 50% in the epidural and the 64% in the analgesic cocktail did not use any kind of analgesic medications for ambulation, even though few used pain killers as SOS basis for severe pain (8 out of 49 in epidural and 14 out of 50 in analgesic cocktail. The difference in the usage of pain killers was significant (P = 0.04) [Table 2] and [Table 3].
|Table 3: The different implants and the different type of knee component used and the analgesia given|
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Knee society score
Knee society score has two components: knee score and functional score. This was assessed for all the study subjects. The mean average score of the study subjects were 50. The score of the analgesic cocktail being higher than the epidural group. The analgesic cocktail had a score of 53 when compared to 46 for the epidural group. The mean average functional score was 53 for the whole study group. Both the scores were marginally better in the analgesic cocktail group, but the difference was not statistically significant (P = 0.306) [Table 3] and [Table 4].
Preoperative range of movement was better in epidural but was not significant statistically (P = 0.315).
The implant used included PS and CR knees, from 2 companies, Genesis II (Smith and Nephew, Memphis, TN, USA) and PFC Sigma CR fixed bearing (DePuy, Johnson and Johnson, Warsaw, IN, USA). In the epidural group 32 had PFC and 17 had Genesis II while in the analgesic cocktail group 32 had PFC and 18 Genesis II implants. Of this 32 in the epidural and 36 in the analgesic cocktail had cruciate retaining and 17 in the epidural and 14 in the analgesic cocktail had posterior stabilized type of knees [Table 5].
The mean score on the 1st day in the epidural was 7 and in the analgesic cocktail group it was 3.6. On the 2nd day and 3rd day, it was 4.3 and 3.2 and 3.8 and 3 out of ten respectively. On the 14th day, this almost became equal with the values being 2.4 and 2.7 respectively. The range in the epidural group on the 1st day was 1–10 with 13 out of 49 experiencing the maximum score of 10 while this was 0–9 in the analgesic cocktail and only 3 had the maximum pain score of nine. On the 2nd and 3rd days, this was 2–9 and 0–6 and 2–8 and 0–6, respectively. On the day of suture removal, this was 1–4 and 0–6 out of ten in the numerical pain score. This points to the fact that in the initial days analgesic cocktail has a better pain control and as the days go by the pain equals in both the groups.
In the group receiving epidural, first choice on having pain is increasing the dosage of epidural either giving as a bolus or the rate of infusion is increased. In the epidural group, 18 patients received injection tramadol (Total of 2500 mg), 24 had epidural top up (4–7 ml/h), and 7 had epidural bolus (Total of 24 mg). In two patients, the epidural pump was not working and to these bolus/top up and injection tramadol were all used. One of the patients in this group, the epidural was continued for 36 h due to severe pain. One of the patients had the epidural line coming out while turning on the second postoperative day. In the cocktail group seven had received injection tramadol (total of 500 mg).
Range of movement at time of discharge
There was not any marked difference in the range of movement at the time of suture removal with the mean range of movement in the epidural group being 97 degrees when compared to 93° in the analgesic cocktail group.
Lag on supine straight leg raising
33% in the epidural and 43% in the analgesic cocktail group were able to do straight leg raising without on the first postoperative day. Another 16% in epidural and 19% in the analgesic cocktail were able to do it on the 2nd day. The number of patients able to do it on third in the analgesic cocktail group was 12.5% while this in the epidural group was 8.5% [Figure 3],[Figure 4],[Figure 5].
|Figure 3: Bar diagram showing the preoperative lag in the sitting posture and the analgesia given|
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|Figure 4: Bar diagram showing the visual analog score during the first postoperative days and the analgesia given|
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|Figure 5: Lag on supine straight leg rising without the help of the brace plotted against the time period in days of both the groups|
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Number of days taken to walk 50 m without brace
Fifty percent of the epidural study group could walk 50 m on the 3rd day. Fifty-seven percent in the pericapsular group walked 50 m on the 3rd day.
The time taken to walk 50 m was less in the pericapsular group, though the difference was not statistically different (3.57 days vs. 4.17 days).
Distance walked in 6 min on day 14
The mean distance walked on the day of suture removal (14th postoperative day) for the epidural group was 142.5 m and for the analgesic cocktail it was 135 m. This difference was not statistically significant (P = 0.796) [Table 5] and [Table 6].
| Discussion|| |
Our study was aimed at studying comparing the efficacy of periarticular infiltration of a cocktail of drugs and epidural analgesia in controlling pain and enabling early functional recovery after TKA for those patients presenting to a tertiary hospital with degenerative arthritis.
