Maturitas 112 (2018) 78–84

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Assistive technologies to overcome sarcopenia in ageing T

a b,c d c,d b,c,d,⁎
Rachel A. Scott , Michele L. Callisaya , Gustavo Duque , Peter R. Ebeling , David Scott
a
Department of Occupational Therapy, Austin Health, Heidelberg, Australia
b
Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
c
Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
d
Australian Institute for Musculoskeletal Science (AIMSS), Department of Medicine - Western Health, Melbourne Medical School, The University of Melbourne, St Albans,
Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Sarcopenia is an age-related decline in skeletal muscle mass and function that results in disability and loss of
Sarcopenia independence. It affects up to 30% of older adults. Exercise (particularly progressive resistance training) and
Assistive technology nutrition are key strategies in preventing and reversing declines in muscle mass, strength and power during
Functional decline ageing, but many sarcopenic older adults fail to meet recommended levels of both physical activity and dietary
Device
nutrient intake. Assistive technology (AT) describes devices or systems used to maintain or improve physical
Exercise
Nutrition
functioning. These may help sarcopenic older adults to maintain independence, and also to achieve adequate
physical activity and nutrition. There is a paucity of research exploring the use of AT in sarcopenic patients, but
there is evidence that AT, including walking aids, may reduce functional decline in other populations with
disability. Newer technologies, such as interactive and virtual reality games, as well as wearable devices and
smartphone applications, smart homes, 3D printed foods, exoskeletons and robotics, and neuromuscular elec-
trical stimulation also hold promise for improving engagement in physical activity and nutrition behaviours to
prevent further functional declines. While AT may be beneficial for sarcopenic patients, clinicians should be
aware of its potential limitations. In particular, there are high rates of patient abandonment of AT, which may be
minimised by appropriate training and monitoring of use. Clinicians should preferentially prescribe AT devices
which promote physical activity. Further research is required in sarcopenic populations to identify strategies for
effective use of current and emerging AT devices.

1. Introduction with its own International Classification of Diseases, 10th Revision,

Clinical Modification (ICD-10-CM) code (M62.84). This may result in
Recent international consensus operational definitions have enabled significant increases in diagnoses of sarcopenia in clinical settings [6]
researchers to elucidate the prevalence and functional consequences of but in order for this to occur, clinicians require evidence-based guide-
sarcopenia, the age-related decline in skeletal muscle mass and func- lines to treat and manage sarcopenia.
tion. According to the European Working Group on Sarcopenia in Older Promising sarcopenia drugs including myostatin and activin in-
People (EWGSOP) definition, 30% of community-dwelling older adults hibitors are in development but not yet approved. Supplementation of
have sarcopenia [1] and this is associated with almost 60% greater protein, essential amino acids, β-hydroxy β-methylbutyric acid, omega-
hazard for hospitalisation and three-fold increased likelihood of dis- 3 fatty acids, and vitamin D [1,7,8] may improve muscle composition
ability [2]. Sarcopenia defined according to both the EWGSOP and and function, particularly in older adults with inadequate dietary in-
Foundation for the National Institutes of Health (FNIH) definitions is takes. Unequivocally however, exercise (particularly progressive re-
associated with 60–70% higher falls rates in community-dwelling sistance training; PRT) is most effective for improving muscle mass,
Australian older men [3]. FNIH-defined sarcopenia has also been as- strength and physical performance in older adults [8]. Even in non-
sociated with almost four-fold greater risk of mortality [4]. Assessment agenarians, short-term high-velocity PRT has resulted in increases in
and treatment pathways are poorly implemented in clinical settings muscle strength of > 100%, and significant improvements in mobility
with only one in five health care professionals knowing how to cor- [9,10].
rectly diagnose sarcopenia [5]. In 2016, the condition was recognised Sarcopenia-related functional deficits are a barrier to completing

⁎
Corresponding author at: Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, 246 Clayton
Road, Clayton, Victoria, 3068, Australia.
E-mail address: [email protected] (D. Scott).

