Abstract
Background:
The duration of postoperative leave varies by the carpal tunnel release (CTR) technique. This study aimed to determine the time to return to work (RTW) after CTR with ultrasound (CTR-US) guidance and identify factors contributing to this duration.
Methods:
This was a multicenter postmarket registry of patients treated with CTR-US. Time to RTW was analyzed with Kaplan–Meier methods. Logistic regression identified the association of patient, work, and procedural factors with the probability of RTW within 5 days (a standard work week) after CTR-US.
Results:
A total of 544 employed patients (655 hands) from 24 centers were treated with CTR-US between November 2019 and August 2022. The mean patient age was 50 years, 62% were women, and most (76%) were full-time employees, where work activities were desk-based (49%), light manual (28%), or heavy manual (23%). The complication rate was 0.8%. After CTR-US, the median RTW was 3 days (interquartile range: 1–6 days), with 74.6% returning by 5 days, 87.8% by 10 days, and 97.1% by 30 days. Work activity (desk-based versus heavy manual: odds ratio = 2.93, 95% confidence interval: 1.70–5.04, P < 0.001) and sex (man versus woman: odds ratio = 1.85, 95% confidence interval: 1.15–2.98, P = 0.01) were associated with higher probability of RTW within 5 days. The median RTW ranged from 2 to 4 days in all patient subgroups, including heavy manual laborers (median 4 days) and women (median 3 days).
Conclusions:
CTR-US offers an efficient approach to treating CTS, enabling most patients to RTW with minimal delay. The short recovery periods observed across diverse patient and work characteristic subgroups compare favorably to other CTR techniques.
Takeaways
Question: What is the typical timeframe for returning to work after carpal tunnel release with ultrasound (CTR-US) guidance?
Findings: Among 544 employed patients (655 hands) treated with CTR-US in a multicenter registry, the median time to return to work was 3 days. This time ranged from 2 to 4 days across all patient and work characteristic subgroups.
Meaning: The typical patient returned to work 3 days after CTR-US, and patient characteristics minimally influenced this duration.
INTRODUCTION
Carpal tunnel syndrome (CTS) is a prevalent condition affecting 7.8% of working-age adults, with an annual incidence of 2.3%.1 Affected individuals frequently experience pain, paresthesia, weakness, or loss of manual dexterity. The negative impact of CTS on occupational productivity is considerable because work accommodations or extended leaves for treatment and recovery are often required. Individuals unable to return to work (RTW) due to CTS may experience numerous challenges, including anxiety, depression, social isolation, limited career opportunities, and significant income loss.2 Notably, 18% of employees with CTS leave their job within 18 months of diagnosis,3 underscoring the negative socioeconomic impact of the condition. Work absences from CTS also result in higher employer expenses due to reduced productivity and potential temporary staffing requirements.2,4 Addressing the occupational implications of CTS is essential to mitigate its detrimental effects on individual well-being and organizational productivity.
In instances where conservative care does not sufficiently relieve symptoms, carpal tunnel release (CTR) can facilitate a timely return to occupational duties, thus reducing overall costs compared with prolonged reliance on conservative care strategies.5 Approximately 600,000 CTR procedures are performed in the United States annually,6 with favorable safety and effectiveness outcomes overall. However, the duration of postoperative leave following CTR varies tremendously, complicating the determination of an appropriate recovery period. A meta-analysis of 43 studies reported an average time to RTW of 23 days after CTR7 with substantial variability among the studies, ranging from 7 to 75 days. The RTW timeframe varied by the CTR technique, averaging 18 days for endoscopic CTR, 21 days for mini-open CTR, and 31 days for open CTR. Additionally, other factors are known to influence RTW after CTR, including patient motivation, physician recommendations, physical work demands, and legal considerations.7–9 Ultimately, the time to RTW after CTR is traditionally understood as a complex process, influenced by patient, surgeon, procedural, and socioeconomic factors.7–10
CTR with ultrasound (CTR-US) guidance is a less invasive surgical alternative that may expedite patient recovery periods compared with other CTR procedures. CTR-US involves a minimal incision, typically less than 1 cm, to access and divide the transverse carpal ligament (TCL). Patients tend to favor CTR procedures involving smaller incisions,11 and these techniques have been linked to faster RTW.7 Several smaller-scale studies have reported rapid RTW after CTR-US, ranging from 3 to 7 days.12–16 The primary objective of this study was to corroborate these previous findings by reporting the time to RTW after CTR-US among employed adults, using the final data from a large multicenter registry. A secondary objective was to identify the factors that influenced postoperative RTW.
