Royal Hallamshire Hospital Research Articles

UNVEILING THE VEIN

Cerebrospinal fluid (CSF)-venous fistula represents a formidable yet often overlooked neurosurgical dilemma. Despite its disabling consequences, it remains significantly underdiagnosed. This abstract sheds light on the clinical intricacies, diagnostic challenges, and therapeutic interventions associated with CSF-venous fistula. Early diagnosis is paramount, yet hindered by its rarity and diverse and often unspecific clinical presentations. The importance of heightened awareness among clinicians and radiologists for timely detection and management cannot be overstated. This presentation will draw upon a review of clinical cases operated in the Royal Hallamshire Hospital, supplemented by a concise surgical video which is focused on surgical technique and benefit of microscope mediated augmented reality.

ADVANCING PRECISION

Augmented reality (AR) technology is revolutionizing spine surgery, offering unprecedented intraoperative image guidance and enhancing patient safety, particularly in complex procedures. This presentation explores the expanding applications of AR in spinal surgery, highlighting recent technological advances that have transformed surgical practices. In addition to improving surgical precision and accuracy, AR provides real-time visualization of critical anatomical structures, aiding in navigation and decision-making during intricate spinal procedures. This presentation will delve into the benefits that AR brings compared to classical techniques, including enhanced visualization, improved spatial awareness, and reduced radiation exposure for both patients and surgical teams. By overlaying virtual information onto the surgeon’s view of the patient, AR facilitates a more intuitive understanding of complex spinal anatomy and pathology, leading to optimized surgical outcomes. Furthermore, this session will cover the diverse applications of AR in a range of spinal conditions operated in Royal Hallamshire Hospital, Sheffield, UK - including spinal tumors, calcified disc herniation, spinal CSF-venous fistula etc. By showcasing the benefits of AR technology across various pathologies, this presentation aims to underscore its transformative potential in advancing spinal surgical care.

DNAR-05. VALIDATING THE ERK5 PROTAC OS11 AS A POTENTIAL NOVEL THERAPEUTIC INEX VIVO GLIOMA STEM CELL MODELS OF INTRATUMOURAL HETEROGENEITY AND RESIDUAL DISEASE

Abstract Glioblastoma is a grade IV brain tumour with poor survival rates of 15 months post-diagnosis, and 5-year survival rates of 10%. Limited progress over the past 40 years to improve the current treatment regimen of surgery and chemo-/radio-therapy are mainly due to tumour heterogeneity that drive resistance mechanisms. The persistence of glioma stem-like cells (GSCs) sub-populations, particularly within post-surgical residual tumour tissue. ERK5 is an emerging oncology drug target that we previously highlighted as a potential target for combined therapy with temozolomide (TMZ) in glioblastoma due to heightened ERK5 expression, which is associated with poor survival. This current project aims to expand on our previous findings by establishing whether targeting ERK5 can sensitise glioblastoma cells to TMZ using primary derived ex vivo GSC models of intratumor heterogeneity and residual disease. Primary GSC models were derived from patients at the Royal Hallamshire Hospital. The PROTAC OS11 (CRUK & University of Manchester) was used to degrade ERK5. DNA damage and cell survival were evaluated following treatment of TMZ alone and in combination with OS11. Consistent with our findings in established glioma cell lines, OS11 was able to robustly degrade ERK5 in a 3D GSC model for at least 72hrs. Combining OS11 and TMZ in GSCs led to a significant increase in DNA damage, with MGMT negative cells exhibiting a greater increase in DNA damage compared to MGMT positive cells. However, unlike our previous findings in established cell lines, this did not lead to reduced cell survival in combination with TMZ. These findings further support the preclinical use of ex vivo models that better represent intratumoural heterogeneity and post-surgical GCS niches. Overall, these data highlight the value of preclinical validation in more clinically relevant models to identify the best possible novel therapeutic approaches to pursue further towards clinical delivery.

The Burden of Stroke Mimics Among Hyperacute Stroke Unit Attendees with Special Emphasis on Migraine: A 10-Year Evaluation.

