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. Author manuscript; available in PMC: 2026 Jul 21.
Published in final edited form as: Clin Biomech (Bristol). 2025 Jul 21;128:106630. doi: 10.1016/j.clinbiomech.2025.106630

Hip-Related Symptom Duration is Associated with Alterations in Hip Mechanics During a Single Leg Squat

Holly M Stanze 1, Bethany J Wilcox 2, Anthony A Mangino 3, Michael A Samaan 1,*, Kate N Jochimsen 4,5,*
PMCID: PMC12319413  NIHMSID: NIHMS2100464  PMID: 40714734

Abstract

Background:

Individuals with hip joint-related pain (HRP) exhibit high kinesiophobia and altered movement patterns compared to asymptomatic controls. Potential differences in kinesiophobia, movement, and hip pain during movement between individuals with shorter- and longer-term HRP are not well understood. The purpose of this study was to analyze whether self-reported hip pain during a single leg squat task, kinesiophobia, and total support moment parameters during the eccentric and concentric phases of a single leg squat task differ based on hip symptom duration in individuals with HRP.

Methods:

Involved limb hip, knee, and ankle sagittal plane moments during the single leg squat were obtained for 25 individuals with HRP. Participants reported kinesiophobia and hip pain during the squat. The total support moment was calculated by summing the average hip extensor, knee extensor and ankle plantarflexor moments during the squat. Between-group differences in kinesiophobia, hip pain and total support moment parameters were assessed using independent t-tests and Mann-Whitney U tests.

Findings:

The longer symptom duration group exhibited lower average hip extensor moments and lower hip joint contributions to the total support moment during both phases of the squat. Despite similar levels of kinesiophobia, the longer symptom duration group reported significantly higher hip pain during the squat.

Interpretation:

Alterations in lower-limb mechanics observed in the longer symptom duration group may be associated with more severe hip-related pain as opposed to worse fear of movement. Further study is required to determine the association between kinesiophobia and movement patterns in individuals with HRP.

Keywords: Hip-Related Pain, Single-Leg Squat, Total Support Moment, Kinesiophobia, Hip Symptom Duration

INTRODUCTION

Hip joint-related groin pain (HRP) is a term used to describe a group of non-arthritic, intra-articular hip conditions (Reiman et al., 2020; Weir et al., 2015). HRP includes conditions associated with abnormal hip joint morphology, such as femoroacetabular impingement syndrome (FAIS) and acetabular dysplasia, and other non-morphologic conditions (Reiman et al., 2020). Most individuals with HRP have chronic symptoms (e.g., hip joint pain, giving way, clicking/locking lasting longer than three months), including episodic hip/groin pain that is exacerbated with activity, and in the case of FAIS, certain hip motions (i.e., deep flexion and internal rotation). Treatment options include non-operative (e.g., injections, rehabilitation) or surgical intervention. In this patient population, symptom duration is often categorized as “shorter” or “longer” given the mean and median durations of 24 to 36 months reported in the literature (Jochimsen et al., 2021; Kahlenberg et al., 2014). Individuals with HRP exhibit altered movement patterns (Bagwell et al., 2016; Malloy et al., 2019) compared to asymptomatic controls, and high levels of kinesiophobia (fear of painful movement/re-injury) (Jochimsen et al., 2021). Yet the associations between these common patient impairments: hip pain during movement, aberrant movement patterns, and kinesiophobia, are not well understood. Given that longer symptom duration is a risk factor for worse surgical outcomes (Basques et al., 2019; Kim et al., 2023; Kunze et al., 2020), understanding the potential connections between symptom duration, lower limb mechanics, kinesiophobia, and hip pain during movement may allow for more efficient referrals to clinicians with expertise in HRP and more targeted interventions.

In terms of hip mechanics, prior gait-related studies in individuals with HRP demonstrated inconsistent results (Alshameeri and Khanduja, 2014; Bergmann et al., 2001; Brisson et al., 2013; Diamond et al., 2016; Hunt et al., 2013; Kannan et al., 2022; Kennedy et al., 2009; Rylander et al., 2011; Samaan et al., 2017b), which may be because walking gait does not stress the hip joint enough to provoke alterations in lower-limb mechanics. Therefore, more recent studies have investigated bilateral deep squatting tasks (Bagwell et al., 2016; Cvetanovich et al., 2020; Diamond et al., 2017; Lamontagne et al., 2009) that place the hip joint in a more provocative position, potentially inciting hip-related symptoms. However, the findings in these biomechanical assessments of lower limb mechanics during a bilateral squat task are also inconsistent. Individuals with FAIS exhibit a more pronounced reduction in peak hip extensor moment during the single limb squat (SLS) compared to the double leg squat (Malloy et al., 2019). Therefore, the SLS may place more demand on the painful hip joint and potentially expose alterations in lower limb mechanics that are masked in the bilateral squat task.

