Close social relationships and connections with our wider community are extremely important for not just out mental health but also our physical health. 

Thanks to the pandemic all of us will be familiar with the impact physical confinement has on our, relationships, jobs, health and wellbeing. While lockdowns forced the global population into physical isolation many of us turned to social media to try maintain contact with loved ones.

But does social media replace physical interactions?  

Recently, as part of post graduate research, I conducted a qualitative study looking at males’ perceptions of social media and its impact of social isolation. Perhaps unsurprisingly we found that even though it’s a useful tool it does not replace face to face interactions for the vast majority of men. Interestingly this doesn’t extend to business transactions, where contact via social media is preferable for most. While for men, business networking felt as successful online, the genuine, emotional communication required for personal relationships could not be recreated on social media. 

But what does this have to do with injury and pain? 

Pain research demonstrates a complex but significant relationship between pain, mental health, epigenetics, culture and social interactions. Due to lockdowns and forced isolation the world saw a significant rise in mental health concerns particularly among men and a significant increase in those seeking treatment for physical pain conditions such as low back or neck pain. This is due to the underlying neurophysiological and neuropsychological processes in which our brains process and interpret pain. Although the exact mechanism is still up for debate, we know the regular social interactions and engagement with our wider communities have a protective and relieving effect on pain. Essentially time with friends and loved one’s results in faster recovery from injury and illness and can also prevent and relieve pain and disease. 

Although it is unlikely that we will experience further lockdowns (fingers crossed), injuries (and illness) can result in a similar period of isolation for many. A large part of our jobs as clinicians is to help keep clients engaged in “regular” life during the rehab process. This is 2-fold: one reason is the continue to stimulate tissue growth and maintain normal loads, the other is to minimise negative social and mental impacts of disengagement.  

A big concern for many coming to physio is that we will stop you from training or exercising! But, long gone are the days when we recommend rest for injuries. At no point in your rehab should you ever have to stop moving (unless medically unwell) or mentally you need a break.  

Basically, if it is important to you is important to your rehab!  

Practically this means rehab programs aim to keep you involved in your normal life as much as possible. You and your therapist should set time sensitive goals that progressively move you towards full recovery. This means training around, not through injury and working with your therapist to identify training and lifestyle factors that are important to you. 

 In sports this can look like reducing volume, intensity or frequency of training, focusing on technical aspects of sport, or modifying strength and conditioning programs to reduce load through the injured structure. Following surgery, it will include early mobilisation ( often within the first 24hours) and early rehab beginning within the first 3-7days. In your work and home life it may include modifying the environment such as using a sit to stand desk or timing self-administered pain therapies such as specific exercises, relaxation techniques or pain medication. It may also mean working from home in order to allow for more flexibility with your physical demands and more energy to maintain social connection (even though it shouldn’t be it can be a little hard to do exercises in the office or in formal clothing!). 

Outside of these it may also include thinking about things like how to play with your children, how to continue rehab when on holiday, how to sit through a movie or dinner with friends. Your clinician will work with you to tailor your program to suit your lifestyle and training needs, making sure your injury has as little impact as possible on your ability to stay connected with those around you.  

While injury can be frustrating and scary, remember that it is temporary. The human body is capable of incredible things and so long as you are alive it is constantly adapting to stimulus, growing new tissue and learning new things. Getting an appropriate diagnosis is the first step as this will determine the time frame for your recovery. The next step is developing a treatment plan that fits your goals, social, mental and physical needs. Getting this right will help you recover faster and reduce the chance of recurrent pain or injury.  

Thankfully you have the wonderful team at Anatomy Rehab who can help with these!  

 

By physio Lucy Woodham

If you think professional athletes are superhuman you are not alone. The recent 2022 Football world cup in Qatar highlighted some of the unbelievable athleticism that humans are capable of.

But what makes these professional athletes unique?

How do they manage an insane training schedule while remaining for the most part injury free?

And when they do get injured how do they return to sport so quickly?

 

It is true that some athletes have a significant genetic advantage that allows them to reach the pinnacle of their sports.

I am sure you have all heard of Michael Phelps( AKA the flying fish), the most decorated Olympic swimmer, who has an unusual arm span to height ratio, not to mention large hands and feet. All of which allow him to swim at speeds of up to 6MPh, while most of us mere mortals will reach 2mph if we are lucky.

