{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T09:52:21Z","timestamp":1787737941992,"version":"build-2784847793"},"reference-count":40,"publisher":"Springer Science and Business Media LLC","issue":"2","license":[{"start":{"date-parts":[[2025,1,29]],"date-time":"2025-01-29T00:00:00Z","timestamp":1738108800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,1,29]],"date-time":"2025-01-29T00:00:00Z","timestamp":1738108800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100001782","name":"University of Melbourne","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100001782","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Curr Oncol Rep"],"published-print":{"date-parts":[[2025,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose of review<\/jats:title>\n                    <jats:p>Breast malignancy is the most common cancer in females. Symptoms of pelvic floor disorders and sexual dysfunction secondary to systemic cancer treatment may occur. Non-surgical, non-pharmaceutical conservative therapies, namely pelvic floor muscle (PFM) and education-based therapies, could be beneficial to reduce these symptoms in this population. This systematic review aimed to examine the evidence regarding their effectiveness on bladder, bowel, vaginal, sexual, psychological function, quality of life, and PFM function in breast cancer populations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Recent findings<\/jats:title>\n                    <jats:p>Six databases were searched to identify interventional studies on the effect of PFM therapies, education-based therapies, or combined (multimodal) therapies on any outcome of interest. The search yielded 603 results, from which 12 studies were included. Of these, six (50%) were RCTs, one (8%) was a non-RCT with two groups, and five (42%) were non-RCTs with a single group. Findings suggest that PFM therapies (active) may be beneficial, and education in the format of CBT may improve bladder function. No data were found for bowel function and results from two RCTs were inconclusive to draw conclusions for vaginal function. Sexual function was the most frequently reported outcome. PFM therapies (active\u2009&gt;\u2009passive) may be beneficial, and education is more likely than not to improve sexual function. For psychological function, PFM therapies (active\u2009+\u2009passive) may be beneficial, and education is more unlikely than likely to improve psychological function. For quality of life, PFM therapies (active\u2009+\u2009passive) may be beneficial, and education is more unlikely than likely to improve quality of life, although CBT combined with physical exercise may provide further improvement. PFM therapies (active\u2009\u00b1\u2009passive) may improve PFM function. Given the limited number of studies and their methodological limitations, caution should be exercised when interpreting these study results. More research is needed to confirm findings and to investigate the clinical value of PFM therapies and combined, multimodal therapies for breast cancer populations.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>Non-surgical, non-pharmaceutical conservative therapies may be helpful for breast cancer populations. Clinicians should consider the highest level of available evidence to guide their practice and use their clinical judgement to select the treatment components and appropriate dosages.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11912-024-01633-3","type":"journal-article","created":{"date-parts":[[2025,1,28]],"date-time":"2025-01-28T21:27:14Z","timestamp":1738099634000},"page":"168-189","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Effectiveness of Pelvic Floor Muscle and Education-based Therapies on Bladder, Bowel, Vaginal, Sexual, Psychological Function, Quality of Life, and Pelvic Floor Muscle Function in Females Treated for Breast Cancer: A Systematic Review"],"prefix":"10.1007","volume":"27","author":[{"given":"Marie-Pierre","family":"Cyr","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tamara","family":"Jones","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Udari N.","family":"Colombage","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helena C.","family":"Frawley","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,1,29]]},"reference":[{"key":"1633_CR1","unstructured":"World Cancer Research Fund. Worldwide cancer data: Global cancer statistics for the most common cancers. https:\/\/www.wcrf.org\/cancer-trends\/worldwide-cancer-data. 2022."