Individuals with HRP exhibit decreased hip muscle strength (Casartelli et al., 2011; Frasson et al., 2020; Harris-Hayes et al., 2020; Kierkegaard et al., 2017; Nepple et al., 2015), yet muscle function during dynamic activities required to stabilize the lower limb is not well understood in the HRP population. Additionally, the muscle contribution from individual joints may differ during eccentric and concentric contractions during a dynamic activity such as a squat. A prior study did not find between-group differences in sagittal plane hip joint moments between individuals with FAIS and asymptomatic controls during the eccentric or concentric phases of a bilateral squat task (Diamond et al., 2017). However, assessment of lower extremity mechanics during the eccentric and concentric phases of the SLS may be more beneficial in determining the potential muscular-related impairments. The total support moment (TSM) is a biomechanical composite metric that provides a quantitative measure of the total hip, knee, and ankle joint extensor torque needed to support the lower extremity during dynamic activity (Winter, 1980). A prior study (Samaan et al., 2017a) demonstrated that the TSM may be a sensitive enough measure to detect alterations in concentric muscle function during the bilateral sit-to-stand task that is associated with aberrant lower limb kinetics in the FAIS population. Therefore, the use of the TSM may be beneficial in indirectly assessing eccentric and concentric lower limb muscle function during the SLS.

Higher levels of kinesiophobia are associated with 6.2 and 7.5 times higher odds of experiencing elevated post-operative pain and worse hip function, respectively, in patients who underwent hip arthroscopy for FAIS (Jochimsen et al., 2021). Prior work has demonstrated a relationship between kinesiophobia and lower limb kinematics in some patient populations (Souza de Vasconcelos et al., 2023; Dudley et al., 2022; Trigsted et al., 2018), such that higher levels of kinesiophobia are associated with aberrant movement patterns. However, the relationship between kinesiophobia and lower extremity joint mechanics in individuals with HRP is unknown. Understanding the potential connections between hip-related symptom duration, kinesiophobia, and lower limb mechanics during a unilateral-based task, may provide clinicians with the knowledge needed to develop a biopsychosocial-based intervention to more optimally treat patients with HRP.

The purpose of this study was to analyze whether self-reported hip pain during a SLS task, kinesiophobia, and TSM-related parameters during the eccentric and concentric phases of an SLS task differ based on symptom duration in individuals with HRP. It was hypothesized that individuals with a longer symptom duration would report higher kinesiophobia and hip-related pain during the SLS as well as exhibit different TSM-related parameters during the SLS compared to individuals with a shorter duration of hip-related symptoms.

METHODS

Study methods were approved by the West Virginia University (WVU) IRB (Study protocol #2205585218 and 2106336942). Adults aged 18 to 45 years old with current hip pain were recruited from the community using study flyers and word of mouth. Individuals under the age of 18 were excluded because patient reported outcome measures have not been validated in pediatric populations, and those over the age of 45 were excluded to minimize the risk of enrolling patients with osteoarthritis (Young et al., 2020). Individuals were screened on the phone for inclusion/exclusion criteria. Individuals must have had their current hip and/or groin pain most days of the week for a minimum of 3 months (i.e., chronic). They were excluded if they had a history of prior hip joint surgery to the involved hip, a history of slipped capital femoral epiphysis (SCFE) or Legg-Calve-Perthes disease, or current spine or other lower extremity injuries other than their current hip pain. Those who met these criteria came into the lab for a clinical screening by the PI (KNJ). The clinical screening included a flexion/adduction/internal rotation (FADIR) impingement test, flexion/abduction/external rotation (FABER) test, straight leg raise test, and full lower quarter screen. To be included, individuals must have had a positive FADIR test, negative straight leg raise test, and negative lower quarter screen. They may have had a positive FABER test for pain in the anterior hip/groin. However, if they had a positive FABER test for pain in the low back/sacroiliac joint, they were excluded. These methods have been used in prior HRP studies to categorize a group of patients with similar clinical presentations (Harris-Hayes et al., 2016). All participants provided written and verbal informed consent prior to participation.