Or maybe you have watched the NBA and noticed that you come nowhere close to the average height of a professional basketball player which happens to be 8 inches taller than the average man.

Perhaps less apparent are those with slight biological differences including athletes such Jamaican sprinter Usain Bolt who has a usual capacity to build fast twitch muscle fibers. Or cyclist Miguel Indurain with his massive 7.8L lunge capacity, most of us are around 6L.

 

Clearly, there are intrinsic factors such as genetics, that influence our capacity to perform at a given sport. But do these genetic factors play a role in recovery?

It’s not hard to understand how factors such as improved oxygenation or muscle building capacity, help increase recovery from training and injury. But even with these genetic variations, athletes like Bolt, Phelps and LeBron didn’t become great without a lot of discipline, work and of course, avoiding injury.

Every athlete at the top of their game is getting the 4 key basics right, but we will get to that.

 

First let’s talk about what performing and your best and recovering from an injury have in common. In order to perform at your maximum potential, you need to have energy reserves to fuel muscle contraction and mental work. When you run out is when you are most vulnerable to injury, this is called fatigue. Now our high performing athletes spend years building resistance to fatigue through training allowing them to function better when tired but also train or play at a greater intensity before experiencing fatigue. But essentially, we can think of performing and injury as being on opposite ends of the same spectrum.

 

In order to train more frequently and intensely ( and therefore perform better) we must restore depleted energy and repair any minor damage caused by fatigue.

 

The four key parts of any great recovery are:

Sleep: sleep cannot be underestimated. Have you ever experienced that feeling like you slipped down the stairs? Well, this happens sometimes as we release a hormone into our nervous system to limit skeletal muscle activity. Our brain does this so our muscle tissue and nervous tissues can repair. It is the only chance our body has to do this as when we are awake, we can’t just switch off our legs or our brain ( although it sometimes feels like it). When we don’t get enough sleep our capacity to make decisions is significantly impaired meaning we are more likely to react slower to potential harm and more likely to miss calculate the action required. When training hard or recovering from injury we can require 1-2 hours more sleep per night!

Eat: a lot of us think we should diet when we are injured but actually it is the opposite. We require more energy when injured, for example a broken leg needs around 15-20% more energy just to rebuild tissue and probably a little more to use the crutches.

Reduce stress: Our nervous system processes all of our stress the same, when we are injured, our brain is busy trying to protect our injured tissue, it changes the way we make decisions, access memories and interact with the world around us. If we are more stressed our nervous system will have to split its attention resulting in poorer recovery.

Load: Nowadays total rest is not recommended unless a major, multi trauma injury or a head injury has been sustained. Even post op you are expected to be up moving within 12-24 hours. This is because loading tissues helps to guide new cells on where to go, resulting in stronger tissue and faster recovery. When injured the load must be appropriate to the level of damage and the tissue type. Therefore, proper diagnosis is key. When healthy the load needs to stimulate tissue growth through microtrauma, but not cause excessive damage.

 

Recovery is so important that many teams I have worked with have contracts that dictate athletes’ diets and other lifestyle factors, especially when injured. Professional athletes are so impressive because they priorities recovery, meaning they don’t lose time not being able to train. Whether you are injured or wanting to perform better, get the basics right. If you can do that you will recover faster and stronger!

 

By Physio Lucy Woodham 

Breath is vital to life, we enter the world with an inhale and we leave the world with a final exhale. We all know we cant live without breathing and it is believed by many people and many cultures or religions as the most vital form of energy and life. Breath is given many different names in these practices such as prana.

 

Breathing influences us in both a physiological way by stimulation the parasympathetic nervous system, which controls the body’s ability to relax, as well as in a psychological way by diverting attention to thought and in that way can divert some attention away from pain.

 

Breathing is a very interesting body function as It is both involuntary and voluntary as we are able to control and manipulate our breath. Here I’m going to focus more on the voluntary side of breathing and how and why we should focus on some breath work.

It is a very common saying when people are stressed or have too much on their plate to say “Just breathe” But why?

This is because breathing switches our body to the parasympathetic nervous system which is our rest and digest mode. When the PNS is activated your body is at ease and relaxed and involuntary functions such as digestion are taking place without any additional stress to hinder their performance.

