Is the physio2future model suitable as an orientation for sustainable physiotherapy?

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Abstract

Background
Vulnerabilities of physiotherapy, such as the question of uniqueness, sustainability, and internal conflicts of interest appear to slow the unleashing potential of physiotherapy for becoming a sustainable resource in the healthcare system.
Aim
This work aims (1) to construct a thought model as an orientation tool for sustainable physiotherapy and (2) to evaluate for the first time its suitability as an orientation for sustainable physiotherapy.
Method
A hypothetical and narrative approach was applied to construct the Physio2Future model. A descriptive approach based on structured qualitative content analysis was used to obtain reflections from physiotherapists on the suitability of the model for sustainable physiotherapy. Interviews were conducted with 10 physiotherapists in a variety of positions.
Results
The hypothetical approach resulted in the construction of the model with 6 dimensions, and 21 variables assigned to the dimensions. The descriptive approach resulted in confirmations and innovations for changes by the interviewed physiotherapists. Autonomy and human-centeredness are interpreted by worries about enforcement. It was also advised to replace essential elements of the model.
Conclusion
The Physio2Future model was perceived for the first time as a suitable orientation for sustainable physiotherapy. With the support of expert discussions, the model will be discussed more closely.
Keywords: Physiotherapy, sustainability, health for future, conscientious physiotherapy, environmental health

Is the physio2future model suitable as an orientation for sustainable physiotherapy?

INTRODUCTION

The vulnerability of physiotherapy (PT), for example, as a challenge in providing effective and relevant treatment strategies, led to the development of the Physio2Future model (P2FM). Organisations, such as the Critical Physiotherapy Network or the Environmental Physiotherapy Association illustrate the recent weaknesses of PT that create its vulnerability (Maric & Nicholls, 2021; Nicholls, 2021).

The fundamental weaknesses of PT seem to be the lack of uniqueness, the internal conflicts of interest within the “best practice” framework, e.g., bio vs. psychosocial approaches, and the often-questionable effectiveness of therapeutic strategies concerning popular ailments (e.g., chronic pain conditions, specific back pain, tendon disorders, etc.) (Hayden et al., 2021; Walton et al., 2020). Moreover, the almost all-encompassing economisation that seems to affect the overall quality and sustainability of medicine today can also be understood as a weakness for PT (Barth et al., 2021; Hensher et al., 2020; Lüscher, 2020; Schiller, 2021). Its consequences can affect the “human-centeredness” of patients and professionals (Lindsay et al., 2008; van Dorssen-Boog et al., 2020). As more focus is on price and economical competition as worse the quality of PT becomes for patients’ care and creates other negative influences in the value-based health approach (Cook et al., 2021; Pekola et al., 2017). But also, physiotherapists as employees benefit from a human-centered orientation in terms of clinical quality and sustainability (van Dorssen-Boog et al., 2020).

The barriers to the acceptance of the dimensions, methods, strategies, and approaches relevant to the sustainability of PT have been initialized and reinforced in different ways. To reduce barriers to “best practice”, the national care guidelines are suitable. However, it is also conceivable that the sensitivity and acceptance of moral and ethical values about the needs of healthcare providers, healthcare recipients, and environmental influences could promote the implementation of physiotherapeutic basic dimensions such as evidence, autonomy, clinical relevance, and some more (Richardson 2015; Ringel, 2021).

On one side, the weaknesses of PT seem to slow down effective and relevant resources in the health care system. On the other side, the identification of physiotherapists with the need for these dimensions, such as sustainability, could help to set free the potential of PT for the healthcare system.

The P2FM must be convinced as a hypothetical “thought model” to provide a clearer picture and orientation of a sustainable and worthy profession for the healthcare system to conscientious physiotherapists in different major sections (clinical, educational, managing). The term “conscientious” in this context means responsible, ambitious, and sustainable thinking. The clinical section means practicing regular PT with patients in an appropriate institution. The educational section refers to physiotherapists, teaching students, e. g.  in universities, and the managing section corresponds to physiotherapists managing a PT institution (personnel, economic, qualitative, etc.). Currently is not known, how physiotherapists from different positions and countries think about the suitability of the P2FM as an orientation tool for sustainable and valuable PT for the healthcare system.

This work aims (1) to construct a thought model as an orientation tool for sustainable PT and (2) to evaluate for the first time its value as an orientation for sustainable PT.

