c copyright 2011 elsevier notice changes introduced … · 57 nester et al., 2007, leardini et al.,...

This is the author’s version of a work that was submitted/accepted for pub-lication in the following source:

Bishop, Chris, Paul, Gunther, & Thewlis, Dominic(2011)Footwear modifies foot and ankle kinematics during stance phase of walk-ing gait.Journal of Science and Medicine in Sport, 14(Sup1), e39-e40.

This file was downloaded from: https://eprints.qut.edu.au/49111/

c© Copyright 2011 Elsevier

This is the author’s version of a work that was accepted for publication in Journal of Sci-ence and Medicine in Sport. Changes resulting from the publishing process, such aspeer review, editing, corrections, structural formatting, and other quality control mecha-nisms may not be reflected in this document. Changes may have been made to this worksince it was submitted for publication. A definitive version was subsequently published inJournal of Science and Medicine in Sport, [VOL: 14, ISSUE: Supplementary, (2011)] DOI:10.1016/j.jsams.2011.11.082

Notice: Changes introduced as a result of publishing processes such ascopy-editing and formatting may not be reflected in this document. For adefinitive version of this work, please refer to the published source:

https://doi.org/10.1016/j.jsams.2011.11.082

https://eprints.qut.edu.au/view/person/Paul,_Gunther.html

https://eprints.qut.edu.au/49111/

https://doi.org/10.1016/j.jsams.2011.11.082

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A radiological method to determine the accuracy of motion

capture marker placement on palpable anatomical landmarks through a shoe

Journal: Footwear Science

Manuscript ID: Draft

Manuscript Type: Original Article

Keywords: Anatomical markers, Reliability, Kinematic model, X-ray, footwear, Foot & ankle

URL: http:/mc.manuscriptcentral.com/tfws Email: [email protected]

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Manuscript Title: A radiological method to determine the accuracy of motion capture marker 1

placement on palpable anatomical landmarks through a shoe 2

3

Abstract 4

The accuracy of marker placement on palpable surface anatomical landmarks is an important 5

consideration in biomechanics. Although markers may be able to be applied consistently in the same 6

position on the foot between rater’s or sessions, it remains unknown whether these markers accurately 7

reflect the location of the underlying anatomical landmark they are intended to represent. A novel 8

method was developed to identify the accuracy of markers placed on the shoe surface by palpating 9

landmarks through the shoe. An anterior-posterior and lateral-medial x-ray were taken on 24 10

participants with a custom marker set applied to both the skin and shoe. The vector magnitude of both 11

skin and shoe mounted markers from the anatomical landmark was calculated, as well as the mean 12

marker offset between skin and shoe mounted markers. The mean difference in displacement of 13

the shoe mounted marker relative to the skin mounted marker, accounting for shoe thickness, 14

was less than 10 mm for all markers studied. Further, when using the developed guidelines 15

provided in this study, the method was deemed reliable (Intra-rater ICC’s = 0.61-0.96). In 16

addition to proposing a method to determine marker placement accuracy, this paper also 17

provides a series of offsets to account for shoe-marker thickness in an in-shoe kinematic 18

model. 19

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Keywords 28

Anatomical markers; Kinematic Model; X-ray; Reliability; Foot and ankle 29

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Background 53

Kinematic marker sets are commonly used to quantify the foot and ankle mechanics during 54

gait and have interchangeably been applied to both the skin surface of the foot and on the 55

shoe surface with little consideration for accuracy in the latter condition (Carson et al., 2001, 56

Nester et al., 2007, Leardini et al., 2007, Cheung and Ng, 2007, Stacoff et al., 1992, Nigg and 57