METHODS
Study Design
This was a multicenter observational registry in the United States of patients with CTS treated with CTR-US (UltraGuideCTR; Sonex Health, Eagan, Minn.). WCG IRB (Puyallup, Wash.) approved the study, and the reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for observational studies.17
Participants and Eligibility Criteria
Adults 18 years of age and older clinically diagnosed with CTS were eligible for the study. Physicians used nerve conduction studies and other diagnostic tools at their discretion. The study did not impose restrictions on maximum patient age, medical or surgical history, or clinical presentation. Overall, the study cohort represented a broad spectrum of patients encountered in real-world clinical practice.
Procedure
A detailed description of the CTR-US procedure has been described previously.18 Briefly, a small (<1 cm) wrist incision was made to provide access to the carpal tunnel and TCL. Real-time US monitoring was used to visualize critical structures during the procedure, including the median nerve, palmar cutaneous branch, thenar motor branch, digital nerves, ulnar artery, and superficial arch. Upon making the incision, the device tip was inserted into the carpal tunnel, and sterile saline-filled balloons were inflated to create additional space. A retracted blade in the tip was then activated to divide the TCL in a retrograde manner. The blade was then retracted, the balloons deflated, the device removed, and the TCL probed using US guidance to ensure complete release (Fig. 1). Anesthesia and postoperative care followed practice-specific preferences.
Fig. 1.
A, Intraoperative US during CTR-US. The image shows a transverse view of the distal carpal tunnel at the level of the HAM. The device (seen in cross-section) has been inserted into the transverse safe zone just deep into the transverse carpal ligament and between the MN and HAM. The balloons have been inflated (asterisks) to create space between the MN and UA and the centrally located blade track located in the device tip (blade not shown in this image). B, Longitudinal view showing the device shaft and tip directly under the TCL. The retrograde blade has been activated to transect the TCL from distal to proximal. The SPA is visualized distal to the device tip. C, Transverse view of the proximal carpal tunnel region at the level of the PIS. The device (D, seen in cross-section) is directly under the TCL, and the activated balloons (asterisks) maintain the space between the adjacent MN and UA and the centrally located blade track. The blade has been activated and is visualized relative to the surrounding anatomy. B, blade; D, device; HAM, hamate; MN, median nerve; PIS, pisiform; Right, ulnar; SPA, superficial palmar arterial arch; T, tip; TCL, transverse carpal ligament; Top, superficial; ThM, thenar muscles; UA, ulnar artery.
Outcome Measures
The time to RTW after CTR-US was determined by asking participants when they returned to work in any capacity after surgery, a definition commonly used in CTR studies.8,9 Participants indicated RTW status daily via electronic diaries for the first 14 days after surgery, then at 1, 3, 6, and 12 months until they reported returning to work. Pretreatment patient assessments included demographics, medical and surgical history, work status, and patient-reported outcomes. The patient-reported outcomes included the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire, the Boston Carpal Tunnel Questionnaire Symptom Severity Scale and Functional Status Scale, and the pain visual analogue scale. Postoperative complication data were obtained via chart review performed by the treating physician. A prespecified list of major complications was developed including superficial infection, deep infection, arterial laceration, permanent nerve injury, and reoperation for incomplete release.
Statistical Methods
Patient and procedural characteristics were summarized using the mean and SD for continuous variables or counts and percentages for categorical variables. The time to RTW was analyzed using Kaplan–Meier methods and reported as the median and interquartile range (IQR). Univariable logistic regression determined the association of baseline patient characteristics, work characteristics, and procedure details with the probability of returning to work within 5 days. Variables with a P value of less than 0.20 in the univariable model were included in the multivariable model. The multivariable model employed a best-subsets variable selection process that optimized the Akaike information criterion,19 and a P value of less than 0.05 was considered statistically significant. Statistical analyses were performed using Stata v18 (StataCorp, College Station, Tex.).