MATERIALS AND METHODS

A qualitative mixed method consisting of (1) the hypothetical approach (HA) for the construction of the P2FM and (2) a descriptive approach (DA) to receive first information about the suitability of the model was conducted in this work (Creswell & Poth, 2018) (figure 1).

This project is registered in the Business Administration System for Ethics Committees (BASEC), the portal of Swissethics: Req-2022-01273. It has been confirmed that there are no ethical concerns. The project is registered with Open Science Framework and its available here: https://osf.io/edkyp/

For this project, no funders existed and therefore, funders played no role in the design, conduct, or reporting of this study. The physiotherapists participating in interviews during the DA part of this study were educated about the methodology and objectives before the interviews began. There were no concerns about this on the part of the participants.

Figure 1) Methodical process

The illustration of the methodological process is intended to give the reader an overview of the methods used in this work.

The Construction of the Physio2Future model

The hypothetical basic idea of the visual form of the P2FM exists before the evaluation of further construction and research. The basic design of the model was imagined as a tube, which represents a continuum. The continuum should contain essential dimensions that represent sustainable PT. The dimensions should be surrounded by supporting variables. The variables illustrate additional elements that are necessary to support the dimensions. The factor “relevance” was considered for the selection of dimensions and associated variables. A dimension should be accompanied by at least 2 to a maximum of 4 variables so that it is recognisable what the segment (dimension and variables) means. To avoid confusion caused by too many variables, a maximum of 4 variables was decided to be sufficient. The detailed explanation of the segments was planned as a separate text. 

The HA was influenced by observations and experiences of PT major sections (clinical, educational, managing) by the author of this project over a period of the least 5 years. Studies were used to verify the observations. A narrative approach (NA) was conducted for this purpose. Most of the included articles were written in English but 5 in German. These include Dresing and Pehl (2010), Konrad et al. (2017), Kornwachs and Coy (2009), Lüscher (2020), and Ringel (2021). Clinical observations included collaboration with colleagues mainly in the musculoskeletal sector, educational related observations included study courses, congresses, and lectures. The managing-related observations included personnel management, qualitative management of internal clinical procedures with physiotherapists, and marketing in PT institutions (private institutions, rehabilitation centers).

Descriptive approach

The DA was used to evaluate how physiotherapists think about the suitability of the P2FM for the future of PT. The identifying data of the interviewees were anonymised by numbers during the evaluation and are only accessible to the author of this paper. All physiotherapists interviewed declared their interest and were informed about the project by verbal explanation before they were interviewed.

Included were, clinically active physiotherapists in the musculoskeletal area, managers of PT facilities, and physiotherapists who are active in education and teaching. Physiotherapists who were not aware of P2FM, and physiotherapists who work with inpatients or with patients with serious diseases and injuries such as cancer, neurological or internal diseases, etc. were not interviewed (table 1). 10 physiotherapists from Switzerland, Austria, and Germany in various positions (clinical, managing, and educational) were heterogenic (women, men, various positions) conducted and interviewed as experts of PT. The physiotherapists interviewed were instructed by the interviewer before the survey to give as objective answers as possible to the respective questions. The different positions should allow for different perspectives of PT from which to view the model (table. 1).

InclusionExclusion
Active physiotherapists (clinically, teaching, science, management)Physiotherapists who work with patients suffering from serious illnesses and injuries such as cancer, neurological or internal systemic diseases, etc.
Physiotherapists interested in sustainable futurePhysiotherapists who do not know the P2FM before the interview
Muskuloskelettal area 
Physiotherapists‘ positionCountry
Clinical fieldSwitzerland, Germany, Austria
Educational fieldSwitzerland, Germany, Austria
Managing fieldSwitzerland, Germany, Austria
Table 1) Eligibility criteria and sampling

The surveys of the physiotherapists were taken in the professional environment of the interviewer and at physiotherapeutic events, e. g. congresses. The interviews were conducted digitally via Cisco Webex audio calls from October 14, 2022, to October 24, 2022, and lasted around 20 minutes per interview. An interview guide with 10 primary questions was used for the interviews. The interviews were computer-assisted simple transcribed (only words) via Amberscript software (Dresing & Pehl, 2010).