Stroke and migraine are common neurological illnesses that cause tremendous suffering for patients. Certain diseases can mimic the clinical manifestations of an actual stroke. Migraine is one of the most commonly reported stroke mimics. The main goals of this study are to look at the prevalence of stroke mimics on the stroke pathway of Sheffield Teaching Hospitals and how many of them are migraines. A retrospective service evaluation was conducted at the hyperacute stroke unit (HASU) of the Royal Hallamshire Hospital (RHH) in the United Kingdom. The total admissions from 2013 to 2022 were collected from the Sentinel Stroke National Audit Programme database, and the number of stroke mimics was evaluated each year. The burden of migraine stroke mimics was also evaluated. Then, a one-year sample of stroke mimics was extracted to look for the types of each mimic. From 2013 to 2022, 45.75% (n = 12156) of the stroke pathway patients (n = 26573) were stroke mimics, with an increment of up to 55% in the years 2021and 2022. During these10 years, migraine stroke mimics accounted for 10.21% of admissions (n = 1240). The three most common mimics in a one-year sample of stroke pathway patients were migraine (14.70%) (n = 373), functional neurological disorders (FNDs) (7.17%) (n = 182), and Guillain-Barré syndrome (6.66%) (n = 169). Seizures, syncope, and metabolic derangements were reported as mimics in 4.17% (n = 106), 3.14% (n = 80), and 1.77% (n = 45), respectively. About half of the HASU attendees were stroke mimics rather than actual strokes, and the most common mimics were migraines.

Sensory Symptoms without Structural Pathology in Patients with Gluten Sensitivity.

The patients were selected from the gluten neurology clinic based at the Royal Hallamshire Hospital, Sheffield, UK, on the basis of sensory symptoms but normal neuroaxis imaging and peripheral nerve evaluation. A total of 30 patients were identified with a mean age at presentation of 47 years. The prevalence of enteropathy was 78%. The sensory disturbance was characterised by tingling at 50%, numbness at 27%, pain at 20%, burning at 13% and "buzzing" feeling at 7%. The distribution of the sensory symptoms included hands and feet in 27% of the patients, torso in 27%, legs only in 23%, face in 17% and arms only in 10%. For five patients, the sensory disturbance was migratory and affected different parts of the body at any given time. After the introduction of a gluten-free diet, 77% of patients noted significant improvement in their sensory symptoms. In one-third of the patients, there was a complete resolution of the sensory symptoms. Unexplained sensory symptoms can be seen in patients with gluten sensitivity and respond to strict adherence to a gluten-free diet.

A Comparison Between Ultrasound Pachymetry and CASIA2 (Anterior-Segment Optical Coherence Tomography) in the Measurement of Central Corneal Thickness.

Background and objective Due in part to its effect on intraocular pressure (IOP) measurements, the assessment of central corneal thickness (CCT) is recognized as an essential part of the initial glaucoma assessment. The most widely utilized clinical technique to measure CCT is ultrasound pachymetry (USP). In recent years, many dedicated anterior-segment optical coherence tomography scanners (AS-OCTs) have been developed. Previous studies have compared CCT measurements between USP and various AS-OCTs. This study aimed to assess the degree of agreement between USP and CASIA2 (Tomey Corporation, Nagoya, Japan), a second-generation swept-source AS-OCT developed in Japan. Methodology The data on CCT screening measurements of 156 eyes (88 patients)performed over a period of three months, from January to March 2020, on glaucoma patients attending the Royal Hallamshire Hospital (RHH) in Sheffield, UKwere collected retrospectively and statistically analyzed. Results The average age of the 88 patients included in the study was 66 years (range: 20-86 years). Our findingsshow that when compared to CASIA2 measurements, USP measurement of the CCT resulted in significantly thicker values (paired t-test: t=23.15,p<2.2 x 10-16). The average difference between the two methods was 19.98 ±10.78 μm. It is hypothesized that this difference may be duein partto inaccurate probe placement during ultrasound probemeasurement, resulting in thicker CCT values. Conclusion The observed difference may be clinically significant as it could induce clinical discrepancy in terms of perceived glaucoma risk in patients. Therefore, USP and CASIA2 should not be used interchangeably, and clinicians should take into account the significant difference between these methods.