},{"key":"1633_CR2","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1002\/nau.24531","volume":"40","author":"UN Colombage","year":"2021","unstructured":"Colombage UN, Lin KY, Soh SE, Frawley HC. Prevalence and impact of bladder and bowel disorders in women with breast cancer: a systematic review with meta-analysis. Neurourol Urodyn. 2021;40:15\u201327.","journal-title":"Neurourol Urodyn"},{"key":"1633_CR3","doi-asserted-by":"publisher","first-page":"329","DOI":"10.1007\/s12020-015-0812-6","volume":"54","author":"MI Maiorino","year":"2016","unstructured":"Maiorino MI, Chiodini P, Bellastella G, Giugliano D, Esposito K. Sexual dysfunction in women with cancer: a systematic review with meta-analysis of studies using the Female Sexual Function Index. Endocrine. 2016;54:329\u201341.","journal-title":"Endocrine"},{"issue":"5","key":"1633_CR4","doi-asserted-by":"publisher","first-page":"1674","DOI":"10.1007\/s11764-023-01407-z","volume":"18","author":"M Mangiardi-Veltin","year":"2023","unstructured":"Mangiardi-Veltin M, Mullaert J, Coeuret-Pellicer M, Goldberg M, Zins M, Rouzier R, et al. Prevalence of sexual dysfunction after breast cancer compared to controls, a study from CONSTANCES cohort. J Cancer Surviv. 2023;18(5):1674\u201382.","journal-title":"J Cancer Surviv."},{"key":"1633_CR5","doi-asserted-by":"publisher","first-page":"600","DOI":"10.1007\/s11764-015-0506-3","volume":"10","author":"A Ben Charif","year":"2016","unstructured":"Ben Charif A, Bouhnik AD, Courbi\u00e8re B, Rey D, Pr\u00e9au M, Bendiane MK, et al. Sexual health problems in French cancer survivors 2 years after diagnosis-the national VICAN survey. J Cancer Surviv. 2016;10:600\u20139.","journal-title":"J Cancer Surviv"},{"issue":"26","key":"1633_CR6","first-page":"e1","volume":"204","author":"J Baumgart","year":"2011","unstructured":"Baumgart J, Nilsson K, Stavreus-Evers A, Kask K, Villman K, Lindman H, et al. Urogenital disorders in women with adjuvant endocrine therapy after early breast cancer. Am J Obstet Gynecol. 2011;204(26):e1-7.","journal-title":"Am J Obstet Gynecol"},{"key":"1633_CR7","doi-asserted-by":"publisher","unstructured":"da Concei\u00e7\u00e3o TMA, Roza TD, dos Santos KM, da Luz SCT, da Luz CM. Pelvic floor muscles contraction and sexual function are associated with hormonal treatment in women after breast cancer? Man Ther Posturology Rehabil. 2017:1\u20135. https:\/\/doi.org\/10.17784\/mtprehabjournal.2017.15.462","DOI":"10.17784\/mtprehabjournal.2017.15.462"},{"key":"1633_CR8","doi-asserted-by":"publisher","first-page":"983","DOI":"10.1093\/annonc\/mdp394","volume":"21","author":"HG Mar Fan","year":"2010","unstructured":"Mar Fan HG, Hou\u00e9d\u00e9-Tchen N, Chemerynsky I, Yi QL, Xu W, Harvey B, et al. Menopausal symptoms in women undergoing chemotherapy-induced and natural menopause: a prospective controlled study. Ann Oncol. 2010;21:983\u20137.","journal-title":"Ann Oncol"},{"key":"1633_CR9","doi-asserted-by":"publisher","first-page":"468","DOI":"10.1080\/13697137.2020.1724942","volume":"23","author":"J Mercier","year":"2020","unstructured":"Mercier J, Morin M, Tang A, Reichetzer B, Lemieux MC, Samir K, et al. Pelvic floor muscle training: mechanisms of action for the improvement of genitourinary syndrome of menopause. Climacteric. 