For example when we are in a stressful situation (such as being chased by a bear)  your breathing rate increases, your heart rate increases, your blood pressure increases and focus is moved away from certain functions such as digestion. As in that moment, digesting your over indulgent lunch is not the most vital process in the body and it is more crucial to get out of danger, so you are running on adrenaline and your cortisol levels increase. Your body is functioning in a stress response.

City life may not be the same in the way that you are being chased by a bear and fear for your life, however your body doesn’t know the difference between the stress of the bear or being stuck in traffic, work deadlines or stressful financial responsibilities. These are all detected as a threat to the body. Long term stressors can be more harmful to the body as we never shake them off and you remain in the fight or flight response which will further increase your cortisol levels and in time may even alter hormonal levels.

We all definitely need this stress response otherwise we will never get anything done but the body needs to be able to freely switch within the nervous system.

 

In my clinical practice I have found the most effective way to treat the central nervous system, decreasing chronic pain , stress and anxiety is by using Craniosacral therapy. It is the good way to work on the environment of the source of pain. The same way in which you would nourish the soil of a pot plant for the flower to grow. You need a craniosacral therapist to help you with this treatment. What I have found is that breathwork is something that you can do on your own, anyway and it is another way in which you can train your nervous system. Breathing improves the connection between the body and the brain, mainly by the vagus nerve. Vagus is the Greek work for traveller, and it is collecting information from the body and travelling with this information to the brain.

 

Breath work is currently a very popular topic and there are so many different types of breathing you can focus on depending on what outcome you are looking for, such as energising or calming the body. This is a brief introduction to breathing so for now “Just breathe” and that awareness of breath is already providing many benefits to your body

Many people have had their fair share of “starting again” in their sporting careers.

We are talking about being a few weeks out of competition, months of preparation behind you, at your peak fitness level and then BAM, the curveball. Illness, injury, accidents, unexpected surgery. This is what I’m talking about and I’m sure many of you can relate. 

It’s heart breaking. The commitment, dedication, discipline and sacrifices. All seems wasted at the time. You enter what I sometimes call the black hole. You see nowhere out. Your goals crushed, your efforts fruitless, nothing to look forward to, nothing to drive you. You lose all motivation.

Since I just recently had my own experience with covid, I’m going to be talking about “starting again” after a viral infection. I have previously managed to avoid covid and unfortunately AGAIN, a virus nailed me close to another Ironman. Many of you that know me well, would know that in 2016 I was training for my first Ironman in South Africa. 6 weeks out of the race, I was diagnosed with the coxsackie virus and subsequent myocarditis. It was hell. 8 months of hell. So when I tested positive for covid, I had that horrible sinking feeling. Knowing that I have previous cardiac issues and an abnormal heart rhythm, the odds were stacked against me.

HOWEVER I quickly pulled myself together, including my mental state and got to work. Researching, reading, trying to find the best way possible to fight this virus, keeping myself healthy, keeping my heart in check and knowing how and when to get back to training. I started getting messages, “take it easy”, “don’t rush back”, “many people took weeks/months to recover”, “becareful”. Whilst all with good intention, this does play your mind. All I could think of was, I’m still going for this. 

As with any injury or post surgery rehabilitation, there is a return to sport protocol. Muscles, joints, tendons, bones and ligaments need time to heal and then time to adapt to the training load again. If not followed, it can lead to weakness/ long term injuries/ permanent damage. The same goes for a viral infection. But what’s more dangerous with a viral infection, is that it can affect your organs and blood, in the case of covid. Clotting has been a huge issue post covid infection, my colleagues have seen a few cases of deep vein thrombosis. The heart, lungs, kidneys and brain also seem to be the organs most affected. When returning to sport the heart needs time to adapt to the cardiovascular load again, otherwise you can cause damage to it. Sudden cardiac death. Ever heard of that? Young, fit, healthy athlete drops dead from a heart attack. Fortunately (and unfortunately), I have been through a near heart attack situation, so I am well aware of this. Also be aware that the period of inactivity before you can begin exercising also causes a degree of detraining and increases the risk for potential musculoskeletal injury, particularly if you resume exercise too fast and aggressively.

The big question is, ARE YOU IN IT FOR THE LONG RUN? Excuse the pun 😊 Looking at the longevity of your sporting career. Or are your goals more important than your body? It’s really tough, I’ve been there! Wanting to get back at it because you’ve put so much work towards a race. However,  I know that I’m definitely and have always been in it for the long run. I want this body to be able to run marathons at 60!