RESULTS
Between November 2019 and August 2022, 544 employed patients from 24 centers in the United States were treated with CTR-US and provided postoperative RTW information. The mean patient age was 50 years, 62% were women, and the mean BMI was 32 kg/m2. The most common medical history factors were anxiety (21%), depression (19%), thyroid disease (13%), diabetes mellitus (12%), and current tobacco use (12%). More than half (52%) of the patients had long-standing (>2 years) CTS symptoms before receiving CTR-US. The preoperative symptom and functional status scores were consistent with those from previous CTR studies20 (Table 1). Most (76%) patients were full-time employees and working regular duty (92%) before CTR-US. Self-reported work activities encompassed desk-based (49%), light manual (28%), or heavy manual (23%) activity (Table 2). The CTR-US procedures predominantly involved the dominant hand (68% of cases), bilateral simultaneous procedures comprised 20% of cases, and concomitant procedures were performed in 7% of cases.
Table 1.
Characteristics of Employed Patients Treated Using CTR-US
| Variable | Value |
|---|---|
| Demographics | |
| Age (y) | 50 ± 11 |
| 18–34 | 9% (47/543) |
| 35–64 | 81% (440/543) |
| ≥65 | 10% (56/543) |
| Female sex | 62% (336/544) |
| BMI (kg/m2) | 32 ± 8 |
| Medical history | |
| Anxiety | 21% (113/530) |
| Depression | 19% (101/530) |
| Thyroid disease | 13% (67/530) |
| Diabetes mellitus | 12% (65/530) |
| Current tobacco use | 12% (64/529) |
| Rheumatoid/inflammatory arthritis | 5% (29/530) |
| Chronic pain syndrome | 5% (28/530) |
| Anticoagulant therapy | 4% (20/529) |
| Current opioid use | 3% (14/529) |
| Polyneuropathy/nerve disorder | 2% (12/530) |
| Renal failure | 1% (3/530) |
| Carpal tunnel history | |
| Symptom duration | |
| ≤6 mo | 10% (46/449) |
| >6 mo–1 y | 18% (83/449) |
| >1–2 y | 19% (86/449) |
| >2 y | 52% (234/449) |
| Previous CTR on treated hand | 1% (6/529) |
| Symptoms and function | |
| QDASH (0–100 scale) | 38 ± 18 |
| BCTQ-SSS (1–5 scale) | 3.0 ± 0.7 |
| BCTQ-FSS (1–5 scale) | 2.3 ± 0.8 |
| Pain (0–10 scale) | 3.9 ± 2.8 |
BCTQ-FSS, Boston Carpal Tunnel Questionnaire Functional Status Scale; BCTQ-SSS, Boston Carpal Tunnel Questionnaire Symptom Severity Scale; QDASH, Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire.
Table 2.
Preoperative Employment Characteristics of Patients Treated Using CTR-US
| Variable | Value |
|---|---|
| Employment status | |
| Full-time employee | 76% (414/544) |
| Part-time employee | 11% (61/544) |
| Self-employed | 13% (69/544) |
| Job role at time of surgery | |
| Normal duty | 92% (498/544) |
| Modified duty | 8% (46/544) |
| Work activity | |
| Desk-based | 49% (267/544) |
| Light manual activity | 28% (151/544) |
| Heavy manual activity | 23% (126/544) |
| Routine manual work duties* | |
| Lift 20 pounds | 45% (202/449) |
| Operate vibrating equipment | 19% (86/449) |
| Operate heavy equipment | 18% (79/449) |
| Workers compensation case | 4% (19/532) |
Categories not mutually exclusive.
Among 655 treated hands, there were five (0.8%) complications, including two (0.3%) deep infections, two (0.3%) incomplete releases requiring revision, and one (0.2%) suspected small finger tendon injury. The median time to RTW after CTR-US was 3 days (IQR: 1–6 days), with 74.6% of patients returning to work within 5 days, 87.8% returning within 10 days, and 97.1% returning within 30 days (Fig. 2). The median RTW ranged from 2 to 4 days for all patient subgroups (Table 3). In the multivariable logistic regression model, work activity (desk-based versus heavy manual: odds ratio = 2.98, 95% confidence interval: 1.73–5.15, P < 0.001) and sex (man versus woman: odds ratio = 1.81, 95% confidence interval: 1.12–2.92, P = 0.01) were independently associated with higher odds of returning to work within 5 days of the procedure (Table 4). Among men, the percentage returning to work within 5 days of surgery was 88.2% for desk-based workers, 70.3% for light manual laborers, and 73.3% for heavy manual laborers. Among women, the percentages were 78.6%, 69.6%, and 48.5%, respectively (Fig. 3).