https://doi.org/10.1016/j.maturitas.2018.04.003
Received 27 February 2018; Received in revised form 4 April 2018; Accepted 5 April 2018
0378-5122/ © 2018 Elsevier B.V. All rights reserved.
R.A. Scott et al. Maturitas 112 (2018) 78–84

activities of daily living (ADLs), and maintaining adequate physical 3.1. Emerging technologies for maintaining independence
activity and a healthy diet. Interventions which maintain independence
and support participation in desirable lifestyle behaviours are clearly Exoskeletons (external orthoses which are often powered robotic
required. Assistive technology (AT) is an umbrella term for devices or devices placed over limbs) can support ambulation including for those
systems used to maintain or improve functioning and independence, with spinal cord injury [17]. Powered orthoses have also been devel-
and/or prevent impairments and comorbidities [11]. Examples of AT oped to assist older adults in walking, stair climbing and chair rising
include mobility aids, communication devices, prostheses, bathroom [18], but their effectiveness for increasing ADL capacity is yet to be
equipment, and specialised computer software and hardware. The established. Robotics are also expanding into the area of personal care
World Health Organisation states that AT is most needed by older and domestic robots to assist people with ADLs [19]. Currently, com-
adults, and those with disabilities, gradual functional decline and/or mercial robots can fetch items such as food or drink, and also aid in
chronic conditions. feeding and grooming tasks. Robots are also being developed to assist
This review explores the role of AT in overcoming functional de- with other ADLs such as showering, cooking, and cleaning [19].
clines associated with sarcopenia, through managing components in- ‘Smart homes’ utilise the Internet of Things (IoT), connected devices
cluding poor strength and mobility, and/or supporting health beha- that can automate the home environment to meet individual needs.
viours which prevent sarcopenia progression. Smart home technology is rapidly developing with a focus on medical
assistive technology to keep older people safe and healthy within their
own home [20]. In-home sensors, cameras and wearable sensors are
2. Methods being used to externally monitor activity, gait, falls and general health
of people, providing alerts to carers when abnormal activity patterns or
We examined both traditional devices as well as emerging tech- falls occur. Smart home technology also allows operation of numerous
nologies that demonstrate promise for sarcopenic patients via a non- household appliances and systems (eg. lights, heating/cooling) through
systematic search of the MEDLINE and CINAHL databases using search voice activation or touch screens, thereby supporting older adults with
terms including (but not limited to) “sarcopenia”, “muscle weakness”, functional limitations to maintain independent living. Current limita-
“muscle wasting”, “functional decline”, “ageing”, “mobility” “dis- tions of smart home technology include usability by older adults, cost,
ability”, “exercise”, “nutrition”, “assistive”, “technology” “device” and privacy concerns and limited high-quality evidence of its effectiveness
“self-help”, with additional review of personal reference libraries. in improving safety, function and health [20].
No studies specifically addressed use of AT in patients with sarco- Thus, evidence is lacking for existing and newer forms of AT in
penia. While AT may reduce falls risk in older adults [12], falls were patients with sarcopenia due to the absence of trials in this specific
considered beyond the scope of this review. Rather, we focused on AT’s population, and the emerging nature of many forms of AT.
role in managing functional decline and improving physical activity Nevertheless, AT may be beneficial in other populations with physical
and nutrition behaviours. disability and so holds promise for those with sarcopenia. As described
in Fig. 1, AT may theoretically prevent accelerated declines in muscle
mass and function resulting from cessation of ADLs (e.g. housework,
3. Assistive technologies for functional decline grooming, gardening etc.) in sarcopenic patients by enabling ongoing
participation.
Commonly prescribed (or sourced) AT for patients with mobility
disability include walking aids (eg. walking sticks and frames). A sys-
tematic review reported that walking aids can improve mobility and 4. Assistive technologies for increasing physical activity
balance in older adults, thus increasing independence [13]. A rando-
mised controlled trial (RCT) examined effects of AT and environmental PRT is effective for maintaining and improving both muscle mass
interventions compared with usual care in 104 frail older adults [14]. and function however less than 15% of older adults participate in any
Participants in the intervention group were assessed for, provided with, form of PRT [21]. Key issues for both clinicians and older adults in
and trained in use of AT addressing motor (including a range of walking prescribing or participating in PRT include lack of access, cost, safety
aids, bathroom equipment, hygiene aids and kitchen aids), visual and concerns, and also poor self-efficacy and perceptions that PRT is too
hearing impairments, with follow-up assessments and further provision challenging, particularly for those with injuries or comorbidities
as needs changed. Change in the Functional Independence Measure [21,22]. These concerns are likely common to sarcopenic patients, and
(FIM), comprising 18 items assessing severity of disability across motor AT may support these individuals to engage in muscle-building ex-
and cognitive domains, was the primary outcome. After 18 months, the ercise.
intervention group demonstrated reduced functional decline compared
with controls (mean declines of 4% and 11%, respectively; P = .01)
[14]. Similarly, a two-year RCT of 91 younger and older adults with
disabilities reported that participants randomised to prescribed AT and
home modifications (including grab rails, bathroom equipment, hy-
giene and kitchen aids) experienced functional decline of a smaller
magnitude compared to that of controls who received no AT [15]. In
319 community-dwelling older adults who reported difficulty with one
or more ADLs, intervention group participants received five occupa-
tional therapy contacts involving assessment, task modification and AT
prescription (predominately grab rails and bathroom equipment), and
one physiotherapy session on balance and strength training, over six
months. This intervention resulted in reduced self-reported ADL dis-
ability (the greatest benefits were observed for bathing and toileting)
compared with a no-treatment control group [16]. However, it is un-
clear whether the benefits were attributable to AT, education, balance
and/or strength training, or their combination. Fig. 1. The potential role of AT in preventing loss of independence due to
functional decline.