During my time in isolation I read numerous research papers, articles, blogs. I even did my own research with athletes’ experiences on Instagram. It has been very interesting getting feedback and also quite scary to realize that there is an entire process to go through when returning to sport post covid, that many people including many coaches are not aware of. In fact, this protocol should be used for any virus. 

So I thought I’d share what I have learnt, read and been advised, just to make some sense out of it all. The information is confusing and continually changing. It also all depends on the individual, your symptoms and any previous health issues. I’m no medical doctor or specialist. I am using information from medical publications and comparing it to what people have told me and what I’ve seen people doing. Remember this is for mild/moderate cases ONLY!

I have taken the following information from the British Journal of Sports Medicine and the American Medical Society for Sports Medicine.

 

 

This figure from the British Journal of Sports Medicine seems to explain it best.

 

 

It is suggested that you should increase exercise frequency of exercise first, then duration, and finally intensity. Each parameter should be increased gradually. Increasing training intensity or volume no more than 10 percent per week or every three to five training sessions. This can be modified according to your age, severity of symptoms, pre- existing conditions and pre covid conditioning.

 

Factors to consider before testing positive:

• Fitness and goals
• Physical conditioning
• The amount of hours spent training per week
• The state of your health (sleep, diet, alcohol, smoking, stress levels)

Some of the factors to monitor after you tested positive

• Resting heart rate. Take this everyday!!
• Symptoms. The progression and regression of them and the time frame.
• Need for medication
• Rate of perceived exertion doing simple tasks. How do you feel showering, walking around/ doing the washing?
• Sleep, stress, fatigue and muscle soreness during the illness
• Mental state. I added this here as I feel it is so important. Are you positive about your recovery, are you telling yourself that you want to feel good again? Being negative and “down in the dumps” can affect your recovery time

Important considerations for deciding to Return to Sport

• It is obviously recommend not to exercise whilst you have symptoms. The duration varies depending on individual factors including severity of your symptoms. 
• The recommendations are continually changing. But the current protocol is as follows. The asymptomatic athlete: three days abstinence following positive test. Mild illness: three days abstinence from symptom onset. Moderate illness or cardiopulmonary symptoms: minimum five days abstinence and an advised evaluation prior to return (note that this period has been reduced from 10 days in previous recommendations).
• Before considering starting your return to sport , you must be able to complete activities of daily living and walk 500 m on the flat without excessive fatigue or breathlessness.
• At any stage, if you experience any fatigue, elevated morning heart rate, breathlessness or any other symptoms you must take a day to rest and take a step back in the protocol.
• Athletes with pre existing conditions and diagnosed with covid should have a medical assessment.
• You must be off all symptom-related treatment before beginning your return to activity. As loss of taste or smell may persist but this is not considered when returning to sport.

Red Flags!!!

• Chest pain or palpitations
• Breathlessness out of proportion to that expected during recovery from exercise
• Findings associated with thrombosis or pulmonary embolism (eg, swollen leg, tachycardia, or dyspnea at rest)

My experience with covid and returning to training with an Ironman looming

I have been training for a full Ironman. Training between 15-20 hours per week. My symptoms went from sneezing and a very bad post nasal drip to full on fever and muscle/joint pain for 3 days. I have never had pain like this even with the flu. Felt depleted and fatigued for 3 days following this. I still moved, did mobility and breathing work. Throughout having symptoms my heart rate remained low and I had no involvement of my lungs. 6 days after the acute symptoms subsided, 3 days after my fatigue subsided, I did my first indoor bike session. Monitoring my heart rate, had no spikes and no breathlessness. Did not feel fatigued on the day or the day after. The next day I did a gym session and 5km run on the treadmill. The next day another bike, increasing the time by 15 mins. Again, no worrying symptoms. All whilst making sure I increase duration and frequency before intensity.  So far I have been fortunate.

Comments and experience from others

“I literally took it easy on the way back cause my heart rate used to spike with minimal effort, then started increasing effort whenever I felt I can and as days passed by, things are back to normal now. Just didn’t rush, at all”. – triathlete

 

“I had a mild ish one. Ended up in my lungs. I waited one week when I had it. Then did weights only for the first 5 days. Then on the 6th did a 10km run which felt like my lungs were on fire. But I eased back into it with running and biking”.