Data analysis

Data analysis was based on structured qualitative content analysis (Hsieh & Shannon, 2005). The level of analysis refers to the literal sense and the topic. The analysis was based primarily on predefined, deductive categories corresponding to the dimensions of P2FM (sustainability, autonomy, evidence, effectiveness, relevance, and human-centered). Secondary, flexible, inductive categories were also recorded, corresponding, for example, to the question about the vision for the future of PT. The Coding was based on different forms. That is if different words contained the same word sense, such as “science” and “evidence,” they were assigned to the same category. Once judgmental words were identified that resulted in a statement that could be understood differently, this was noted in the analysis. An example of this rule is ” Focusing on evidence makes physiotherapists clinically worse rather than better.” No corroboration was recognized for the “evidence” category in such a case. The same rule applies to all other categories. Irrelevant words that have nothing to do with the qualitative analysis of the statements were ignored. Each category was coded with specific statements that applied to that category (table 2). The coding was done by hand.

Text sectionCategoriesCodes
“Autonomy in PT could reduce unnecessary costs but it needs sensibility for responsibility.” AutonomyUnnecessary costs, responsibility
“Sustainability is an essential factor for the future of healthcare and its resources and PT can support it with an ambitioned self-management orientation for the patients. ”SustainabilityFuture for healthcare, self-management, resources
“Evidence is important in the daily practice of PT. For the patients’ rehabilitation success but also the qualitative development of PT.”EvidenceQualitative development, rehabilitation success
“Effectiveness is a meaningful factor of every kind of process and it proves the value of PT methods. It is a key element of evidence”EffectivenessMeaningful, proving value, key element
“Clinical, medical and social relevance is always important in professional healthcare. It makes it more efficient but some patients do not agree with correspondent suggestions.”RelevanceClinical, medical, social, efficient
“PT staff deserves personal-centered management and patient-centered management with respectful and valuing principles.”Human-centeredPersonal-centered, patient-centered, respectful, value
“Identification is necessary to support the P2FM and its dimensions. It needs general explanations and education of the dimensions that everyone understands.”IdentificationNecessary for P2FM, education, general explanations
“Terms such as “tight” or “tense” muscles are often used, but they should be replaced by correct terms, such as “tolerance of muscular load capacity is reduced”.WordingTight muscles, muscular tolerance, replaced by 
“It can be useful as a motivation for ambitious and conscientious physiotherapists. It shows some necessary criteria for a sustainable PT but maybe not everybody understands it because it looks complex.” Value of P2FMSustainability, ambitious, conscientious, complex  
Table 3) Coding guide

RESULTS

With the HA, it was initially possible to confirm the weaknesses of the PT that were already known from the background information and to identify the potential for a sustainable PT. Subsequently, the basic version of the P2FM was constructed from this (figure 2). The model contains 6 dimensions, namely autonomy, sustainability, relevance, evidence, effectiveness, and human-centered, and 21 variables assigned to the dimensions.

Figure 2) Illustration of the Physio2Future model

The illustration of the Physio2Future model is intended to give the reader an insight into its construction and essential elements, such as its 6 dimensions and 21 variables.

All 6 dimensions interact with each other and are equally important. The driving force of the P2FM was defined as “identification”. All physiotherapists should be able to identify all parts contained in it. The functioning of the model as a continuum is accompanied by the philosophical idea of emergence (Mnif & Müller-Schloer, 2006; Schiller, 2021). The dimensions and the associated variables are explained below:

Sustainability

Sustainability represents the current opportunity for conscientious PT in the future and contains the variables supportive, social, ecological, and economical. Sustainability has the potential to develop a future-oriented PT competence because emission-free PT that is available according to relevance and used efficiently is almost synonymous with evidence-based and conscientious medicine (Maric and Nicholls, 2021; Palstam et al., 2021).

Autonomy

Autonomy is to be understood as self-motivated self-regulation (Tezuka, 2014). The variables assigned are process, motivation, responsibility, and legislation to the dimension of autonomy. The legal basis is crucial for translating the findings from science into practice. In some countries, this is difficult because direct access is prohibited by law. Irrespective of this, motivation, and a sense of responsibility at an ethically and professionally high level could help to implement clinical, scientific, and bureaucratic processes in a high-quality and goal-oriented manner (Sandstrom, 2007).