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R.A. Scott et al. Maturitas 112 (2018) 78–84

4.1. Walking aids function in passive or assisted ways, and potentially, to improve their
capacity for engaging in traditional PRT. Whole-body vibration training
Walking is not as effective as PRT for improving muscle mass and (WBVT), where high-frequency vibrations are applied to the body while
function, but is a popular activity in older adults, positively associates a patient is in a static position, generally targets improvements in bone
with lower-limb muscle mass and strength [23], and can improve phy- structure but has also resulted in increases of approximately 15% in
sical performance (assessed by the Short Physical Performance Battery; lower-limb muscle strength after six months in postmenopausal women
SPPB) [24]. It has been reported that older adults who use walking aids [36]. A recent network meta-analysis concluded WBVT ranks above
complete less physical activity than those who do not [25], but walking endurance training (but below PRT) for improving physical perfor-
aids may increase walking activity in sarcopenic patients, particularly mance in older adults [37]. Neuromuscular electrical stimulation
those with significant mobility disability. Environmental factors such as (NMES) elicits contraction and relaxation of underlying muscles via
poor street conditions and lack of resting places are barriers to activity in conductive electrodes attached to the skin. In adults with progressive
older adults using walking aids and so need to be considered when diseases such as chronic heart failure and cancer, NMES has resulted in
prescribing [26]. Body weight support treadmills are used to support significantly improved quadriceps strength and performance in walking
walking activity in rehabilitation centres, generally for patients with tests [38], suggesting a possible benefit in sarcopenia. Indeed, a study in
neurological conditions [27]. These devices allow patients supported by which 16 older adults (mean age 73 years) self-administered 24 NMES
a harness to treadmill walk for longer periods [27], and so may be ef- sessions over 15 weeks reported that timed up-and-go time (−16%)
fective for supporting increased walking activity in sarcopenic patients. and SPPB scores (+11%) improved significantly at follow-up [39].
Finally, in addition to supporting ADLs as described above, robotic
4.2. Wearable technology and smartphone/tablet applications devices also allow engagement in passive or active training. A meta-
analysis of 38 trials in post-stroke patients reported small but sig-
Between 2010 and 2016, internet use increased from 12% to 67% nificant improvements in motor control and muscle strength of the
and smartphone use increased from 11% to 42% in US older adults upper limb following exercise with a robotic device [40]. PRT using
(> 65years) [28], indicating digital AT may feasibly be implemented in robotic devices may be a feasible option for older adults with sarco-
this population to increase participation in physical activity [29] [30]. penia [41], but RCTs are required to confirm whether this enhances
Wearable devices and smartphone/tablet applications track indicators functional adaptations to exercise.
of activity such as steps taken, distance, and physical activity intensity,
providing real-time user feedback. Some devices provide advanced 5. Assistive technologies for improving nutrition
metrics such as heart rate, and importantly for sarcopenia, estimate
repetitions during resistance training exercises [31]. Many applications Adequate nutrition may reduce age-related declines in muscle mass
provide exercise programs, including PRT and balance exercises, with and function, and enhance benefits of exercise interventions targeting
features including video demonstrations and exercise diaries. The suc- sarcopenia [42]. Older adults experience physiological, social and en-
cess of wearables and applications in facilitating health behaviour vironmental changes that negatively affect eating processes and food
change is likely dependent on their capacity for effective engagement, intake, potentially resulting in malnutrition [43]. Sarcopenic dys-
