Treatment Of Foot Pain Research Articles

Muscle Strength and Foot Pressure Vary Depending on the Type of Foot Pain

Category: Midfoot/Forefoot; Hindfoot Introduction/Purpose: Foot pain is highly prevalent at various ages and is especially common in middle-aged and older females. To the best of our knowledge, there have been no studies directly comparing muscle strength, foot pressure, and foot posture between metatarsalgia, plantar fasciitis, and normal controls, and the available study data in metatarsalgia is limited. Therefore, this study aimed to compare muscle strength, foot pressure, and foot posture between patients with metatarsalgia, plantar fasciitis, and normal controls. We hypothesized that metatarsalgia and plantar fasciitis would have decreased muscle strength, increased foot pressure, and different foot postures compared to normal controls. Methods: To compare the muscle strength and foot pressure between patients with metatarsalgia and plantar fasciitis and healthy controls. 31 patients with foot pain (n=14 for metatarsalgia and n=17 for plantar fasciitis) and 29 healthy controls participated. The muscle strengths of the plantar flexor and hip muscles were measured using an isokinetic dynamometer and handheld dynamometer, respectively. Foot pressure parameters, including the pressure-time integral (PTI) and foot arch index (AI), were assessed using pedobarography. Results: Compared with the normal control group, plantar flexor strength was significantly reduced in the affected feet of the metatarsalgia and plantar fasciitis groups (F: 0.083, all p< 0.001), but hip strength was significantly decreased only in the affected feet of the metatarsalgia group (F: 20.900, p< 0.001). In particular, plantar flexor strength (p< 0.001) and hip strength (p=0.004) were significantly lower in the metatarsalgia group than in the plantar fasciitis group. PTI was lower in the forefoot of the affected feet in metatarsalgia (p< 0.001) and plantar fasciitis (p=0.004). Foot AI (p< 0.001) was significantly reduced only in he metatarsalgia group. Conclusion: The study results suggest that the evaluation of muscle strength and foot pressure should be considered in both feet for the diagnosis and treatment of foot pain.

Muscle strength and foot pressure vary depending on the type of foot pain

This study compared muscle strength and foot pressure among patients with metatarsalgia, patients with plantar fasciitis, and healthy controls. A total of 31 patients with foot pain (14 metatarsalgia and 17 plantar fasciitis) and 29 healthy controls participated in the study. The strengths of the plantar flexor and hip muscles were measured using isokinetic and handheld dynamometers, respectively. Foot pressure parameters, including the pressure–time integral (PTI) and foot arch index (AI), were assessed using pedobarography. Compared with the healthy control group, plantar flexor strength was significantly reduced in the affected feet of the metatarsalgia and plantar fasciitis groups (F = 0.083, all p < 0.001); however, hip strength was significantly decreased only in the affected feet of the metatarsalgia group (F = 20.900, p < 0.001). Plantar flexor (p < 0.001) and hip (p = 0.004) strength were significantly lower in the metatarsalgia group than in the plantar fasciitis group. The PTI was lower in the forefeet of the affected feet in the metatarsalgia (p < 0.001) and plantar fasciitis (p = 0.004) groups. Foot AI (p < 0.001) was significantly reduced only in the metatarsalgia group. These results suggest the need to consider the evaluation of muscle strength and foot pressure in both feet for the diagnosis and treatment of foot pain.

Kinematic Effect on the Navicular Bone with the Use of Rearfoot Varus Wedge.

Background: The rearfoot varus wedge (RVW) is a common treatment for foot pain and valgus deformity. There is research on its effects in the calcaneus, but there is little research on the navicular. More research is needed with the use of RVW due to the relationship that exists between the position of the navicular and the risk of suffering an injury. Objectives: this study sought to understand how RVW can influence the kinematics of the navicular bone, measuring their movement with the 6 SpaceFastrak system. Methods: a total of 60 subjects participated in the study. Two sensors were used to measure the movement of the calcaneus and navicular using RVWs as compared in the barefoot position in a static way. Results: there were statistically significant differences, the use of RVWs caused changes in the navicular bone, with subjects reaching the maximum varus movement with the use of RVW 7 mm of 1.35 ± 2.41° (p < 0.001), the maximum plantar movement flexion with the use of RVW 10 mm of 3.93 ± 4.44° (p < 0.001). Conclusions: when RVWs were placed under the calcaneus bone, the navicular bone response was in varus movement too; thus, the use of rearfoot varus wedge can influence the movement of the navicular bone.