Morlock, 1987, Lundgren et al., 2008). The markers are intended to define anatomical frames 58

that allow for the description of joint kinematics (Cappozzo et al., 1995). The focus of the 59

majority of the literature over the past twenty years has been on reliability. It is widely 60

accepted that the intra-rater reliability of marker application is good (Kadaba et al., 1989), yet 61

the largest source of marker placement variation is found between raters from different 62

laboratories (Gorton et al., 2009). 63

64

While reliability is essential, it is seemingly worthless if the accuracy of the anatomical frame 65

is defined incorrectly, as marker placement errors as small as 10 mm have been shown to 66

significantly alter joint moments (Thewlis et al., 2008, Holden and Stanhope, 1998). Where 67

reliability analyses will show whether marker researchers and scientists can place markers in 68

the same position, it gives no information in regards to whether the markers are placed on the 69

anatomical landmark of interest. Achieving acceptable marker placement accuracy may be 70

enhanced with strict adherence to guidelines designed to improve the consistency in 71

identifying anatomical landmarks on the skin surface (Van Sint Jan, 2007). Inaccuracies in 72

marker placement as small as 10 mm are conceivable at large joints; however this problem is 73

much aggravated for feet covered by shoes. The relatively small surface area and close 74

proximity of palpable anatomical landmarks on the foot presents a problem where marker 75

misplacement is a genuine possibility. 76

77

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This paper presents a method we have developed to quantify the accuracy of marker 78

placement on palpable anatomical landmarks of the foot through shoes. The paper will also 79

develop a set of offset values for the compensation of shoe thickness in models used to 80

investigate in-shoe foot kinematics. 81

82

Methods 83

This study was approved by the Human Research Ethics Committee, University of South 84

Australia. Twenty-four participants (mean age of 22.4 yrs (SD = 4.8 yrs), height of 1.79 m 85

(SD = 0.10 m) and body mass of 75.8 kg (SD = 13.4 kg)) were recruited to the study. An 86

weight bearing anterior-posterior and lateral-medial x-ray were taken of a marker set (seven x 87

10 mm markers [Figure 1]) affixed to each participant in two experimental conditions: 88

barefoot [A] and shod [B]. A basic structured shoe (Mexico 66, ACICS Corporation, Japan) 89

consisting of an outsole, midsole and upper was used. A Shimadzu Computer Radiography 90

(CR) machine (Shimadzu, Japan) was used to take all x-rays. 91

92

To take the weight-bearing A-P view, the participant stood on the floor with their feet on the 93

CR x-ray plate. The x-ray tube was angled at 20˚ to the perpendicular line coming from the 94

floor. The source-image distance (SID) used was 1.0 m. To take the lateral-medial view, the 95

participant stood on a raised platform, with the CR cassette mounted between the two feet. 96

This ensured even distribution of the centre of mass over the base of support. The x-ray beam 97

was (perpendicular) to the foot sagittal plane. The source-image distance used was 100 cm. 98

The data was automatically digitised by computational software (Voyager PACS digitization 99

software, 3.2 Release 7 Build 3, Voyager Imaging, Australia) and provided for analysis as 100

raw, unidentified, digital imaging and communications in medicine (DICOM) files. The 101

exposure settings used (A-P View – 5 mAs and 55 kVp and lateral-medial view – 5 mAs and 102

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59 kVp) ensured the correct contrast and density of image was obtained. The two x-ray 103

images were calibrated with a standard reference object. The 2D positions of each marker and 104

corresponding anatomical landmark were manually digitised in Matlab (Matlab 2010b, 105

Mathworks, USA) following custom guidelines (Appendix 1). This was repeated for each 106

experimental condition on both the A-P and lateral-medial x-ray images. 107

108

To assess the accuracy of marker placement, the vector magnitude between the underlying 109

anatomical landmark and each of the skin (d1) and shoe mounted (d2) markers was calculated. 110

The vector magnitude between the skin and shoe mounted markers was also calculated (d3), 111

which was assumed to be a measure of shoe thickness. The adjusted measure of shoe mounted 112

marker displacement (d4) was defined as the vector magnitude between the anatomical 113

landmark and shoe mounted marker minus the vector magnitude between the two markers. 114