achieved through strategies including clear user feedback and en- phagia, characterised by loss of mass and function of swallowing
couragement [32]. As such, these devices may be most effectively muscles, may be common in sarcopenic patients and contribute to on-
prescribed for sarcopenic patients by clinicians who access activity data going malnutrition through loss of interest in eating and increasing risk
remotely, and monitor patient adherence and exercise progression [29]. of aspiration pneumonia, choking and dehydration [44]. Further, poor
Interventions which provide engagement with peers through social dentition and edentulousness result in difficulties chewing food and
networking may also increase activity levels in older adults [33]. avoidance of protein-rich foods such as meat [45]. Dentures are an AT
which can assist in increasing food intake but must be appropriately
4.3. Video gaming and virtual reality prescribed. Compared with patients with well-fitted dentures, commu-
nity-dwelling Japanese adults with ill-fitting dentures were five-fold
Interactive video gaming and virtual reality (VR) provide new more likely to have sarcopenia as defined by the Asian Working Group
platforms for delivery of exercise programs. These can be utilised in the for Sarcopenia criteria [46]. Dentures may therefore prevent sarcopenia
home and provide immersive experiences that for some users may be in older adults through improving nutrient intake, although the cross-
more enjoyable than typical exercise. VR has been trialled in a range of sectional nature of this study limits comments on causation.
patient populations for improving mobility, leg strength and balance One in five community-dwelling older adults report requiring as-
[34]. A systematic review of 13 studies found inconclusive results to sistance with food-related activities (eating, meal preparation and
support the use of VR for physical function due to limited studies and shopping) [47], and this is likely to be greater in sarcopenic popula-
poor methodology, but reported a consistent positive motivational ef- tions. No studies were identified that used AT to overcome difficulties
fect [34]. A trial of a six-week balance-focused VR interactive game with these ADLs. However, provision of AT may assist sarcopenic pa-
(using the Nintendo® Wii balance board) versus therapeutic balance tients to remain independent with nutrition-related ADLs by providing
classes in Malaysian older women reported that both groups improved devices to overcome impairments such as poor hand grip strength and
their physical performance, but more therapeutic balance group parti- mobility [48]. Table 1 provides examples of potential AT solutions for
cipants had significant improvements in the timed up-and-go test (an meal preparation, self-feeding and shopping/community access in sar-
assessment of mobility) than VR group participants (23 vs 13%; copenic patients.
P < 0.05) [35]. This result is unsurprising given that the VR inter- Many smartphone applications provide nutritional information and
vention was restricted to the area of the balance board and so did not allow people to track their nutritional intake. The majority of these
encourage increasing mobility. Interactive games which encourage applications have not been validated in research studies and generally
PRT-type activities and increased mobility may demonstrate greater focus on dietary restriction, with a review demonstrating that use of
effectiveness for reversing functional decline in sarcopenic older adults. applications may result in modest but significant reductions in caloric
intake and body weight [49]. Dietary goals and advice for primary and
4.4. Emerging technologies for increasing physical activity secondary prevention of sarcopenia clearly differ significantly from
those for weight loss, and as such apps with a specific focus on
Some emerging technologies mimic beneficial effects of exercise on achieving adequate intakes of protein and other nutrients relevant to
muscle, allowing sarcopenic patients to increase muscle mass and muscle health are needed for older adults.