A Cross-Sectional Web Survey of Satisfaction with Treatment for Pain in Participants with Suspected Diabetic Peripheral Neuropathic Pain in Both Feet.

IntroductionDiabetic peripheral neuropathic pain (DPNP), a symptom of diabetic polyneuropathy (DPN), is underdiagnosed in people with diabetes. To date, no studies have determined the relationship between diagnosis of DPN and satisfaction with treatment for pain. Additionally, the factors that influence satisfaction with treatment for pain remain unknown. This questionnaire study was conducted to understand satisfaction with treatment for pain among participants with diabetes who experienced bilateral pain or numbness in their feet.MethodsThis cross-sectional, observational, web-based questionnaire study for participants with diabetes and suspected DPNP was conducted in Japan. Potential respondents were registered in the INTAGE Disease Panel or the Rakuten Insight Disease Panel. The primary endpoint was the number and percentage of participants who were satisfied with their DPNP treatment. Secondary endpoints included participant opinions regarding treatment-related efficacy, side effects, and economic burden, and factors affecting satisfaction with treatment.ResultsThe questionnaire was accessed by 7565 potential participants; 777 met the eligibility criteria (final analysis set). Satisfaction with treatment for bilateral foot pain was low (satisfied, 27.9%; neither satisfied nor unsatisfied, 42.2%; unsatisfied, 23.4%; very unsatisfied, 6.4%). Participants were somewhat more satisfied with treatment side effects than with treatment efficacy and economic burden. Satisfaction with treatment mainly differed by improvement in actions in daily life, improvement in quality of life, and communication with doctors. The diagnostic testing rate for DPN was low, and diagnosis was more common in participants who complained of symptoms of pain and numbness (any visit) versus those who did not.ConclusionParticipants with diabetes who experience bilateral foot pain or numbness reported a low level of satisfaction with treatment for pain.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01810-x.

Assessment of the Efficacy of Insoles in Treatment of Foot pain in Rheumatoid Arthritis Patients

Abstract Background Customized toot insoles. Were commonly used as a conservative treatment for the foot pain in rheumatoid arthritis (RA) to prevent and control joint damage, and to improve foot function. Objective to assess the efficacy of total contact soft foot insoles in treatment of foot pain in RA patients. Methods 20 RA patients with foot pain were randomized into 10 patient as foot insole group plus physiotherapy and foot exercise and other 10 patients without insole, with only physiotherapy and foot exercise. Foot pain and disability were assessed by visual analogue scale (VAS) and foot function index (FFI%). other parameters to assess foot involvement such as conventional radiography and diagnostic ultrasound and power Doppler ultrasound to assess joint involvement in addition to pedobarography (planter pressure assessment) to measure the static planter peak pressure (SPPP) and dynamic planter peak pressure (DPPP) of both feet. Results At the end of the study period analyses were performed on data collected at baseline and after 2 months of randomized clinical trial. Twenty women (mean age, 39.20±5.35years; mean disease duration, 7.68 ± 3.71y-ears) were evaluated, before and after clinical trial. We found highly significant reduced in pain, disability scales and joint inflammation in the insole group more than in non-insole group. Conclusion customized total contact foot insole with physiotherapy and foot exercise have a significant positive effect on the pain, disability, joint and soft tissue inflammation and planter pressure distribution.

Treatment for Foot Pain Caused by Diabetic Neuropathy Using Recurrent TransCutaneous Magnetic Stimulation (TCMS)

Treatment for Foot Pain Caused by Diabetic Neuropathy Using Recurrent TransCutaneous Magnetic Stimulation (TCMS)

Are custom-made foot orthoses of any interest on the treatment of foot pain for prolonged standing workers?