An update and journey through the small bowel.

aAcademic Department of Gastroenterology & Liver Unit, Royal Hallamshire Hospital bDepartment of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK Correspondence to Professor Reena Sidhu, Consultant Gastroenterologist & Hon Professor, Room P12, P Floor, Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Room P11 Sheffield S10 2JF, United Kingdom. Tel: +44 114 2261180; e-mail: [email protected]

Dyspnea and Weight Loss following Left Internal Jugular Vein Dialysis Catheter Placement.

AIMS--To evaluate the adequacy of documentation of blood culture results in patients9 medical notes. METHODS--A pro-forma was completed following review of medical notes at 24 and 48 hours after a blood culture had been reported as positive. The study was performed on blood cultures received at the Department of Microbiology, Royal Hallamshire Hospital, Sheffield, from two local hospitals. Two periods were studied: (A) May to June 1993 and (B) September to October 1993. RESULTS--There were 43 results studied in period A and 79 in period B, giving a total of 122 results studied. Overall, 72 (59%) of 122 results were recorded in the medical notes at 24 hours. Of those results deemed highly significant, 40 (63%) of 63 were recorded. There was no significant difference in the documentation of results if the result was given personally or via the telephone. Nor was there any difference in documentation between different medical grades. Throughout the study there were six inaccurate records. The cumulative documentation over 48 hours of positive results was 54 (86%) of 63 of highly significant, 27 (69%) of 39 of uncertain significance, and 11 (55%) of 20 probable contaminant results. CONCLUSIONS--Documentation of blood culture results is currently suboptimal.

Female Voice-Related Sexual Attractiveness to Males: Does it Vary With Different Degrees of Conception Likelihood?

Previous investigations have found that female voice-related attractiveness to males increases when both conception likelihood (CL) and voice fundamental frequency (fo) are elevated. To test this hypothesis, we conducted a perceptual experiment where 78 heterosexual males rated sexual attractiveness of 9 female voice samples, recorded at menstrual, follicular and luteal phases of the menstrual cycle under two double-blinded randomly allocated conditions: a natural menstrual cycle (placebo condition) and when using an oral contraceptive pill (OCP condition). The voice samples yielded a total of 54 stimuli that were visually sorted and rated using Visor software. Concentrations of estrogens, progesterone and testosterone were analyzed, and measurements of speaking fundamental frequency (sfo) and its standard deviation (sfoSD), fo derivative (dfo) and fo slope were made. A multilevel ordinal logistic regression model nested in listeners and in females, and adjusted by phase and condition, was carried out to assess the association between ratings and: (1) phases and conditions; (2) sex steroid hormonal concentrations; and (3) voice parameters. A high probability of obtaining high ratings of voice sexual attractiveness was found for: (1) menstrual phase of placebo use and follicular phase of OCP use; (2) for low estradiol to progesterone ratio and testosterone concentrations; and (3) for low dfo. The latter showed a moderate statistical association with ratings of high attractiveness, as compared with the small association found for the remaining variables. It seems that the voice is a weak cue for female CL. Female sexual attraction to males may be a consequence of what females do in order to regulate their extended sexuality across the menstrual cycle rather than of estrus cues, the use of paralinguistic speech patterns being an example.

Gamma Knife Stereotactic Radiosurgery for the treatment of chordomas and chondrosarcomas.

Primary chordomas and chondrosarcomas of the skull base are difficult tumours to treat successfully. Despite advances in surgical techniques, a gross total resection is often impossible to achieve. In addition, some patients may be deemed unsuitable or not wish to undergo extensive surgery for these conditions. This study examines the role of Gamma Knife Stereotactic Radiosurgery (GKRS) in the treatment of these difficult cases. All patients harbouring either a chordoma or chondrosarcoma treated at the National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK, between 1985 and 2018, were reviewed with regard to their clinical presentations, pre- and post-treatment imaging, GKRS prescriptions and outcomes. In total, 24 patients with a mean tumour volume of 13 cm3 in the chordoma group (n=15) and 12 cm3 in the chondrosarcoma group (n=9) underwent GKRS. The 5- and 10-year overall survival rates for the chordoma group were 67% and 53% respectively, while for the chondrosarcoma group, they were 78% at both time points. The tumour control rates at 5 and 10 years in the chordoma group were 67% and 49% and for the chondrosarcoma group 78% at both time points. Patients with tumour volumes of less than 7 cm3 before GKRS treatment demonstrated a statistically significant longer overall survival rate (p=0.03). GKRS offers a comparable option to proton beam therapy for the treatment of these tumours. Early intervention for tumour volumes of less than 7 cm3 gives the best long-term survival rates.