Evidence

Evidence is the driving force of development and consists of the variables quantitative, qualitative, and standardized (Veras et al., 2016). Evidence provides clarity about misunderstandings and disagreements, generates autonomous development, teaches how to create competencies, and explains how to interpret relevance (Abduldull et al., 2018). Evidence related to practice and to the recognition of trends in society that influence PT should be respected everywhere in PT as a quality driver of the profession’s goals. This includes quantitative methods for determining effects as well as qualitative approaches for identifying potentials.

Relevance

Relevance, in the context of the P2FM, means the productive challenge of PT and the entire health system. Other dimensions, such as evidence, should be able to withstand judgment by relevance. Thus, the risk of implementing clinically unnecessary and perhaps even damaging methods (e.g., waste of resources, feigned benefit, etc.) could be reduced (Lo et al., 2009; Waldmann, 1996). The variables medical, clinical, and social are assigned to the dimension of relevance. The clinical relevance corresponds to the minimally significant difference in the effect of one method on another. Medical relevance indicates whether medical treatment is generally justifiable or whether the problem can be solved without medical services (Armijo-Olivo, 2018). Added to this is the social relevance, which helps to clarify the subjective needs (e. g., PT) of people who feel a deficiency (Kornwachs & Coy, 2009).

Effectiveness

Effectiveness clarifies the honorarium and at least the benefit of PT, in addition to relevance (Enrique & Marta, 2020). The variables timeless, efficiency and cooperation mean in the P2FM the basis of effectiveness. The value of effectiveness is determined by efficiency. The goal is to find the method and collaboration with other experts that require the least amount of resources (time, energy, cost, etc.) and is as effective as possible in the long term and at any time of day (Burches & Burches, 2020; Haik et al., 2020; Kumar, 2019; Robinson et al., 2019). PT methods should be constantly improved, but causality should already be present (compare the effect of insulin in diabetics or the anesthetic used before surgery, etc.). Without efficiency, the power of effectiveness is lower and the effort is higher (Kumar, 2019).

Human-centered

This dimension includes the variables qualitative, interactive, appreciative, and meaningful. Conscientious physiotherapists seek meaning in their work that excites them (Bailey et al., 2019). Otherwise, the risk of negative consequences, such as burnout, etc., could increase (Bashir et al., 2021). A human-centered approach in the management of physiotherapists, like self-determination and autonomy in the workplace, is valuable for clinical quality and the potential development of individuals and facilities (van Dorssen-Boog et al., 2020). The appreciative interaction between professionals, physicians, and managers is significant for this (Chamangwana et al., 2021). Employee-centeredness seems to be at least as important as the patient-centered approach (Morera-Balaguer et al., 2021).

Results of the Interviews

Within the DA, 10 physiotherapists could be interviewed, who represented a total of 3 different positions. A total of 4 women and 6 men were interviewed. Of these participants, all women and men are clinicians, but some of them are involved in education and management at the same time (table 3). No participant from Austria could be interviewed regarding management.

Country Physiotherapists‘ positionNumber of interviewed physiotherapistsGender of interviewed physiotherapists (m/f) 
Germany,Clinical field Educational field Managing field5 3 23/2 2/1 1/1 
Total: 53/2 
SwitzerlandClinical field Educational field Managing field  3 1 12/1 0/1 1/0 
Total: 33/1 
AustriaClinical field Educational field Managing field2 1 01/1 1/0 0/0 
  Total: 22/1
Table 3) Sampling results

The interviews resulted in confirmations and interest by all interviewed physiotherapists about the suitability of the model but not all its elements. A part of the interviewed physiotherapists found the model partially confusing and it took them a few minutes to understand what it says.

When the physiotherapists were questioned, there were sometimes different thoughts and opinions. The potential for autonomy, relevance, evidence, humanity, and sustainability was supported by all. The effectiveness dimension was advised for removal as a separate part of the model, because it may be an element of evidence. The dimensions “politic” and “ethics” mentioned in the answers were supported as further dimensions of the P2FM (table. 4). Evidence was interpreted as a weakness by respondents from Germany and Austria. The dimensions of autonomy, human-centered, and relevance were also criticised by them and by the physiotherapists of Switzerland. These respondents also expressed concerns about enforcing the autonomy and human-centered dimensions (table. 4). Sustainability was criticised by all physiotherapists from Switzerland. Only managers added, when asked about human-centered, that looking at it individually is difficult in larger settings because “you must estimate the effort to do it with the cost” (table. 4).