The mean shoe marker offset (MMO) was calculated as the adjusted shoe mounted marker 115

displacement minus the vector magnitude between the anatomical landmark and skin mounted 116

marker (Figure 2). The MMO was considered a medial-lateral offset on the A-P x-ray image 117

and a superior-inferior offset on the lateral-medial image. The MMO was assumed to be a 118

direct measure of shoe mounted marker placement accuracy. 119

120

Two independent researchers with a minimum of five years expertise working with foot and 121

ankle radiography identified the coordinates of markers separately, one week apart to analyse 122

both intra- and inter-rater reliability. Rater 1 re-identified marker positions one week later to 123

assess intra-rater reliability. Intra-class correlation coefficients were used as measures of 124

reliability of the method (Landis and Koch, 1977). 125

126

127

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Results 128

The results of the accuracy assessment indicate that shoe mounted markers were placed 129

further away from the anatomical landmarks compared to the equivalent skin mounted 130

markers (Table 1). On the A-P view, the greatest displacement of a shoe mounted marker 131

from an anatomical landmark was the styloid process (MMO = 6.9 mm). The mean marker 132

offset between all other markers was < 5 mm, which was equivalent to the radius of the 133

markers. On the lateral-medial view, the greatest displacement of a shoe mounted marker 134

from an anatomical landmark was the apex of the 2nd toe (MMO = 9.2 mm). Four markers 135

resulted in mean marker offsets of < 1 mm. The calculated mean marker offset also provides a 136

method to compensate for shoe thickness in an in-shoe model, with medial-lateral and 137

superior-inferior offset projections provided for each shoe mounted marker (Table 2). 138

139

In respect to the reliability of the method, the application of markers on the anterior-posterior 140

x-ray view resulted in strong to excellent intra-rater reliability (ICC = 0.61 – 0.96). The 141

application of markers on the lateral-medial x-ray view resulted in strong to excellent intra-142

rater reliability (ICC = 0.73 – 0.96). Inter-rater reliability ranged from moderate to excellent 143

on both the A-P view (ICC = 0.44 – 0.96) and the lateral-medial view (ICC = 0.45 – 0.83). 144

145

Discussion 146

This study presents a method to determine the accuracy of markers placed on either the skin 147

or shoe surface in relation to the underlying anatomical landmark they are purported to 148

represent. We present data pertaining to the measured accuracy of markers from the 149

underlying anatomical landmark as well as the reliability of the measurement protocol 150

proposed. The mean difference in displacement of the shoe mounted marker, accounting for 151

shoe thickness, was less than 10 mm for all markers studied. Previously proposed methods to 152

assess reliability focus on static marker placement, indicating that reliable marker placement 153

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can result in consistent joint kinematics. However, this paper presents a novel method using 154

radiology designed to quantify the accuracy of motion capture marker placement on palpable 155

anatomical landmarks through a shoe. 156

157

This study has established that when using the developed guidelines (Appendix 1), the 158

method is reliable. In the participants used in this study, the method identified that the 159

application of markers was accurate to < 10 mm with respect to the underlying anatomical 160

landmark. 161

162

When accounting for shoe thickness, the application of shoe mounted markers resulted in sub-163

millimetre accuracy in 43% of cases. The recorded accuracy was < 5mm in 78% of cases. The 164

large mean marker offsets demonstrated in respect to the forefoot markers on the lateral-165

medial x-ray image can be explained by the presence of the shoe toe box, whereby the dorsal 166

surface of the shoe does not directly articulate with the dorsal aspect of the toes. Despite this, 167

the high accuracy demonstrated in this study is testament to the strength and transparency of 168

the guidelines and methods proposed to assess the accuracy of marker placement on the shoe 169

overlying anatomical landmarks. 170

171

Although the development of this method is novel and provides a significant step forward in 172

footwear research, it does have its limitations. The proposed method may prove to be more 173

difficult in the presence of a more structured shoe (i.e. heel counters), especially given the 174

likelihood of increased difficultly in palpating anatomical landmarks through rigid shoe 175

componentry. Furthermore, this method managed the accuracy individually in the sagittal and 176

coronal planes. The lack of measured accuracy in the transverse plane limits the interpretation 177

and consequent validation of the dynamic displacement of markers in 3-D space. Future 178