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R.A. Scott et al. Maturitas 112 (2018) 78–84

Table 1 Table 1 (continued)

Assistive technology solutions to address difficulties with nutrition in sarco-
penic patients. Problem Potential assistive technology solution Method/reason for
use
Problem Potential assistive technology solution Method/reason for
use Difficulty with Can assist with
shopping/ mobility, provides
Difficulty with Spikes and rim to community seat for resting and
meal hold food in place access basket for
preparation for people with shopping items
upper limb
weakness

Allows people with

mobility disability
Aids in opening to travel longer
jars/bottles for distances
people with upper
limb weakness

Can be used to
access food
Reduces need for delivery services
standing whilst and to track food
preparing meals for intake
people with lower-
limb or back
weakness

Difficulty with Enlarged handles

self-feeding and right-angled 5.1. Emerging technologies for improving nutrition
cutlery can
overcome weak
grip and reduced Three-dimensional (3D) food printers are emerging in commercial
range of movement kitchens and can be expected to be common in homes of the future,
in the upper-limbs presenting a novel approach to allow personalised nutrition for older
adults [50]. Meals can potentially be printed in the home, reducing the
need to travel to shops. Furthermore, meals can be customised to pro-
vide nutrient contents which can assist sarcopenic individuals in
meeting dietary prescriptions. Developers are also using 3D printers to
Aids in getting
food onto cutlery
modify food textures, and this technology could be adapted to provide
by pushing food food which is appealing and safe to consume for those with poor den-
against side of tition and sarcopenic dysphagia. Challenges still to overcome are the
plate for people current high cost of printers and food materials, as well as limited shelf
with upper-limb
life of these materials [50].
weakness
As previously described, the smart home of the future will include
numerous connected devices that can support independent living.
Smart refrigerators in particular have the potential to assist older adults
to maintain adequate nutrition through monitoring dietary intake,
Prevents liquid providing reminders to eat and individualised eating plans, and or-
spills for people dering food through online services [20].
with upper-limb
weakness
6. Limitations of assistive technology

While AT may be beneficial for older adults with sarcopenia, it is

important to consider potential negative outcomes. Ongoing use of AT,
especially devices such as electric lift chairs, electric beds or stair lifts
may accelerate lower-limb muscle atrophy through disuse [51]. Clin-
icians should preferentially prescribe AT devices that minimise further
progression of sarcopenia and assess the patient’s capability for enga-
ging in PRT rather than selecting AT as a first option. AT including
walking aids or manual wheelchairs place repetitive stresses on upper-

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R.A. Scott et al. Maturitas 112 (2018) 78–84