 

“Not a triathlete. But from an avid runner, when I had covid. I took a full week rest. Then 1 week only cycling and on the 3rd week running at 60 to 70% and by 4th week I ran back at full capacity. My wife said I was too conservative 😂. But I wanted to be safe. It’s not like few weeks are gonna make a difference. I’m in it for the long run”. YES YES YES!

 

“Symptoms were night chills for 4 nights , loss of appetite (not smell or taste) for about a week to varying degrees. returned to training on day 14. started with some easy body weight, gentle bike . 2 weeks back to almost normal”. – cyclist

 

“I had body ache and fewer for 2 days and then pressure on my chest and dry cough.
Then I read this book and I did exercise 6. I was like new next day. Please check it and let me know what you think. True is that I had very mild symptoms and for hard cases it wouldn’t be that smooth, but it will definitely help. I am 100% sure, because with breathing exercises I improved a lot not only with physical health but also mental”. 

 

“We only had sinus . Lasted 4 days started training 2 days after symptoms were gone . Just monitored HR and reaction to training . Did only one session of about 45 minutes each day for the first week and then built up to longer sessions and double days . Still did lots of resting in between and 😴. Took a few weeks to get back to quality sessions but we didn’t have any complications or set backs . Just used HR as a guide as well as how I felt day to day 😃”- triathlete

 

“I had body aches, headaches and sore throat. Lasted 4-6 days. Sore throat was the last go at about 7-10days
2) from about day 7 I started
3)Started with 30mins low heart rate movement (kept it under 100) I just started on the rower at home. Felt like I needed to move to help speed up recovery which I really think it did. Sweated quite a bit with the first and second one and definitely felt better after.
4) slowly upped intensity and duration over about 2 weeks
5) from 4 weeks I was back to similar volume of training but was still feeling like it took more out of me than before and would reach heart rate percentages earlier in training. I would say by about 2 months I was same if not better than pre covid. I feel like the slow start at base levels and building up slowly over 2 months benefitted my training in the long term and helped with heart rate control and self knowledge.
6) I can recommend starting moving early with low impact and HR” – Crossfit Athlete

 

“Took me 2 weeks to regain my weight and a month to reach my prior performance levels.”- triathlete

 

“We had covid. 3days headaches body aches and mild fever. I stayed under 135bpm and walked for 30/45min on day 5/6/7 then cycled from day 10 for 45min zone 2. Kept zone 2 and skipped every 2nd day training until 3weeks”. 

 

“I had mild symptoms last year dec. My symptoms were serve headaches, tiredness, and no energy. I isolated for ten days. And because I didn’t show hectic symptoms I went for a 30km cycle the day after my isolation and it knocked me down for twos day were all I did was sleep. After the two days I tried to go for a slow run and we’ll that end up being a walk. Running took me a while before I could run far. The whole of dec I think my longest run was 6km and very slowly. I used to get tired going up stairs. But I’m January I decide to build up slowly again” .

In conclusion

• A return to training protocol should be followed post viral infection but should be individualized to the person.
• Intensity should be the last parameter included. So is it safe to return to racing a week or 2 post infection?
• Use your heart rate and post exercise symptoms as a guide when returning to training.
• Always put your body before a race
• See a sports doctor and have a full medical done if you have any concerns or if you have any races lined up after having a virus.

 

Recommended reads:

 

• https://bjsm.bmj.com/content/54/19/1174
• https://www.uptodate.com/contents/covid-19-return-to-sport-or-strenuous-activity-following-infection
• For triathletes: https://joefrieltraining.com/covid-and-return-to-training-comments/

 

By Chiropractor Kirsten Evans

Covid and calf pain – what you need to know: 

As we all know covid has come with some pretty strange side effects and although it has been in our lives for a little over two years there is still a lot we don’t know. As more people are infected with the virus, we are learning more about its potentially harmful impacts, its mechanisms and how to treat it. One lesser-known side effect of the SARs- Covid virus is its potential to cause blood clots. 

Our ability to form blood clots is crucial to our survival, when we cut or damage tissue, we produce proteins that attract platelets and cells called clotting factors. These help us to stop bleeding and initiate healing. However, clotting can be a problem if it occurs inside blood vessels such as in the brain (stroke) or heart (heart attack). 