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research utilising computer tomography (CT scans) will aid in the 3-D interpretation of 179

marker placement accuracy. Despite this limitation, the results presented can still inform 180

future development of in-shoe kinematic models, whereby the shoe thickness is accounted for 181

as either a medial-lateral or superior-inferior offset for true estimation of in-shoe foot segment 182

geometry and coordinate systems. 183

184

Conclusion 185

We have developed a reliable radiologic method that is capable of describing the accuracy of 186

markers placed on the surface of the shoe with reference to an underlying anatomical 187

landmark. As expected, all shoe mounted marker were placed further away from the 188

referenced anatomical landmark than their skin-mounted counterparts, yet when accounting 189

for shoe thickness, the mean marker offset of shoe mounted markers was less than 10 mm for 190

all markers. Based on the results of this study, the protocol described serves as an additional 191

tool for footwear researchers given its ability to determine the accuracy of markers placed on 192

either the skin or shoe surface in reference to the underlying anatomical landmark they are 193

intended to represent. 194

195

Acknowledgements 196

We would like to acknowledge ASICS Oceania for supplying the footwear used in this study and the 197

Medical Radiation Department, University of South Australia providing access to the radiology suite. 198

Ergolab is supported by AutoCRC and the South Australian Government. 199

200

201

202

203

204

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205

206

207

208

Appendix 1– Identification of Anatomical Landmarks on X-ray 209

Navicular Tuberosity 210

Lateral-Medial View A-P View 211

212

213

214

1st Metatarsal head 215


217

218

219

220

Identification of Apex of 1st Toe (hallux) 221


The navicular tuberosity on the lateral-

medial x-ray view is located in the

inferior-posterior corner of the navicular

bone

The navicular tuberosity on the A-P x-ray

view is located at the most medial point of

the navicular bone.

The 1st

metatarsal landmark on the lateral-

medial x-ray view is identified as the

median point on a line connecting the two

widest points of the 1st

metatarsal head.

The 1st

metatarsal landmark on the A-P x-

ray view is identified as the most medial

point of the 1st

metatarsal head.

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224

225

Identification of Apex of 2nd

Toe 226


228

229

230

231

Identification of 2nd

Metatarsal Head 232


234

235

236

237

Identification of 5th

Metatarsal Head 238


The Apex of the 1st

toe landmark on the

lateral-medial x-ray view is identified as the

most dorsal point of the distal 1st

phalanx.

The Apex of the 1st

toe landmark on the A-

P x-ray view is identified as the median

point on a line connecting the two widest

points of the distal 1st

phalanx.

The Apex of the 2nd

toe landmark on the


most dorsal point of the distal 2nd

phalanx.

The Apex of the 2nd




points of the distal 2nd

phalanx.

The 2nd

metatarsal head landmark on the


most dorsal point of the 2nd

metatarsal head.

The Apex of the 2nd




points of the 2nd

metatarsal head.

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241

242

Identification of Styloid Process 243


245

246

247

248

249

250

251

252

253

254

255

256

257

258

259

260

The 5th


lateral x-ray view is identified as the most

lateral point of the 5th

metatarsal head.

The 5th


A-P x-ray view is identified as the median


points of the 5th

metatarsal head.

The styloid process landmark on the A-P x-

ray view is identified as the median point on

a line connecting the two widest points of

the styloid process (5th metatarsal base).

The styloid process landmark on the lateral-

medial x-ray view is identified as the most

lateral point of the styloid process (5th

metatarsal base).