The driving factor of “identification” for implementing the dimensions of the model was highlighted by the interview results. Besides the major dimensions of the model, physiotherapists confirmed the influence of clinical quality by changing outdated terms like “tight” or “shortened” muscles by “the sensitivity of musculature is increased”.

CategoryIndication
Politics“We might need better political support as self-protection.”
Ethics“To decide what is relevant in PT, we need to be well-informed ethically. Perhaps ethics should be added as another dimension to the model.”
Effectiveness“Effectiveness is a key component of evidence, which also exists as a dimension in P2FM. Effectiveness as a separate dimension could therefore perhaps be removed.”
Human-centered“It is difficult to address the needs of each employee at larger facilities, especially when you have to be mindful of budget.”
Wording“Terms such as “tight” or “shortened” muscles should be replaced with: “The sensitivity of your musculature is increased.”.
Value of the P2FM“I can well imagine the model as a guide and motivation for ambitious physiotherapists. It shows some necessary criteria for a successful and sustainable PT, such as in the dimensions of sustainability, autonomy, evidence, and human-centeredness. However, it seems a bit confusing at first glance, which could put off some colleagues and it should be open to modifying it.”
Table 4) Inductive results of the interviews with physiotherapists

The most frequent answers to the first question about the vision of future PT can be illustrated with this example:

“In the future, PT should be independent of physiotherapists, content should be guided by evidence-based guidelines, and physiotherapists should be paid the same as doctors.”

The question about the dimension human-centered was answered with general support but also with worries from the managing physiotherapists. The answers can be illustrated in one like this:

“It would be nice if physiotherapy staff was promoted as well as they are in other professions and if their needs were taken as seriously as the patients’ needs are respected.”

Managers also highlighted the importance of human-centeredness about patients and professionals, but also expressed concern: 

“It is difficult to address the needs of each employee at larger facilities, especially when you have to be mindful of budget.”

The question about the dimension autonomy was answered differently but always with interest and focus on the potential, like:

“I think, more autonomy in PT would lead to an improvement of the healthcare system. The unnecessary costs caused by the intermediate step of the patients to the doctor would be avoided.”

Other answers went in this direction:

“I think it would be beneficial, but I do not know if I can bear the responsibility when it comes to wrong clinical decisions that can endanger patients.”

The question about the dimension evidence was answered highly supportive, especially by the German physiotherapists, in a kind of:

“Evidence is far too little considered in daily practice. It is so important for the patients but also the recognition of the profession”

The question about the dimension sustainability was answered with a high interest especially by the Swiss physiotherapists but also with worries in a kind of:

“Sustainable thinking has become an important factor in my life but I have rarely engaged with it in PT. This dimension could be very useful because PT has a great influence on healthcare resources and efficient self-management for patients.”

Other answers were like:

“Sustainability is an important goal for the future, but I lack the political and legal support for it. Certain methods should be encouraged and others banned.”

The question about the dimension effectiveness was answered with identification, especially by the German physiotherapist but also with a notification in terms of changing the model. Confirmatory answers correspond to this type:

“Effectiveness is a meaningful factor of any physiotherapy application because it illustrates the value of what we do for patients and other healthcare practitioners.”

Suggestions for a change in the model can be described as follows:

“Effectiveness is a key component of evidence, which also exists as a dimension in P2FM and could therefore be removed as a separate dimension.”

The question about the dimension relevance was initially often noticed with a little confusion because for most physiotherapists asked, relevance was only combined with clinical, not with medical and social. The answers were like this:

“Clinical relevance should always be sought. It is sometimes difficult because some patients prefer other methods and other professionals, such as physicians, make recommendations that are not clinically relevant. I thought medical relevance was the same as clinical relevance and I have never heard of social relevance in the context of physiotherapy.”

In addition, ethics was mentioned in this context as another dimension for P2FM:

“To decide what is relevant in PT, we need to be well-informed ethically. Perhaps ethics should be added as another dimension to the model.”

The question about identification as a driver of the P2FM was consistently answered with support, like:

“In the context of P2FM aimed at improving PT, identification with the content that supports it is necessary. But this requires explanations about it that everyone understands.”