BackgroundThe prolonged standing position is an important factor in the onset of foot musculoskeletal disorders among workers. Safety shoes, designed to protect against the physical constraints of the work environment, do not address this issue to date. ObjectivesThe goal of this study is to assess the possible benefits of custom-made foot orthoses among prolonged standing workers. Study designrepeated measures without control group. MethodsThirty-four standing workers who suffer from foot pain volunteered for the study. Custom-made foot orthoses, designed by a podiatrist, were 3D-printed and distributed to each volunteer. Static balance as well as static and dynamic plantar pressure measurements were carried out with sensors inserted in the safety shoes, before and after three weeks of wearing foot orthoses daily. A questionnaire on pain and comfort was also distributed before and after treatment. ResultsFeelings of pain, discomfort and heavy legs were found to be significantly reduced after wearing 3D-printed orthoses (p<0.05). Additionally, in static and dynamic conditions, a significant decrease in mean peak pressure in the rearfoot area was observed along with a significant increase in mean peak pressure in the midfoot area (p<0.05). There was also a significant improvement of balance in the medial-lateral direction. ConclusionCustom-made orthoses significantly increase the well-being of standing workers in our experimental testing conditions. The custom-made shape allows for a better balanced distribution of foot peak pressure thanks to its support and stimulation of the foot arches particularly through a shift of pressure from the heel to the midfoot.

Communication between the distal interphalangeal joint and the navicular bursa in the horse at Computed Tomography Arthrography.

Diffusion of drugs injected into the distal interphalangeal joint or the navicular (podotrochlear) bursa can influence diagnosis and treatment of foot pain. Previous anatomical and radiographic studies of the communication between these synovial structures have produced conflicting results and did not identify the location of any communication if present. This anatomic study aimed to assess the presence and site of communication between the distal interphalangeal joint and the navicular bursa in the horse by computed tomography arthrography. Sixty-six pairs of cadaver forelimbs were injected with contrast medium into the distal interphalangeal joint and imaged by computed tomography arthrography. The presence of a communication, location of the communication and additional structural changes were assessed. Navicular bursa opacification occurred in 7 distal limbs (5.3%) following distal interphalangeal joint injection. One limb showed a communication through the T-ligament and 6 limbs showed a communication through the distal sesamoidean impar ligament. In 3 cases, the communication through the distal sesamoidean impar ligament was associated with a distal border fragment. Our study showed that communication between the distal interphalangeal joint and navicular bursa is uncommon and inconsistent. Clinically, the presence of a communication could (1) influence the interpretation of diagnostic analgesia of the distal interphalangeal joint or the navicular bursa by facilitating the diffusion of local anaesthetic between these structures; (2) allow the drug and its potential adverse effects to spread from the treated synovial cavity to the non-targeted synovial cavity; (3) be responsible for the failure of joint drainage in the case of sepsis.

A protocol for a randomised controlled trial of prefabricated versus customised foot orthoses for people with rheumatoid arthritis: the FOCOS RA trial [Foot Orthoses \u2013 Customised v Off-the-Shelf in Rheumatoid Arthritis

BackgroundFoot pain is common in rheumatoid arthritis and appears to persist despite modern day medical management. Several clinical practice guidelines currently recommend the use of foot orthoses for the treatment of foot pain in people with rheumatoid arthritis. However, an evidence gap currently exists concerning the comparative clinical- and cost-effectiveness of prefabricated and customised foot orthoses in people with early rheumatoid arthritis. Early intervention with orthotics may offer the best opportunity for positive therapeutic outcomes. The primary aim of this study is to evaluate the comparative clinical- and cost-effectiveness of prefabricated versus customised orthoses for reducing foot pain over 12 months.Methods/designThis is a multi-centre two-arm parallel randomised controlled trial comparing prefabricated versus customised orthoses in participants with early rheumatoid arthritis (< 2 years disease duration). A total of 160 (a minimum of 80 randomised to each arm) eligible participants will be recruited from United Kingdom National Health Service Rheumatology Outpatient Clinics. The primary outcome will be foot pain measured via the Foot Function Index pain subscale at 12 months. Secondary outcomes will include foot related impairments and disability via the Foot Impact Scale for rheumatoid arthritis, global functional status via the Stanford Health Assessment Questionnaire, foot disease activity via the Rheumatoid Arthritis Foot Disease Activity Index, and health-related quality of life at baseline, 6 and 12 months. Process outcomes will include recruitment/retention rates, data completion rates, intervention adherence rates, and participant intervention and trial participation satisfaction. Cost-utility and cost-effectiveness analyses will be undertaken.DiscussionOutcome measures collected at baseline, 6 and 12 months will be used to evaluate the comparative clinical- and cost- effectiveness of customised versus prefabricated orthoses for this treatment of early rheumatoid arthritis foot conditions. This trial will help to guide orthotic prescription recommendations for the management of foot pain for people with early rheumatoid arthritis in future.Trial registrationISRCTN13654421. Registered 09 February 2016.