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Reference list 261

CAPPOZZO, A., CATANI, F., DELLA CROCE, U. & LEARDINI, A. 1995. Position and orientation in space of 262

bones during movement: anatomical frame definition and determination. Clinical Biomechanics, 10, 263

171-178. 264

CARSON, M. C., HARRINGTON, M. E., THOMPSON, N., O'CONNOR, J. J. & THEOLOGIS, T. N. 2001. 265

Kinematic analysis of a multi-segment foot model for research and clinical applications: A 266

repeatability analysis. Journal of Biomechanics, 34, 1299-1307. 267

CHEUNG, R. T. H. & NG, G. Y. F. 2007. Efficacy of motion control shoes for reducing excessive rearfoot 268

motion in fatigued runners. Physical Therapy in Sport, 8, 75-81. 269

GORTON, G. E., HEBERT, D. A. & GANNOTTI, M. E. 2009. Assessment of the kinematic variability 270

among 12 motion analysis laboratories. Gait & Posture, 29, 398-402. 271

HOLDEN, J. P. & STANHOPE, S. J. 1998. The effect of variation in knee center location estimates on 272

net knee joint moments. Gait & Posture, 7, 1-6. 273

KADABA, M. P., RAMAKRISHNAN, H. K., WOOTTEN, M. E., GAINEY, J., GORTON, G. & COCHRAN, G. V. 274

B. 1989. Repeatability of kinematic, kinetic, and electromyographic data in normal adult gait. Journal 275

of Orthopaedic Research, 7, 849-860. 276

LANDIS, J. R. & KOCH, G. G. 1977. The measurement of observer agreement for categorical data. 277

Biometrics, 33, 159-174. 278

LEARDINI, A., BENEDETTI, M. G., BERTI, L., BETTINELLI, D., NATIVO, R. & GIANNINI, S. 2007. Rear-foot, 279

mid-foot and fore-foot motion during the stance phase of gait. Gait and Posture, 25, 453-462. 280

LUNDGREN, P., NESTER, C., LIU, A., ARNDT, A., JONES, R., STACOFF, A., WOLF, P. & LUNDBERG, A. 281

2008. Invasive in vivo measurement of rear-, mid- and forefoot motion during walking. Gait & 282

Posture, 28, 93-100. 283

NESTER, C., JONES, R. K., LIU, A., HOWARD, D., LUNDBERG, A., ARNDT, A., LUNDGREN, P., STACOFF, 284

A. & WOLF, P. 2007. Foot kinematics during walking measured using bone and surface mounted 285

markers. Journal of Biomechanics, 40, 3412-3423. 286

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NIGG, B. M. & MORLOCK, M. 1987. The influence of lateral heel flare of running shoes on pronation 287

and impact forces. Medicine and Science in Sports and Exercise, 19, 294-302. 288

STACOFF, A., REINSCHMIDT, C. & STUSSI, E. 1992. The movement of the heel within a running shoe. 289

Medicine and Science in Sports and Exercise, 24, 695-701. 290

THEWLIS, D., RICHARDS, J. & BOWER, J. 2008. Discrepancies in knee joint moments using common 291

anatomical frames defined by different palpable landmarks. Journal of Applied Biomechanics, 24, 292

185-190. 293

VAN SINT JAN, S. 2007. Color Atlas of Skeletal Landmark Definitions: Guidelines for Reproducible 294

Manual and Virtual Palpations, Elsevier. 295

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Table 1 – Skin & Shoe Marker Displacement from Anatomical Landmark 304

Markers A-P View Lateral-Medial View

Skin-mounted Shoe-mounted Skin-mounted Shoe-mounted

Mean (mm) 95% CI (mm) Mean (mm) 95% CI (mm) Mean (mm) 95% CI (mm) Mean (mm) 95% CI (mm)