Money, environment and eyelids

Fireman Z. Biopsy forceps: reusable or disposable? J Gastroenterol Hepatol. 2006;21:1089–92. Article Google Scholar Lockington D, Macdonald E, Mantry S, Ramaesh K. A case for single use disposable corneal forceps: equipment reliability should be the primary concern. Br J Ophthalmol. 2010;94:388–9. Article Google Scholar NHS England. Carbon emissions: carbon footprinting study sustainable development commission. London: NHS England; 2008. Wormer BA, Augenstein VA, Carpenter CL, Burton PV, Yokeley WT, Prabhu AS, et al. The green operating room: simple changes to reduce cost and our carbon footprint. Am Surg. 2013;79:666–71. Article Google Scholar Lockington D, Dutton GN. Eyes, economics and the environment: should green issues drive changes in ophthalmic care?–no. Eye. 2010;24:1312–4. CAS Article Google Scholar Download references Department of Ophthalmology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK Christine A Putri, Parushak Rezai, Jennifer Capel & Zanna Currie You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar You can also search for this author in PubMed Google Scholar Correspondence to Christine A Putri. The authors declare that they have no conflict of interest. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Reprints and Permissions Putri, C.A., Rezai, P., Capel, J. et al. Money, environment and eyelids. Eye (2020). https://doi.org/10.1038/s41433-020-01189-z Download citation Received: 17 July 2020 Revised: 12 September 2020 Accepted: 14 September 2020 Published: 22 September 2020 DOI: https://doi.org/10.1038/s41433-020-01189-z

Evaluation of 0.2 µg/day fluocinolone acetonide (ILUVIEN) implant in a cohort of previously treated patients with diabetic macular oedema (DMO): a 36-month follow-up clinical case series

ObjectiveTo assess the real-world effectiveness and safety of single injection of a fluocinolone acetonide (FAc) implant in previously treated patients with recurrent diabetic macular oedema (DMO) over a 36-month follow-up...

Reply by Authors.

Reply by Authors.

John Thompson Rowling

John Thompson Rowling (“JTR”) was a retired consultant surgeon. He worked in Sheffield at the Royal Hospital and later at the Royal Hallamshire Hospital. He was born in Leeds to...

Abstract P4-02-10: Generation of nomograms to predict non-sentinel node metastasis and poorer patient response to neoadjuvant chemotherapy in primary breast cancer: A 10-year study