2020;23:468\u201373.","journal-title":"Climacteric"},{"issue":"11","key":"1633_CR10","doi-asserted-by":"publisher","first-page":"1293","DOI":"10.1007\/s11912-024-01586-7","volume":"26","author":"MP Cyr","year":"2024","unstructured":"Cyr MP, Jones T, Brennen R, Colombage U, Frawley HC. Effectiveness of pelvic floor muscle and education-based therapies on bladder, bowel, vaginal, sexual, psychological function, quality of life, and pelvic floor muscle function in females treated for gynecological cancer: a systematic review. Curr Oncol Rep. 2024;26(11):1293\u2013320.","journal-title":"Curr Oncol Rep"},{"key":"1633_CR11","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1186\/s13643-021-01626-4","volume":"10","author":"MJ Page","year":"2021","unstructured":"Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev. 2021;10:89.","journal-title":"Syst Rev"},{"key":"1633_CR12","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.l6890","volume":"368","author":"M Campbell","year":"2020","unstructured":"Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ. 2020;368: l6890.","journal-title":"BMJ"},{"key":"1633_CR13","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.g1687","volume":"348","author":"TC Hoffmann","year":"2014","unstructured":"Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348: g1687.","journal-title":"BMJ"},{"key":"1633_CR14","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.d5928","volume":"343","author":"JP Higgins","year":"2011","unstructured":"Higgins JP, Altman DG, G\u00f8tzsche PC, J\u00fcni P, Moher D, Oxman AD, et al. The Cochrane Collaboration\u2019s tool for assessing risk of bias in randomised trials. BMJ. 2011;343: d5928.","journal-title":"BMJ"},{"key":"1633_CR15","unstructured":"Wells GA SB, O\u2019Connell S, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. University of Newcastle (Australia) & University of Ottawa (Canada). https:\/\/www.ohri.ca\/programs\/clinical_epidemiology\/oxford.asp. 2000."},{"key":"1633_CR16","unstructured":"Joanna Briggs Institute (JBI). Critical Appraisal Checklist for Quasi-Experimental Studies. https:\/\/jbi.global\/critical-appraisal-tools. 2020."},{"key":"1633_CR17","unstructured":"OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. UK: Oxford Centre for Evidence-Based Medicine; 2011.\u00a0https:\/\/www.cebm.ox.ac.uk\/resources\/levels-of-evidence\/ocebm-levels-of-evidence"},{"key":"1633_CR18","doi-asserted-by":"publisher","first-page":"477","DOI":"10.1007\/s11764-017-0606-3","volume":"11","author":"P Advani","year":"2017","unstructured":"Advani P, Brewster AM, Baum GP, Schover LR. A pilot randomized trial to prevent sexual dysfunction in postmenopausal breast cancer survivors starting adjuvant aromatase inhibitor therapy. J Cancer Surviv. 2017;11:477\u201385.","journal-title":"J Cancer Surviv"},{"key":"1633_CR19","doi-asserted-by":"publisher","first-page":"171","DOI":"10.1007\/s10549-019-05140-z","volume":"175","author":"S Fatehi","year":"2019","unstructured":"Fatehi S, Maasoumi R, Atashsokhan G, Hamidzadeh A, Janbabaei G, Mirrezaie SM. The effects of psychosexual counseling on sexual quality of life and function in Iranian breast cancer survivors: a randomized controlled trial. Breast Cancer Res Treat. 2019;175:171\u20139.","journal-title":"Breast Cancer Res Treat"},{"key":"1633_CR20","doi-asserted-by":"publisher","first-page":"1328","DOI":"10.1200\/JCO.2016.69.6021","volume":"35","author":"SB Hummel","year":"2017","unstructured":"Hummel SB, van Lankveld J, Oldenburg HSA, Hahn DEE, Kieffer JM, Gerritsma MA, et al. Efficacy of internet-based cognitive behavioral therapy in improving sexual functioning of breast cancer survivors: results of a randomized controlled trial. J Clin Oncol. 2017;35:1328\u201340.","journal-title":"J Clin Oncol"},{"key":"1633_CR21","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1080\/0092623X.2017.1408047","volume":"44","author":"SB Hummel","year":"2018","unstructured":"Hummel SB, van Lankveld J, Oldenburg HSA, Hahn DEE, Kieffer JM, Gerritsma MA, et al. Internet-based cognitive behavioral therapy realizes long-term improvement in the sexual functioning and body image of breast cancer survivors. J Sex Marital Ther. 2018;44:485\u201396.","journal-title":"J Sex Marital Ther"},{"key":"1633_CR22","doi-asserted-by":"publisher","first-page":"4124","DOI":"10.1200\/JCO.2012.41.8525","volume":"30","author":"SF Duijts","year":"2012","unstructured":"Duijts SF, van Beurden M, Oldenburg HS, Hunter MS, Kieffer JM, Stuiver MM, et al. Efficacy of cognitive behavioral therapy and physical exercise in alleviating treatment-induced menopausal symptoms in patients with breast cancer: results of a randomized, controlled, multicenter trial. J Clin Oncol. 