Navicular tub. 5.3 4.2 - 6.3 9.9 8.4 - 11.3 2.6 1.7 - 3.4 3.5 2.3 - 4.8

1st met. head 5.0 4.3 - 5.7 7.4 6.5 - 8.2 2.0 1.4 - 2.5 1.8 1.0 - 2.6

Apex 1st toe 2.1 1.2 - 2.9 2.2 0.6 - 3.9 3.8 2.7 - 5.0 9.6 8.1 - 11.1

Apex 2nd toe 4.1 3.3 - 4.9 4.0 2.4 - 5.6 5.6 4.1 - 7.2 14.5 12.2 - 16.7

2nd met. head 2.4 1.5 - 3.3 2.5 1.1 - 3.9 7.6 6.4 - 8.8 16.7 14.4 - 19.0

5th met. head 4.5 3.5 - 5.5 9.2 7.8 - 10.7 2.3 1.5 - 3.1 3.0 1.4 - 4.5

Styloid process 5.5 4.9 - 6.1 12.4 11.2 - 13.5 1.8 1.0 - 2.5 4.1 2.9 - 5.3

305

306

307

308

309

310

311

312

313

314

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Table 2 - Compensation for Shoe Thickness (Mean Marker Offset) 315

Marker Marker Offset

medial-lateral axis (mm) Dorsal-plantar axis (mm)

Navicular Tub. 5.4 3.9

1st met. head 2.7 2.5

Apex 1st toe 3.8 4.4

Apex 2nd toe 4.3 5.3

2nd met. head 7.3 3.8

5th met. head 10.7 4.5

Styloid process 11.1 5.6

316

317

318

319

320

321

322

323

324

325

326

327

328

329

330

331

332

333

334

335

336

337

338

339

340

341

342

343

344

345

346

347

348

349

350

351

352

353

354

355

356

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Table 3 – Reliability of Identification of Marker Placement 357

358

X-Ray View Marker Intra-rater Inter-Rater

ICC Abs Diff (mm) ICC Abs Diff (mm)

Anterior-Posterior

Navicular tub. 0.73 0.91 0.66 1.40

1st met. head 0.86 0.52 0.58 1.06

Apex 1st toe 0.74 0.62 0.88 0.38

Apex 2nd toe 0.61 0.23 0.44 0.85

2nd met. head 0.93 0.29 0.96 0.52

5th met. head 0.77 0.18 0.86 0.42

Styloid process 0.96 0.08 0.92 0.02

Lateral-Medial

Navicular tub. 0.96 0.12 0.8 1.63

1st met. head 0.78 0.17 0.63 0.49

Apex 1st toe 0.78 0.21 0.5 1.18

Apex 2nd toe 0.79 0.69 0.6 1.13

2nd met. head 0.88 0.25 0.45 1.63

5th met. head 0.92 0.13 0.83 0.09

Styloid process 0.73 0.37 0.49 0.14

Abs Diff – Absolute difference between shoe and skin mounted marker displacement. 359

360

361

362

363

364

365

366

367

368

369

370

371

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Figure Lists 372

Figure 1 – Foot-shoe complex markers : A – Navicular tuberosity, B – 1st Metatarsal head, C 373

– Apex 1st Toe, D – Apex 2nd Toe, E – 2nd Metatarsal head, F – 5th Metatarsal head and G – 374

Styloid process 375

376

Figure 2 – Calculation of Marker Placement Accuracy. Point A- Anatomical landmark, Point 377

B – Skin mounted marker and Point C – Shoe mounted marker. 378

379

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Figure 1 – Foot-shoe complex marker set (static reference markers): A – Navicular Tuberosity, B – 1st Metatarsal Head, C – Apex 1

st Toe, D – Apex 2

nd

Toe, E – 2nd

Met Head, F – 5th Met Head and G – Styloid Process

A

G

F

E B D

C

A B

C

D E

F

G

A

G F

E

B D

C

A B

C

D E

F G

1 – Barefoot Lateral 2 – Barefoot A-P

3 – Shod Lateral 4 – Shod A-P

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Figure 2 – Calculation of Marker Placement Accuracy. Point A- Anatomical landmark, Point

B – Skin mounted marker and Point C – Shoe mounted marker.

Skin

Surface

Shoe

Surface

A B

C

d1

d2

d3

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Footwear Science

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c copyright 2011 elsevier notice changes introduced … · 57 nester et al., 2007, leardini et al.,...

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