Flip-flop footwear with a moulded foot-bed for the treatment of foot pain: a randomised controlled trial.

BackgroundFoot pain is a common problem affecting up to 1 in 5 adults and is known to adversely affect activities of daily living and health related quality of life. Orthopaedic footwear interventions are used as a conservative treatment for foot pain, although adherence is known to be low, in part due to the perception of poor comfort and unattractiveness of the footwear. The objective of this trial was to assess the efficacy of flip-flop style footwear (Foot Bio-Tec©) with a moulded foot-bed in reducing foot pain compared to participant’s usual footwear.MethodsTwo-arm parallel randomised controlled trial using computer generated random allocation schedule at an Australian university podiatry clinic. 108 volunteers with disabling foot pain were enrolled after responding to an advertisement and eligibility screening. Participants were randomly allocated to receive footwear education and moulded flip-flop footwear to wear as much as they were comfortable with for the next 12 weeks (n = 54) or footwear education and instructions to wear their normal footwear for the next 12 weeks (n = 54). Primary outcome was the pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcomes were the foot function and general foot health domains of the FHSQ, a visual analogue scale (VAS) for foot pain and perceived comfort of the intervention footwear.ResultsCompared to the control group, the moulded flip-flop group showed a significant improvement in the primary outcome measure of the FHSQ pain domain (adjusted mean difference 8.36 points, 95 % CI 5.58 to 13.27, p < 0.01). Statistical and clinically significant differences were observed for the secondary measure of foot pain assessed by a VAS and the FSHQ domains of foot function and general foot health. None of the participants reported any pain or discomfort from the intervention footwear and six (footwear group = 4) were lost to follow up.ConclusionsOur results demonstrate that flip-flop footwear with a moulded foot-bed can have a significant effect on foot pain, function and foot health and might be a valuable adjunct therapy for people with foot pain.Trial registration ACTRN12614000933651. Retrospectively registered: 01/09/2014.

Flip-flop footwear with a moulded foot-bed for the treatment of foot pain: A randomised controlled trial

Flip-flop footwear with a moulded foot-bed for the treatment of foot pain: A randomised controlled trial

Topography of human ankle joint: focused on posterior tibial artery and tibial nerve.

Most of foot pain occurs by the entrapment of the tibial nerve and its branches. Some studies have reported the location of the tibial nerve; however, textbooks and researches have not described the posterior tibial artery and the relationship between the tibal nerve and the posterior tibial artery in detail. The purpose of this study was to analyze the location of neurovascular structures and bifurcations of the nerve and artery in the ankle region based on the anatomical landmarks. Ninety feet of embalmed human cadavers were examined. All measurements were evaluated based on a reference line. Neurovascular structures were classified based on the relationship between the tibial nerve and the posterior tibial artery. The bifurcation of arteries and nerves were expressed by X- and Y-coordinates. Based on the reference line, 9 measurements were examined. The most common type I (55.6%), was the posterior tibial artery located medial to the tibial nerve. Neurovascular structures were located less than 50% of the distance between M and C from M at the reference line. The bifurcation of the posterior tibial artery was 41% in X-coordinate, -38% in Y-coordinate, and that of the tibial nerve was 48%, and -10%, respectively. Thirteen measurements and classification showed statistically significant differences between both sexes (P<0.05). It is determined the average position of neurovascular structures in the human ankle region and recorded the differences between the sexes and amongst the populations. These results would be helpful for the diagnosis and treatment of foot pain.