2012;30:4124\u201333.","journal-title":"J Clin Oncol"},{"key":"1633_CR23","doi-asserted-by":"publisher","first-page":"4983","DOI":"10.1002\/cncr.26139","volume":"117","author":"LR Schover","year":"2011","unstructured":"Schover LR, Rhodes MM, Baum G, Adams JH, Jenkins R, Lewis P, et al. Sisters Peer Counseling in Reproductive Issues After Treatment (SPIRIT): a peer counseling program to improve reproductive health among African American breast cancer survivors. Cancer. 2011;117:4983\u201392.","journal-title":"Cancer"},{"key":"1633_CR24","doi-asserted-by":"publisher","first-page":"1389","DOI":"10.6004\/jnccn.2013.0162","volume":"11","author":"LR Schover","year":"2013","unstructured":"Schover LR, Yuan Y, Fellman BM, Odensky E, Lewis PE, Martinetti P. Efficacy trial of an internet-based intervention for cancer-related female sexual dysfunction. J Natl Compr Canc Netw. 2013;11:1389\u201397.","journal-title":"J Natl Compr Canc Netw"},{"key":"1633_CR25","doi-asserted-by":"publisher","first-page":"311","DOI":"10.4103\/jehp.jehp_1318_22","volume":"12","author":"S Zangeneh","year":"2023","unstructured":"Zangeneh S, Savabi-Esfahani M, Taleghani F, Sharbafchi MR, Salehi M. Effectiveness of online sexual education based on the extended PLISSIT model on sexual function and sexual satisfaction in women undergoing breast cancer treatment. J Educ Health Promot. 2023;12:311.","journal-title":"J Educ Health Promot"},{"key":"1633_CR26","first-page":"28","volume":"7","author":"N Alfarra","year":"2022","unstructured":"Alfarra N, Alrashid K, Akomolafe T. Early detection and pelvic floor rehabilitation for sexual dysfunction with or without incontinence in the breast cancer. IJWHC. 2022;7:28\u201341.","journal-title":"IJWHC."},{"key":"1633_CR27","doi-asserted-by":"publisher","first-page":"121","DOI":"10.1007\/s12282-022-01405-6","volume":"30","author":"UN Colombage","year":"2023","unstructured":"Colombage UN, Soh SE, Lin KY, Kruger J, Frawley HC. The feasibility of pelvic floor training to treat urinary incontinence in women with breast cancer: a telehealth intervention trial. Breast Cancer. 2023;30:121\u201330.","journal-title":"Breast Cancer"},{"key":"1633_CR28","doi-asserted-by":"publisher","first-page":"2549","DOI":"10.1111\/jsm.12156","volume":"10","author":"I Juraskova","year":"2013","unstructured":"Juraskova I, Jarvis S, Mok K, Peate M, Meiser B, Cheah BC, et al. The acceptability, feasibility, and efficacy (phase I\/II study) of the OVERcome (Olive oil, Vaginal Exercise, and moisturizeR) intervention to improve dyspareunia and alleviate sexual problems in women with breast cancer. J Sex Med. 2013;10:2549\u201358.","journal-title":"J Sex Med"},{"key":"1633_CR29","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1186\/s12905-022-01628-x","volume":"22","author":"M Bokaie","year":"2022","unstructured":"Bokaie M, Firouzabadi O, Joulaee A. The effectiveness of group problem-solving therapy on women\u2019s sexual function and satisfaction after mastectomy surgery. BMC Womens Health. 2022;22:50.","journal-title":"BMC Womens Health"},{"key":"1633_CR30","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1007\/s11764-019-00800-x","volume":"14","author":"SL Bober","year":"2020","unstructured":"Bober SL, Fine E, Recklitis CJ. Sexual health and rehabilitation after ovarian suppression treatment (SHARE-OS): a clinical intervention for young breast cancer survivors. J Cancer Surviv. 2020;14:26\u201330.","journal-title":"J Cancer Surviv"},{"key":"1633_CR31","first-page":"Cd005654","volume":"10","author":"C Dumoulin","year":"2018","unstructured":"Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10:Cd005654.","journal-title":"Cochrane Database Syst Rev."