Abstract INTRODUCTION: The ability to predict non-sentinel node (non-SLN) metastasis in breast cancer patients has been an area of intense research for the past decade. This study aimed to identify predictors of non-SLN metastasis and level 3 node involvement. Further objectives included identifying factors which predicted poorer patient response to neoadjuvant chemotherapy (NAC). The final objective was to create mathematical models to predict non-SLN metastasis and level 3 disease. METHODS: Electronic patient records of 1088 patients who underwent ANC between 2007-2016 at the Royal Hallamshire Hospital, Sheffield, UK were reviewed. Clinicopathological characteristics were used to identify factors predicting lymph node metastasis. Significant predictors of axillary disease were incorporated into a nomogram using the first 75% of the cohort. Internal validation of the nomogram was performed using the remaining 25% of the study population. Four nomograms were created to predict non-SLN metastasis and level 3 disease in those who were had not received chemotherapy and those who underwent NAC. RESULTS: Larger tumour size (OR=1.025; CI=1.016-1.034; p&amp;lt;0.001), grade 3 (OR=3.706; CI=2.102-6.534) and grade 2 tumours (OR=2.174; CI=1.245-3.795) compared to grade 1 tumours (p&amp;lt;0.001), presence of lymphovascular invasion (LVI) (OR=2.832; CI=2.064-3.885; p&amp;lt;0.001), ER-negative tumours (OR=2.339; CI=1.472-3.717; p&amp;lt;0.001), and number of positive SLNs (OR=1.756; CI=1.333-2.313; p&amp;lt;0.001) were all significantly associated with non-SLN metastasis. In addition to these characteristics, lobular carcinomas (OR=1.832; CI=1.157-2.899; p=0.034) and multifocal tumours (OR=1.717; CI=1.108-2.662; p=0.016) were also significantly associated with level 3 disease. In patients who underwent NAC, larger tumour size (OR=1.040; CI=1.025-1.056; p&amp;lt;0.001), presence of LVI (OR=3.030; CI=1.673-5.488; p=0.001), and HER2-negative tumours (OR=1.983; CI=1.177-3.343; p=0.01) significantly predicted non-SLN metastasis, despite treatment. These same variables significantly predicted level 3 metastasis. In patients who did not receive NAC, the nomogram to predict non-SLN metastasis produced an AUC of 0.721 (CI=0.674-0.768). Internal validation produced an AUC of 0.781 (CI=0.708-0.854). A nomogram was produced to predict level 3 disease in non-NAC patients (AUC=0.771, CI=0.716-0.826). Validation provided accurate results (AUC=0.726, CI=0.625-0.826). A nomogram to predict non-SLN metastasis in NAC patients produced an AUC of 0.767 (CI=0.669-0.864). Validation produced an AUC of 0.838 (CI=0.666-1.000). An AUC of 0.806 (CI=0.0.711-0.901) was derived from the nomogram predicting level 3 disease in NAC patients. Validation produced an AUC of 0.879 (CI=0.742-1.000). CONCLUSION: Generation of a nomogram accurately predicted non-SLN metastasis and level 3 disease in those who did not receive NAC and those who underwent previous NAC. Incorporation of these mathematical models into the management of those with axillary disease will allow patients to make a more informed decision, whether they wish to proceed with full ANC, participate in a clinical trial, or choose to have their axilla re-staged following neoadjuvant chemotherapy. Citation Format: Sam Jenkins. Generation of nomograms to predict non-sentinel node metastasis and poorer patient response to neoadjuvant chemotherapy in primary breast cancer: A 10-year study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-02-10.

Diagnosing coeliac disease in the elderly: a United Kingdom cohort study.

To assess the outcomes for an elderly population with coeliac disease and to compare with younger adults with CD. Coeliac disease in the elderly has been underdiagnosed due to the heterogeneity of presentation as well as lack of physicians' awareness of CD in this population. However, the benefits of diagnosing CD in the elderly may be contentious. Newly diagnosed CD patients were prospectively recruited from the Coeliac Specialist Clinic at the Royal Hallamshire Hospital, Sheffield, between 2008 and 2017. All patients had villous atrophy (VA) on biopsy with positive coeliac serology. Additionally, the patients were retrospectively recruited from 1990 to 2008 to determine the trend in elderly CD diagnostic frequency over time. A total of 1605 patients with CD were recruited (n=644 prospectively, n=961 retrospectively). Of these, 208 patients (13.0%) were diagnosed over the age of 65 years between 1990 and 2017. The proportion of elderly CD diagnoses increased from 0% in 1990-1991 to 18.7% in 2016-2017 (p<0.001). Younger patients more commonly presented with fatigue (p<0.001) and gastrointestinal symptoms including diarrhoea (p=0.005), abdominal pain (p=0.019), and IBS-type symptoms (p=0.008), while older people more frequently presented with B12 deficiency (p=0.037). The prevalence of CD in the elderly has significantly increased over the last two decades, but elderly patients tend to present with fewer symptoms. Further research is required to determine whether a strict gluten-free diet in these patients is a necessity or a burden.