Relationship Between Mental Health and Foot Pain

Although mental health is related to the persistence of musculoskeletal pain, our understanding of the relationship between mental health and foot pain is limited. Subsequently, we conducted a 3-year longitudinal study to examine the relationship between mental health and foot pain in a community-based population. Eighty-three community-dwelling participants (mean ± SD body mass index [BMI] 35.3 ± 9.0 kg/m2) who had foot pain at study inception in 2008 and for whom measures of mental health (Short Form 36 [SF-36] health survey mental component summary [MCS]) were available, were invited to take part in this followup study in 2011. Change in foot pain was determined by the difference between the Manchester Foot Pain and Disability Index score at baseline and followup; therefore, a decrease in the score indicated improved foot pain and an increase indicated deterioration in foot pain. Linear regression was used to determine the factors affecting change in foot pain. Of the 62 respondents (75% response rate, 49 women and 13 men), there were 27 (44%) whose foot pain deteriorated. A higher MCS score of the SF-36 health survey at baseline was associated with a slower progression of foot pain (β coefficient −0.29, 95% confidence interval −0.42, −0.01), adjusted for age, sex, BMI, and physical health. Mental health is associated with changes in foot pain. Clinicians dealing with this population should consider the contribution of mental health in their management and treatment of foot pain.

The relationship between mental health and foot pain

Objective. Although mental health is related to the persistence of musculoskeletal pain, our understanding of the relationship between mental health and foot pain is limited. Subsequently, we conducted a 3-year longitudinal study to examine the relationship between mental health and foot pain in a community-based population. Methods. Eighty-three community-dwelling participants (mean SD body mass index [BMI] 35.3 9.0 kg/m) who had foot pain at study inception in 2008 and for whommeasures of mental health (Short Form 36 [SF-36] health survey mental component summary [MCS]) were available, were invited to take part in this followup study in 2011. Change in foot pain was determined by the difference between the Manchester Foot Pain and Disability Index score at baseline and followup; therefore, a decrease in the score indicated improved foot pain and an increase indicated deterioration in foot pain. Linear regression was used to determine the factors affecting change in foot pain. Results. Of the 62 respondents (75% response rate, 49 women and 13 men), there were 27 (44%) whose foot pain deteriorated. A higher MCS score of the SF-36 health survey at baseline was associated with a slower progression of foot pain ( coefficient 0.29, 95% confidence interval 0.42, 0.01), adjusted for age, sex, BMI, and physical health. Conclusion. Mental health is associated with changes in foot pain. Clinicians dealing with this population should consider the contribution of mental health in their management and treatment of foot pain.

Pain relief, functional recovery and associated medical treatments reduction in large-scale population with osteoarthritis receiving injections of viscosupplement incorporating high concentration of sorbitol

Pain relief, functional recovery and associated medical treatments reduction in large-scale population with osteoarthritis receiving injections of viscosupplement incorporating high concentration of sorbitol

Association of Planus Foot Posture and Pronated Foot Function With Foot Pain: The Framingham Foot Study

To examine the associations of foot posture and foot function to foot pain. Data were collected on 3,378 members of the Framingham Study cohort who completed foot examinations in 2002-2008. Foot pain (generalized and at 6 locations) was based on the response to the following question: "On most days, do you have pain, aching or stiffness in either foot?" Foot posture was categorized as normal, planus, or cavus using static pressure measurements of the arch index. Foot function was categorized as normal, pronated, or supinated using the center of pressure excursion index from dynamic pressure measurements. Sex-specific multivariate logistic regression models were used to examine the effect of foot posture and function on generalized and location-specific foot pain, adjusting for age and weight. Planus foot posture was significantly associated with an increased likelihood of arch pain in men (odds ratio [OR] 1.38, 95% confidence interval [95% CI] 1.01-1.90), while cavus foot posture was protective against ball of foot pain (OR 0.74, 95% CI 0.55-1.00) and arch pain (OR 0.64, 95% CI 0.48-0.85) in women. Pronated foot function was significantly associated with an increased likelihood of generalized foot pain (OR 1.28, 95% CI 1.04-1.56) and heel pain (OR 1.54, 95% CI 1.04-2.27) in men, while supinated foot function was protective against hindfoot pain in women (OR 0.74, 95% CI 0.55-1.00). Planus foot posture and pronated foot function are associated with foot symptoms. Interventions that modify abnormal foot posture and function may therefore have a role in the prevention and treatment of foot pain.