A total of 100 patients were included in the study. One of the patients was excluded due to protocol deviation. 49 patients were in epidural arm and 50 in pericapsular arm.
In the epidural arm, the mean age was 56 years and in pericapsular arm it was 59 years. There were 45% males and 55% females in epidural group and42% males and 58% females in pericapsular group.
Preoperative functional score (KOSS)
In epidural group KOSS was 45.83 and 59.29 in the pericapsular group.
Preoperative pain score
Average preoperative pain score of the epidural group was 6.25 compared to 5.4 in the analgesic cocktail.
Knee society score
The analgesic cocktail had a score of 53 when compared to 46 for the epidural group.
Pain score on the day of surgery
In the epidural pain score was 7.17 and 3.57 in the periarticular group on the day of surgery.
The study shows that the periarticular infiltration is significantly better than the epidural injection in the first 24 h after the surgery. Even after the first 24–48 h, when we would expect the analgesic effect of the injection to wear out, the pain scores were consistently less in the periarticular injection group than in the epidural group. Functional ability in the first 24 h was also significantly better in the periarticular injection group.
An additional advantage of the periarticular injection over the epidural anesthesia is the reduced incidence of side effects like nausea, vomiting and pruritus. Additionally, mobilization is easier, as there are no catheters restricting the patient.
This study was inspired by the local infiltration analgesia technique developed by Kerr and Kohan. Our findings are consistent with the results of following 3 randomized controlled trials by Busch et al. Vendittoli et al. and Toftdahl et al. in knee arthroplasty in which patients received either peri- or intra-articular treatment or patient-controlled analgesia with opioid or femoral nerve blocks. All 3 studies showed reduced postoperative pain and opioid requirements.
Similarly a study by Mullaji et al. on the effectiveness of a mixture of opioid, corticosteroid and a local anesthetic for periarticular injection in patients undergoing bilateral TKR showed significantly lower pain scores and better quadriceps recovery on the side that had periarticular injection of the anesthetic cocktail, as compared to the side that did not have the injection.
Tammachote et al. compared the pain control effect of intrathecal morphine and multimodal drug injections in patients undergoing TKA. They found that though initially there was no difference between the two modalities, 12–16 h postoperatively, the intrathecal group consumed significantly more Ketorolac and that the side effects of nausea and vomiting was also more in this group compared to the group treated with multimodal drug injections.
As mentioned previously, some studies of LIA with Bupivacaine in TKA have reported positive results to LIA and some neutral or negative.
These disparities may be partly attributable to differences in study design and methodology, including infiltration techniques. For example, the neutral results reported by Amundson et al., could reflect several methodological factors, including nonequivalence of the bupivacaine HCl dose in the epidural (75 mg) and control groups (150 mg), which may have led to greater initial pain in the epidural versus control group, and an inability to “catch up” pain control at later periods (data were not stratified by time periods). Other limitations included use of a suboptimal infiltration volume, assessment of pain scores at discrete time points, and lack of opioid minimization. Similar limitations related to infiltration techniques (including partial infiltration, overly large gauge needle, no bupivacaine HCl bridging) in Amundson et al., Alijanipour et al., and Meneghini et al., pain assessment or primary outcome and opioid minimization are evident in other previous studies reporting negative or neutral findings.,,
In the remaining hospital stay as well the level of analgesia was significantly better for. Early functional recovery was possible with periarticular injection. The reason for the prolonged beneficial effect of the periarticular injection has not been fully explained by other investigators. Several theories have been postulated. It is possible that due to the good reduction in pain in the immediate postoperative period, the neural sensitization is minimized. The steroid in the cocktail could also have a role in reducing the inflammatory pain postoperatively. In both groups, adequate control of pain provided the patient an opportunity to participate in the physiotherapy program at an early stage and attain functional independence within 3–4 days.
| Conclusion|| |
The pain relief on the day of surgery (day 1) was significantly better in patients who received pericapsular injection as compared to those who used the epidural injection for postoperative pain relief. The Range of motion on day 2 and day 3 is found to be better in Pericapsular injection group but statistically not significant. The postoperative range of motion and the distance walked in on the day of suture removal (Day 14) was marginally better in the epidural group-though the difference was not significant.
Patients who received epidural infusion for postoperative pain control required more medications as supplements, as evidenced by higher incidence of bolus injections/increased infusion rates/tramadol injections (the difference being not significant). Side effects including nausea, vomiting, pruritus, urinary retention, and respiratory depression were significantly higher in the epidural groups compared to those who received the analgesic cocktail injection. There were no surgical site infections in either group.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]