RETRACTED: Gluten Does Not Induce Gastrointestinal Symptoms in Healthy Volunteers: A Double-Blind Randomized Placebo Trial

RETRACTED: Gluten Does Not Induce Gastrointestinal Symptoms in Healthy Volunteers: A Double-Blind Randomized Placebo Trial

286 Hyperacute stroke unit and hyperacute neurology unit under one roof

The Acute neurology unit (ANU), located at the Royal Hallamshire Hospital, Sheffield is a regional centre for a population of approximately 1.5 million. We are unusual, as our neurologists manage both hyperacute stroke and hyperacute neurology. HASU is located within our ANU. We had 4026 neurology ward admissions, 3265 emergency cases and 761 elective cases last year. We receive acute admissions from Trust A and E, direct admissions from general practitioners and urgent transfers from DGHs.We provide 24 hour stroke thrombolysis and a weekday working hours thrombectomy service. Overnight thrombolysis is supervised through a regional ‘Telemedicine’ system. A 2 week survey in July 2017 showed that only 59% patients, who were referred with suspected stroke, had stroke/TIA. Neurological conditions, such as migraine, seizure, syncope, acute vestibulopathy, Bell’s palsy and medically unexplained symptoms were common ‘stroke mimics’. 46% of patients with ‘stroke mimic’ were discharged on the day of admission. Average length of stay was 3 days. A separate survey of acute neurology referrals showed that 58% of patients did not require admission and were managed through an ambulatory care pathway. Patient satisfaction regarding their rapid assessment and diagnosis was high. Co-location of ANU and HASU allows rapid and effective management of ‘stroke mimics’.

Phenytoin-related ataxia in patients with epilepsy: clinical and radiological characteristics

PurposePhenytoin is an effective anticonvulsant for focal epilepsy. Its use can be associated with long-term adverse effects including cerebellar ataxia. Whilst phenytoin is toxic to Purkinje cells in vitro; the clinical and radiological phenotype and mechanism of cerebellar degeneration in vivo remain unclear. We describe the prevalence, clinical and radiological characteristics of phenytoin-related ataxia. MethodsPatients with epilepsy receiving treatment with phenytoin were recruited from the Epilepsy clinics at Royal Hallamshire Hospital, Sheffield, UK. Neurological examination was performed on all patients after recruitment. Patients were categorised into those with and without ataxia. We determined the severity of ataxia clinically (SARA score) and the pattern of cerebellar involvement by neuroimaging (MRI volumetry and MR spectroscopy). ResultsForty-seven patients were recruited. Median duration of epilepsy was 24 years, median duration of phenytoin treatment was 15 years and current median phenytoin daily dose was 325 mg. Fifty-five percent of patients complained of poor balance. Clinical evidence of ataxia was seen in 40% patients. Gait, stance and heel-shin slide were the predominant features of cerebellar dysfunction. MRI demonstrated structural, volumetric and functional deficits of the cerebellum. Only one patient with ataxia had phenytoin levels above the normal range. ConclusionsCerebellar ataxia is present in 40% of patients with epilepsy and chronic exposure to phenytoin. Patients on long-term phenytoin have reduced cerebellar volume even if they have no clinical evidence of ataxia. Evidence of structural deficits on imaging suggests a predilection for vermian involvement.

Myofascial Release and Muscle Retraining for Dropped Head Syndrome Attributed to Radiation Fibrosis in Hodgkin Lymphoma: A Case Series

Background and Purpose: This article reviews the current knowledge base of dropped head syndrome and presents the case histories of 7 patients with a diagnosis of this condition at the Royal Hallamshire Hospital, Sheffield, through the Late Effects Clinic. All patients were referred for physiotherapy, and the assessment findings and subsequent treatment provided are discussed in detail. Case Description: Seven patients who were consecutively referred to physiotherapy and presented with signs and symptoms of suspected dropped head syndrome following previous treatment with mantle radiotherapy for Hodgkin lymphoma are discussed. Physiotherapy was delivered at various time intervals and duration on a one-to-one basis. Interventions were delivered to restore soft tissue length, rehabilitate proprioception, increase neck stabilizer strength, and retraining of muscles through range both locally and distally. Outcomes: All 7 patients reported subjective improvements in pain and function, with objective improvements in local and distal posture, tolerance to maintain head on neck position, and ability to grade through range neck movement locally. No formal outcome measures were used, as this is a retrospective report. Conclusion: Physiotherapy can offer short-term subjective and objective improvements in head on neck posture and control and effect more distal postural changes. Longer-term maintenance of improvements gained has yet to be determined. The most effective time point posttreatment for therapy intervention requires further research as does the type of physiotherapy intervention to be offered.