Fig. 2.
Kaplan–Meier estimate of time to return to work after CTR-US. Plotted data are Kaplan–Meier estimate and 95% CI truncated at 30 days. The median time to return to work was 3 days (interquartile range: 1–6 days). The percentage of patients returning to work was 57.0% at 3 days, 74.6% at 5 days, 87.8% at 10 days, and 97.1% at 30 days.
Table 3.
Return to Work after CTR-US*
| Variable | Unit of Measure | Median RTW | IQR |
|---|---|---|---|
| All patients | 3 | 1–6 | |
| Demographics | |||
| Sex | Male | 3 | 1–5 |
| Female | 3 | 1–6 | |
| Body mass index | ≥30 kg/m2 | 3 | 2–6 |
| <30 kg/m2 | 3 | 1–6 | |
| Age | ≥65 y | 2 | 1–6 |
| 50–64 y | 3 | 1–6 | |
| <50 y | 3 | 2–6 | |
| Medical history | |||
| Current tobacco use | Yes | 4 | 2–7 |
| No | 3 | 1–5 | |
| Current opioid use | Yes | 3 | 2–6 |
| No | 3 | 1–6 | |
| Diabetes mellitus | Yes | 3 | 1–6 |
| No | 3 | 1–6 | |
| Carpal tunnel history | |||
| Previous CTR on treated hand | Yes | 4 | 3–NA |
| No | 3 | 1–6 | |
| Symptom duration | >2 y | 3 | 1–6 |
| ≤2 y | 3 | 1–5 | |
| Baseline symptoms and function | |||
| QDASH (0–100 scale) | ≥40 | 3 | 2–7 |
| <40 | 3 | 1–5 | |
| BCTQ-SSS (1–5 scale) | ≥3 | 3 | 2–6 |
| <3 | 3 | 1–5 | |
| BCTQ-FSS (1–5 scale) | ≥2.5 | 3 | 2–6 |
| <2.5 | 3 | 1–5 | |
| Pain (0–10 scale) | ≥4 | 3 | 1–6 |
| <4 | 3 | 1–6 | |
| Employment characteristics | |||
| Work activity | Heavy manual | 4 | 2–8 |
| Light manual | 4 | 2–7 | |
| Desk-based | 2 | 1–4 | |
| Employment status | Full-time employee | 3 | 1–6 |
| Part-time employee | 3 | 2–6 | |
| Self-employed | 3 | 1–5 | |
| Job role at time of surgery | Normal duty | 3 | 1–6 |
| Modified duty | 3 | 2–7 | |
| Workers compensation case | Yes | 4 | 2–NA |
| No | 3 | 1–6 | |
| Procedure details | |||
| Surgery type | Unilateral | 3 | 1–5 |
| Simultaneous bilateral | 3 | 2–7 | |
| Surgery on dominant hand | Yes | 3 | 2–6 |
| No | 3 | 1–5 | |
| Concomitant procedure | Yes | 4 | 1–10 |
| No | 3 | 1–6 |
Data derived from Kaplan–Meier analysis.
BCTQ-FSS, Boston Carpal Tunnel Questionnaire Functional Status Scale; BCTQ-SSS, Boston Carpal Tunnel Questionnaire Symptom Severity Scale; NA, not applicable due to missing data; QDASH, Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire.
Table 4.