The question about the wording was answered with interest and suggestions in a kind of:

We do not work on patients. A better way to say it would be: “We treat patients!” Terms such as “tight” or “shortened” muscles should be replaced with: “The sensitivity of your musculature is increased!”.

The question about the suitability of the P2FM was answered with consistent support but also with advice to rethink, like: 

“I can imagine the model as a guide and motivation for ambitious physiotherapists. It shows necessary criteria for a successful and sustainable PT, such as in the dimensions of sustainability, autonomy, evidence, and human-centeredness. However, it seems a bit confusing at first glance, which could put off some colleagues and it should be open to modifying it.”

DISCUSSION

This work has aimed to construct the P2FM as a thought model based on the HA and then present it to a professional community for evaluation of its suitability. From these first interviews with the physiotherapists, there was a consistently positive opinion of the model and its suitability for sustainable PT in the future. Based on HA and NA, relevance to P2FM can be argued, which seems to apply in part to PT around the world (Hayden et al., 2021; Hensher et al., 2020; Lüscher, 2020; Nicholls, 2021; Richardson 2015; Walton et al., 2020).

The results of the interviews are not sufficient to be able to transfer them to the population, because it was the first time that experts in PT have been interviewed about the P2FM. In addition, only physiotherapists from German-speaking countries were interviewed. The variables related to the dimensions were not specifically considered in the interviews.

The advantage of this work lies in the initial results regarding the suitability of P2FM according to its objective, and the basis for discussion thus made possible for future consideration of it.

The potential expressed by the interviewed physiotherapists about dimensions such as evidence, autonomy, human-centered, and relevance are also confirmed by the findings from HA and NA (Bailey et al., 2019; Morera-Balaguer et al., 2021; Sandstrom, 2007; Veras et al., 2016). The potential of the dimensions autonomy, relevance, evidence, humanity, and sustainability was found to be different but they were considered equally relevant by all respondents. The criticism of the separately presented dimension of effectiveness in the P2FM is comprehensible because effectiveness is an essential quality of evidence. Nevertheless, the model is intended to give an understanding that effectiveness also influences other dimensions (Burches & Burches, 2020; Enrique & Marta, 2020).

Some interviewees mentioned the integration of “ethics” and “politics” as other relevant dimensions of P2FM. These dimensions seem generally important (Richardson 2015; Ringel, 2021). However, politics so far falls under the autonomy dimension and is covered there by the “legislation” variable. Ethics is an essential component of the evidence and the relevance dimensions. Nevertheless, the integration of ethics and policy into P2FM should continue to be discussed. The concerns of some managers about the question of human-centered indicate fundamental worries that need to be discussed in more detail for clarification. This argument does not argue against the need for human-centeredness.

The answers to the question of wording show that replacing outdated terms, like “tight” or “shortened” muscles with “the sensitivity of musculature is increased” could support the clinical quality of PT in a simple way.

One of the most important tasks of conscientious PT can be expected in the dimension of sustainability in terms of the environmental impact (Barth et al., 2021; Maric & Nicholls, 2021; Palstam et al., 2021; Sandstrom, 2007; Tezuka, 2014). At this point, PT should be allowed to take a leading role, as it has been doing research on self-management and resource conservation for decades. Concepts for this defined as a clear mission could be developed by appropriate research groups, at universities, and in political focus groups.

CONCLUSION

The Physio2Future model was perceived for the first time as a suitable orientation for sustainable and socially valuable PT. Further discussions with experts of PT are needed to develop the model continuously and to replace unnecessary elements. Thereby, the factors of identification and sustainability should always be respected.

DECLERATION OF INTERESTS

This project has no external funder and was initialized by the developer of the model appearing in it. Therefore, unconscious conflicts of interest cannot be completely ruled out, such as accepting criticism of this model. However, other conflicts of interest are excluded.

ACKNOWLEDGMENTS

Special thanks go to the physiotherapists who made this study and its results possible by their participation and to the colleagues who took part in discussions on this topic. In order to present the approach “Physio2Future” in the sense of sustainability, it needs exactly these engaged persons.

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Conflict of interest statement

This project has no external funder and was initialized by the developer of the model appearing in it. Therefore, unconscious conflicts of interest cannot be completely ruled out, such as accepting criticism of this model. However, other conflicts of interest are excluded.

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