While the mechanism for this increase in clotting is unclear, we now know that there is an elevated risk of blot clots during and in the two weeks following recovery from covid infection. In musculoskeletal physiotherapy blood clots are rare, however they can present similar to soft tissue injuries so it is important that your physiotherapist is aware of your health status including recent covid infection.

A few key things that could increase your risk of developing a clot include non-modifiable risk factors such as

• Underlying health conditions (including heart disease or diabetes)
• Recent covid infection including severity of infection and vaccine status
• Individual or family history of blot clots

Or, modifiable risk factors such as

• Periods of inactivity such as
  • long haul flights
  • bed rest
• General activity levels
• Current smoking status
• Medications including female hormonal contraception

How does this relate to physiotherapy?

In recent months at Anatomy rehab, we have seen a notable increase in presentation of deep vein thrombosis (DVT). DVT is the formation of clot in a peripheral vein, it can occur spontaneously, following trauma or periods of inactivity. While DVT is not something that physiotherapy treat it does present in a similar way to musculoskeletal pain meaning your physiotherapist might be the first healthcare professional you see. To ensure you receive appropriate care, it is important that you seek physiotherapists that are well trained and highly skilled (such as those at Anatomy rehab). As physiotherapists we take a detailed history of your current complaint as well as a comprehensive medical history to help us diagnose the cause of your pain. It is important to note that DVT most commonly occurs in the lower leg, but can occur in any peripheral vein. In the case of DVT a few things symptoms you should look out for are:

• Pain, swelling or tightness without a history of trauma.
• Numbness or pins and needles and fatigue in the limb
• Worsening of symptoms with exertion

*DVT has the potential the be life threatening if untreated so, if you note any shortness of breath, chest pain or discomfort, weakness or difficulty moving or speaking, or you suspect you could have a DVT then you should seek immediate medical care.

 

To confirm a DVT diagnosis a scan such as duplex ultrasound will be done and you may also have a blood test to look at your blood characteristics.

How can you reduce your risk?

Unfortunately, some risk factors you can’t change, however there is a few ways you can reduce your risk of developing blood clots following covid.

✅ Severity of the disease is an important indicator of clot risk factor post covid. We know that vaccinations reduce the severity of the disease so a good place to start is making sure you are up to date on your vaccine and boosters.

✅ While rest is important when sick or injured it is important to keep moving little and often, avoid long periods of best if possible. If you are not well enough to go for a walk (even around the house), try to keep your feet and legs moving at regular intervals throughout the day and once able start with short frequent walks.

✅ Smoking has negative effects on peripheral blood flow and increases likelihood of blood clot formation, so if you currently smoke try to reduce or quit.

If you have had a recent covid infection or think you might be having DVT symptoms then do not hesitate to see a medical professional.

 

By Physio: Lucy Woodham 

References:

LONGCHAMP, G., MANZOCCHI-BESSON, S., LONGCHAMP, A., RIGHINI, M., ROBERT-EBADI, H. & BLONDON, M. 2021. Proximal deep vein thrombosis and pulmonary embolism in COVID-19 patients: a systematic review and meta-analysis. Thrombosis Journal, 19, 15. Available: 10.1186/s12959-021-00266-x

MUMOLI, N., DENTALI, F., CONTE, G., COLOMBO, A., CAPRA, R., PORTA, C., ROTIROTI, G., ZURETTI, F., CEI, M., TANGIANU, F., EVANGELISTA, I., VITALE, J., MAZZONE, A. & GIARRETTA, I. 2022. Upper extremity deep vein thrombosis in COVID-19: Incidence and correlated risk factors in a cohort of non-ICU patients. PLOS ONE, 17, e0262522. Available: 10.1371/journal.pone.0262522

SUH, Y. J., HONG, H., OHANA, M., BOMPARD, F., REVEL, M.-P., VALLE, C., GERVAISE, A., POISSY, J., SUSEN, S., HÉKIMIAN, G., ARTIFONI, M., PERIARD, D., CONTOU, D., DELALOYE, J., SANCHEZ, B., FANG, C., GARZILLO, G., ROBBIE, H. & YOON, S. H. 2021. Pulmonary Embolism and Deep Vein Thrombosis in COVID-19: A Systematic Review and Meta-Analysis. Radiology, 298, E70-E80. Available: 10.1148/radiol.2020203557