Factors Associated with Return to Work within 5 Days after CTR-US
| Variable | Unit of Measure | Odds Ratio* | 95% CI | P |
|---|---|---|---|---|
| Univariable model | ||||
| Demographics | ||||
| Sex | Male vs female | 1.36 | 0.90–2.07 | 0.14 |
| Body mass index | Per 5 kg/m2 decrease | 1.05 | 0.93–1.20 | 0.42 |
| Age | Per 5-y increase | 1.01 | 0.92–1.10 | 0.89 |
| Medical history | ||||
| Current tobacco use | No vs yes | 1.73 | 0.99–3.04 | 0.06 |
| Current opioid use | No vs yes | 1.69 | 0.56–5.13 | 0.36 |
| Diabetes mellitus | No vs yes | 1.00 | 0.55–1.83 | >0.99 |
| Carpal tunnel history | ||||
| Previous CTR on treated hand | Yes vs no | 1.34 | 0.15–12.1 | 0.79 |
| Symptom duration | ≤6 mo | Ref. | — | — |
| >6 mo–1 y | 1.04 | 0.10–10.6 | 0.96 | |
| >1–2 y | 1.14 | 0.11–11.6 | 0.91 | |
| >2 y | 0.90 | 0.09–8.78 | 0.93 | |
| Baseline symptoms and function | ||||
| BCTQ-SSS (1–5 scale) | Per 0.5-point decrease | 1.09 | 0.94–1.25 | 0.24 |
| QDASH (0–100 scale) | Per 10-point decrease | 1.06 | 0.96–1.18 | 0.26 |
| BCTQ-FSS (1–5 scale) | Per 0.5-point decrease | 1.04 | 0.92–1.18 | 0.54 |
| Pain (0–10 scale) | Per 1-point decrease | 1.04 | 0.97–1.12 | 0.29 |
| Employment characteristics | ||||
| Work activity | Heavy manual activity | Ref. | — | — |
| Light manual activity | 1.17 | 0.69–1.98 | 0.56 | |
| Desk | 2.21 | 1.35–3.61 | 0.002 | |
| Employment status | Full-time employee | Ref. | — | — |
| Part-time employee | 1.05 | 0.56–1.97 | 0.87 | |
| Self-employed | 1.67 | 0.86–3.25 | 0.13 | |
| Job role at time of surgery | Normal vs modified duty | 1.37 | 0.69–2.72 | 0.37 |
| Workers compensation case | No vs yes | 1.83 | 0.65–5.15 | 0.25 |
| Procedure details | ||||
| Surgery type | Unilateral vs simultaneous bilateral | 1.46 | 0.91–2.34 | 0.11 |
| Surgery on dominant hand | No vs yes | 1.43 | 0.93–2.23 | 0.11 |
| Concomitant procedure | No vs yes | 1.76 | 0.86–3.58 | 0.12 |
| Multivariable model | ||||
| Work activity | Heavy manual activity | Ref. | — | — |
| Light manual activity | 1.56 | 0.88–2.77 | 0.13 | |
| Desk-based | 2.93 | 1.70–5.04 | <0.001 | |
| Sex | Male vs female | 1.85 | 1.15–2.98 | 0.01 |
Odds ratio >1 indicates higher odds of returning to work within 5 days of the procedure. Odds ratio <1 indicates lower odds of returning to work within 5 days of the procedure.
BCTQ-FSS, Boston Carpal Tunnel Questionnaire Functional Status Scale; BCTQ-SSS, Boston Carpal Tunnel Questionnaire Symptom Severity Scale; CI, confidence interval; QDASH, Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire.
Fig. 3.
Kaplan–Meier estimate of time to return to work after CTR-US by job activity (A) and sex (B). Plotted data are Kaplan–Meier estimate and 95% CI truncated at 30 days.
DISCUSSION
CTS is a pervasive condition that negatively impacts occupational productivity and represents the most costly upper extremity musculoskeletal disorder, with an estimated annual medical care cost exceeding $2 billion in the United States.21 Reintegration into the workforce following injury or illness is instrumental in promoting the patient’s personal health and mental well-being. Early RTW also alleviates substantial financial burdens on employees, employers, and society. This study aimed to determine the time to RTW after CTR-US and identify the factors influencing this duration. Patients treated with CTR-US demonstrated a rapid RTW, with a median time of 3 days and the vast majority (97.1%) returning within 30 days. This rapid RTW was observed across all patient and procedural characteristics, with median RTW times ranging from 2 to 4 days for all subgroups.
The findings of this study are consistent with previous research on CTR-US, where RTW times ranged from 3 to 7 days.12–16 In contrast, alternative CTR techniques are associated with substantially longer recovery times based on the results of a recent meta-analysis, with RTW of 18 days for endoscopic CTR, 21 days for mini-open CTR, and 31 days for open CTR.7 These indirect comparisons highlight the efficiency of CTR-US in facilitating earlier RTW relative to other CTR techniques. A plausible reason for this expedited RTW is the small nonpalmar incision that can typically be closed without sutures, with limited soft-tissue disruption resulting in considerably less postoperative wound sensitivity and pain compared with mini-open CTR.12 Given the lack of direct comparative data between CTR-US and endoscopic CTR techniques, factors associated with differences in RTW outcomes are unclear.