limbs, potentially resulting in shoulder pain, osteoarthritis or carpal Table 2

tunnel syndrome [13,52]. Mobility aids may also increase falls through SARC-F screening tool components and options for assistive technology.
misuse or trip-related falls [13]. There are reported cases of bed sticks Component Question Responses and Potential assistive
(which assist in getting in and out of bed) causing strangulation deaths Score technology solutions
of nursing home residents suffering cognitive impairment and prone to
Strength How much difficulty None = 0 –
falls out of bed [53]. This reinforces the important role of qualified
do you have in lifting Some = 1 Four-wheeled frame
health professionals in prescribing AT and completing risk assessments. and carrying more A lot or Kitchen trolley
Abandonment of AT is common and can result in the needs of a than 10lbs? unable = 2
person with disability being unmet [13,54,55]. Around 30% of AT Assistance in How much difficulty None = 0 –
devices are completely abandoned [54] with factors related to aban- walking do you have walking Some = 1 Consider, or review
across a room A lot, use aids, use of: Walking stick
donment including patients not being consulted about devices, poor
or unable = 2 Elbow crutches
device performance, inappropriateness of device, insufficient training Walking frame
and information, and changing patient needs over time [54,55]. A study Wheelchair (manual or
with a pre-post-test design in 54 multiple sclerosis patients trialled an power)
Scooter
interdisciplinary intervention for prescribing AT including assessment,
Rise from a How much difficulty None = 0 –
training and monitoring, compared to assessment only [55]. During the chair or do you have Some = 1 Consider, or review
intervention period the rate of abandonment decreased significantly bed transferring from a A lot or unable use of: Adjustable
from 37% to 10%, demonstrating that training and regular follow-up of chair or bed? without height chair
AT prescriptions can increase adherence. help = 2 Electric recliner
Bed stick
Costs and funding availability of AT can be a barrier for older adults
Electric bed
with devices including wearables, smartphones and power wheelchairs Bed or chair blocks
costing hundreds to thousands of dollars [32]. Currently, access to AT Leg lifter
in the public sector is often poor with limited countries having AT Climb stairs How much difficulty None = 0 –
funding programs, and even when programs exist, AT is often rationed do you have climbing Some = 1 Rail
a flight of ten stairs? A lot or Walking aid (stick or
with long wait lists [11]. As previously highlighted, barriers for older unable = 2 crutches)
adults to utilising emerging technologies such as apps, smart homes and Stair lift
the IoT centre on costs and usability [20]. However, security and Water or electric lift
privacy concerns regarding safety of sensitive personal and health data Falls How many times None = 0 –
have you fallen in the 1–3 falls = 1 Walking aids
are perhaps the key issue that requires addressing as availability of
past year? 4 or more Bathroom equipment
these systems increases. falls = 2 (shower chair, over
toilet frame)
7. Clinical implications and future directions Home modifications
(rail, ramp, level access
shower, removal of mats
There is currently limited evidence for a role of AT in sarcopenic and clutter)
patients, although some studies demonstrate that AT can reduce rates of Glasses
functional decline in disabled populations. AT may contribute to Modified footwear
maintaining adequate physical activity and nutrition in sarcopenic pa-
tients, both of which may slow its progression. Sarcopenia is a multi-
factorial condition and associated with numerous other comorbidities
and so AT alone is unlikely to prevent functional declines. Nevertheless, smart phone applications and smart homes, wearables, exoskeletons
even small reductions in rates of decline are likely to add quality of life and robotics, and NMES for increasing capacity for engaging in ADLs,
and longevity for sarcopenic patients; a study of Italian older adults physical activity (particularly PRT) and desirable nutritional beha-
demonstrated that low SPPB scores, not other health comorbidities, viours. Future development of these devices should ensure considera-
were predictive of increased mortality in those with sarcopenia [56]. tion of theories of health behaviour change with reinforcement and goal
Furthermore, given average health care costs for those with mobility setting included [59].
disability are 10-fold higher than for those without [57], AT may be a In conclusion, further research is required to determine the role of
cost-effective intervention for sarcopenic patients. currently available and emerging AT for maintaining independence in
Even if AT has only small benefits for preventing or reversing sar- sarcopenia. Nevertheless, clinicians should evaluate AT needs in pa-
copenia, it can support independence, an important outcome for older tients with sarcopenia, and whether an AT device will promote or limit
adults. As such, we recommend that clinicians screen older patients for physical activity should be key in the decision-making process.
sarcopenia and consider potential AT that can help them manage its Importantly, AT devices need to be prescribed with appropriate patient
functional consequences independently. This procedure could be sup- training and consultation, and ongoing adherence should be monitored.
ported by the SARC-F, a simple questionnaire developed to enable
sarcopenia screening without physical measurements [58]. As we have
described in Table 2, the SARC-F can be used to identify functional Contributors
consequences of sarcopenia (difficulty with strength, walking, rising
from a chair, climbing stairs and falls), and this may aid clinicians in Rachel A Scott conceived of and wrote the paper.
appropriately prescribing AT device solutions. Again, use of AT for Michele L Callisaya provided intellectual input and review.
sarcopenia is not without limitations; clinicians need to consider the Gustavo Duque provided intellectual input and review.
justification and safety profile for any AT device and carefully monitor Peter R Ebeling provided intellectual input and review.
its use to ensure it is providing appropriate assistance while encoura- David Scott conceived of and wrote the paper.
ging participation in activity (i.e. not causing further muscle mass and
functional declines).
Due to the emerging nature of modern forms of AT, there is no Conflict of interest
evidence for technological devices in management and treatment of
sarcopenia. High quality studies are needed in many areas such as VR, The authors declare that they have no conflict of interest.

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R.A. Scott et al. Maturitas 112 (2018) 78–84

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