Manipulative therapy in the treatment of non-responsive foot pain: a case study

AbstractObjectiveThe objective of this case study was to review the effectiveness of manipulative therapy in the treatment of long-standing foot pain.MethodsA retrospective review on the treatment of a single subject with a 5-year history of foot pain. Pressure threshold meter testing was used to assess the changes in joint function at each treatment.ResultsUsing algometric pressure threshold measurement, a starting threshold of 1 kg was raised to 7.4 kg over a 2-month period and maintained at this level at a 3-month follow-up. Over the same period, the subject has gone from having constant, debilitating foot pain to being completely pain free.ConclusionThis case suggests that manipulative therapy may be a valid approach in the treatment of foot pain. Such intervention receives some support from the literature and warrants further research.

Outcomes of Subtalar Arthroereisis for the Planovalgus Foot

Chronic pain and gait disturbance are possible complications of subtalar arthroereisis. Despite literature indicating a considerably high rate of such complications, subtalar arthroereisis continues to be commonly performed for children with pes planus. The goals of this study are to identify common presenting features and an approach to the treatment of foot pain after subtalar arthroereisis. This case report includes six feet in which subtalar implants were used to treat flatfoot deformities in children. After failing conservative management for chronic postoperative pain, all patients had their implants removed resulting in relief of pain. The expedited removal of subtalar implants in cases of chronic foot pain after arthroereisis is encouraged. The authors do not recommend the use of subtalar arthroereisis in pes planus given its potential complications and literature review indicating a paucity of cases with improved function and activity level as a result of the procedure.

Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis; an outcome-based investigation for treating pain and gait changes

To evaluate the effectiveness of ultrasonographic guided botulinum toxin type A injections into the plantar fascia to reduce pain and improve gait in patients with unilateral plantar fasciitis. A randomized double-blind control study. Fifty patients with chronic unilateral plantar fasciitis were recruited, and divided into experimental and control groups. Subjects in the experimental group were injected with 50 units botulinum toxin type A, reconstituted with normal saline, into the plantar fascia under ultrasonographic guidance. Follow-up evaluations were made 3 weeks and 3 months after injection. The control group subjects were injected with normal saline under ultrasonographic guidance. Outcome measures included comparing scores from the visual analogue pain scale, changes in thickness of the plantar fascia and fat pad, and gait assessment including the maximal centre of pressure velocity during first step loading response. Visual analogue pain scale and plantar fascia thickness in the symptomatic foot decreased significantly, as noted at follow-up 3 weeks and 3 months after botulinum toxin type A injections (p < 0.001). However, the fat pad thickness remained unchanged. The centre of pressure velocity during loading response increased 3 months after injection (p < 0.05). Outcome measures of the control group remained unchanged. Botulinum toxin type A is effective in the treatment of foot pain associated with plantar fasciitis and increases the centre of pressure velocity during loading response without inducing fat pad atrophy.

Efficacy of tibial nerve block, local steroid injection or both in the treatment of Plantar Heel Pain Syndrome

Background Plantar Heel Pain Syndrome (PHPS) describes centralised plantar heel pain and tenderness. It can account for up to 15% of referrals to clinicians involved in the treatment of foot pain. Objective To compare tibial nerve block, local infiltration with steroid or both combined in the treatment of PHPS. Methods Patients with PHPS were randomly assigned to three treatment groups: Group 1—steroid injection to heel; Group 2—local anaesthetic block to tibial nerve; Group 3—both procedures. Pain visual analogue scale (VAS) was measured at baseline and after 1, 6 and 26 weeks. Heel tenderness index (HTI) was measured at baseline and after 6 weeks. The patient rated their discomfort from the injection(s) using a VAS. Results Forty-five patients (27 female) were recruited, 14 in Group 1, 12 in Group 2 and 19 in Group 3. Median age was 55, disease duration was 10 months and baseline pain VAS was 7.0 cm. All groups experienced a sustained improvement in pain VAS between baseline and weeks 1, 6 and 26 (all p < 0.0001). Group 1 reported significantly lower pain VAS that those in Group 2 ( p < 0.01) or Group 3 ( p < 0.05) at week 6. Group 2 found the procedure less uncomfortable than Group 1 ( p < 0.01). The HTI was significantly higher in Group 2 at 6 weeks compared to Group 1 ( p < 0.005) and Group 3 ( p < 0.05). Conclusions This study suggests that the natural history of PHPS following an injection is encouraging, that a tibial nerve block reduces the discomfort of the procedure, that a steroid injection to the heel may accelerate improvement and that clinicians should consider a combination of both strategies.