},{"key":"1633_CR32","doi-asserted-by":"publisher","first-page":"1566","DOI":"10.1016\/j.jsxm.2017.09.018","volume":"14","author":"PJ Robinson","year":"2017","unstructured":"Robinson PJ, Bell RJ, Christakis MK, Ivezic SR, Davis SR. Aromatase inhibitors are associated with low sexual desire causing distress and fecal incontinence in women: an observational study. J Sex Med. 2017;14:1566\u201374.","journal-title":"J Sex Med"},{"key":"1633_CR33","doi-asserted-by":"publisher","DOI":"10.1016\/j.cont.2022.100494","volume":"2","author":"UN Colombage","year":"2022","unstructured":"Colombage UN, Soh S-E, Lin K-Y, Vincent A, White M, Fox J, et al. Factors associated with pelvic floor dysfunction in women with breast cancer. Continence. 2022;2: 100494.","journal-title":"Continence"},{"key":"1633_CR34","first-page":"Cd005540","volume":"2","author":"B Candy","year":"2016","unstructured":"Candy B, Jones L, Vickerstaff V, Tookman A, King M. Interventions for sexual dysfunction following treatments for cancer in women. Cochrane Database Syst Rev. 2016;2:Cd005540.","journal-title":"Cochrane Database Syst Rev."},{"key":"1633_CR35","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1186\/s40695-015-0009-4","volume":"1","author":"SM Seav","year":"2015","unstructured":"Seav SM, Dominick SA, Stepanyuk B, Gorman JR, Chingos DT, Ehren JL, et al. Management of sexual dysfunction in breast cancer survivors: a systematic review. Womens Midlife Health. 2015;1:9.","journal-title":"Womens Midlife Health"},{"key":"1633_CR36","doi-asserted-by":"publisher","first-page":"217","DOI":"10.1093\/jsxmed\/qdad175","volume":"21","author":"S Faucher","year":"2024","unstructured":"Faucher S, D\u00e9ry-Rouleau G, Bardin M, Morin M. Investigating the role of the pelvic floor muscles in sexual function and sexual response: a systematic review and meta-analysis. J Sex Med. 2024;21:217\u201339.","journal-title":"J Sex Med"},{"key":"1633_CR37","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1080\/00224499.2013.815149","volume":"51","author":"PM Pascoal","year":"2014","unstructured":"Pascoal PM, Narciso Ide S, Pereira NM. What is sexual satisfaction? Thematic analysis of lay people\u2019s definitions. J Sex Res. 2014;51:22\u201330.","journal-title":"J Sex Res"},{"key":"1633_CR38","doi-asserted-by":"publisher","DOI":"10.1002\/pon.6370","volume":"33","author":"B Han","year":"2024","unstructured":"Han B, Zhang P, Zhao H, Zhang X, Gao H, Dong J, et al. Effects of exercise interventions on quality of life in patients with breast cancer: a systematic review and network meta-analysis. Psychooncology. 2024;33: e6370.","journal-title":"Psychooncology"},{"key":"1633_CR39","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1056\/NEJMra1510062","volume":"377","author":"J Woodcock","year":"2017","unstructured":"Woodcock J, LaVange LM. Master protocols to study multiple therapies, multiple diseases, or both. N Engl J Med. 2017;377:62\u201370.","journal-title":"N Engl J Med"},{"key":"1633_CR40","doi-asserted-by":"publisher","first-page":"49","DOI":"10.1038\/s41591-022-02160-z","volume":"29","author":"V Subbiah","year":"2023","unstructured":"Subbiah V. The next generation of evidence-based medicine. Nat Med. 2023;29:49\u201358.","journal-title":"Nat Med"}],"container-title":["Current Oncology Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11912-024-01633-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11912-024-01633-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11912-024-01633-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,2,25]],"date-time":"2025-02-25T05:55:18Z","timestamp":1740462918000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11912-024-01633-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1,29]]},"references-count":40,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2025,2]]}},"alternative-id":["1633"],"URL":"https:\/\/doi.org\/10.1007\/s11912-024-01633-3","relation":{},"ISSN":["1523-3790","1534-6269"],"issn-type":[{"value":"1523-3790","type":"print"},{"value":"1534-6269","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,1,29]]},"assertion":[{"value":"27 December 2024","order":1,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 January 2025","order":2,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}