The rapid RTW after CTR-US has significant implications for patients and employers, not only in terms of minimizing work disruption but also in terms of potential cost savings.22 For patients, an early RTW can help alleviate the financial burden caused by lost wages during their recovery period. Assuming a 3-day RTW with CTR-US and 23 days with traditional CTR,7 and based on the average employee compensation of $29.70 per hour derived from the US Census Bureau,23 the potential lost wage savings per employee taking unpaid leave for surgery would be approximately $4800, solely attributable to faster RTW. In extended leaves, there is also considerable risk that employees do not RTW at all, a likelihood that increases to 50% by the 12th week of leave.4 Though not measured in this study, employer expenditures related to temporary staffing, overtime pay, administrative processes, and potential increases in insurance or workers’ compensation costs may also be reduced. Expedited recovery and RTW can also mitigate productivity loss and diminish the need to retrain other employees, thereby reducing associated indirect costs. Given these significant implications, cost-effectiveness studies quantifying the economic impact of early RTW after CTR-US are warranted.
In this study, we considered 5 days as the threshold for prolonged RTW following CTR-US, with three in four (74.6%) patients returning to work within this period. This threshold was guided by the practicalities of a standard work week, aligning the interests of employees who wish to minimize absence with those of employers who aim for continuity in operations. This concept aligns with the US Department of Labor policies to support a rapid transition back to work after illness or injury.4 Although categorized as prolonged in this study for purposes of subgroup analyses, a 5-day RTW remains remarkably expedient compared with RTW times for other CTR techniques. Even in patients where RTW exceeded the defined 5-day benchmark for classifying subgroups, CTR-US still resulted in accelerated RTW compared with a 23-day RTW typically reported after CTR.7
Although this study presents promising findings of the impact of CTR-US on RTW, there are several limitations to consider. First, the observational design lacked a control group, limiting our ability to draw definitive comparisons to other CTR techniques. Comparisons of the current data to other CTR studies should be interpreted cautiously and considered hypothesis-generating only. Second, the RTW data were self-reported, which may be influenced by recall bias. However, we attempted to mitigate this bias by collecting RTW daily during the 2-week postoperative period. Third, the study did not capture data on other potential factors that may have influenced RTW such as preoperative counseling, job satisfaction, and socioeconomic factors.24 Fourth, although the RTW definition used in this study corresponds with previous studies on CTR,8,9 the study did not distinguish between partial and full RTW. Therefore, it remains uncertain whether a gradual return or additional transition period was necessary to fully reintegrate into the job role, particularly among manual laborers. Fifth, the potential for selection bias must be acknowledged because patients opting for CTR-US may be inherently motivated to RTW quickly versus those receiving CTR involving larger palmar incisions. Sixth, despite the focus on RTW, only 4% of cases involved workers compensation, limiting the generalizability of the findings to occupational injuries. Finally, we did not collect cost-related data, including procedural expenses, wage loss, and employer-incurred costs. Such studies would be informative to provide a complete understanding of the total economic impact and cost-effectiveness of the CTR-US procedure.
CONCLUSIONS
CTR-US offers an efficient approach to treating CTS, enabling most patients to RTW with minimal delay. The short recovery periods observed in this study across a diverse range of patient and work characteristic subgroups compare favorably to other CTR techniques. The implications of these results are significant, suggesting potential cost savings for patients and employers alike.
DISCLOSURES
Dr. Paterson reports consultancy with Sonex Health, Inc., unrelated to the current study. Dr. Kirsch reports consultancy and stock ownership with Sonex Health, Inc., unrelated to the current study. Dr. Miller reports consultancy with Sonex Health, Inc., related to the current study. Dr. Aguila reports consultancy with Sonex Health, Inc., unrelated to the current study. The funding source was involved in the study design; in the collection of data; and in the decision to submit the article for publication.
Footnotes
Published online 27 February 2024.
Disclosure statements are at the end of this article, following the correspondence information.
This study was supported by Sonex Health, Inc. (Eagan, Minn.).
Supporting data from this research will be made available upon reasonable request.
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