DATA COLLECTION

Following informed consent, participants completed a series of surveys including baseline demographics (age, sex, gender, symptom duration [months], race, ethnicity, and symptomatic hip) and patient reported outcome measures including the Tampa Scale for Kinesiophobia (TSK-11). The TSK-11 has shown good internal consistency, test-retest reliability, and validity (Tkachuk and Harris, 2012; Woby et al., 2005). It is scored on a scale from 11 and 44, with higher scores indicating higher levels of fear of movement/reinjury. Each participant’s height (m) and mass (kg) were recorded. Three-dimensional (3D) kinematic and kinetic data were collected with cluster-based surface-mounted retro-reflective markers (Figure 1), a 10-camera motion analysis system (Vicon, Hauppauge, NY) (240 Hz) and 2 in-ground force platforms (Bertec, Worthington, OH) (1200 Hz) during a single leg squat (SLS) task. Rigid marker clusters were placed on the upper thorax, pelvis and bilaterally on the upper arms, forearms, thighs, shanks and superior aspect of the foot. A standing calibration trial was used to create participant-specific models to determine segment pose and ankle, knee, and hip joint centers. Segments were digitized by identifying the following landmarks during calibration: 7th cervical vertebrae, 12th thoracic vertebra, 5th lumbar vertebra, bilateral posterior superior iliac spines (PSIS), bilateral anterior superior iliac spines (ASIS), bilateral greater trochanter, bilateral medial and lateral knee joint line, bilateral medial and lateral malleoli, and bilateral second phalanx. All data were collected through TheMotionMonitor xGen software (Innovative Sports Training, Inc, Chicago, IL). Study personnel provided verbal task instructions and a SLS demonstration. Participants were told to place their arms across their chest, transfer their weight to a single leg, and squat down as far as they could and return to a standing position. All participants performed the SLS on the non-symptomatic leg first followed by the symptomatic leg. Participants were allowed to familiarize themselves with the task prior to data collection. Following familiarization, participants performed three successful trials per leg, one at a time, resting between trials. If participants lost their balance, put their non-test limb down, or uncrossed their arms the trial was deemed unsuccessful and was repeated. Participants were asked to rate their hip pain during the SLS on a verbal Numeric Pain Rating Scale (0–10, where 0 indicates no pain and 10 indicates the worst pain imaginable).

Figure 1:

Figure 1:

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Cluster Based Marker Set Used to Track Segment Positions.

DATA PROCESSING & ANALYSIS

The squat cycle was defined based on the center of mass (COM) vertical position of the pelvis. Events were created to define the initiation, maximum squat depth, and termination of each SLS trial. Maximum squat depth was defined by the minimum vertical pelvic COM position. The initiation and termination events for each SLS trial were defined using a change in position of the vertical COM greater than 2.5 standard deviations from quiet standing. Each trial was time-normalized from initiation to termination of the SLS (0 – 100%).

Internal joint moments for the SLS task were post-processed and analyzed using custom written MATLAB code (Mathworks, Natick, MA). Hip and knee extensor and ankle plantarflexor moments were all designated as being in the positive direction. Marker position and GRF data were filtered with a bidirectional 4th order, lowpass Butterworth filter with a 20 Hz cutoff frequency. All joint moments were normalized to body mass (Nm/kg).

The eccentric phase (descent phase) of the SLS was defined as the first half of the stance phase (0 – 50%), and the concentric phase (ascent phase) was defined as the second half of the stance phase (51 – 100%). The summation of the average hip extensor, knee extensor and ankle plantar flexor moments during the eccentric and concentric phases of the SLS were used to calculate the TSM for both phases. Additional TSM-related outcomes included joint percent contribution and average joint moments during the eccentric and concentric phases. Hip, knee, and ankle joint percent contributions during the eccentric and concentric phases were calculated by dividing the average moment of each joint by the TSM and multiplying by 100%.

STATISTICAL ANALYSIS

Statistical analysis was performed using SPSS Version 29 (IBM, New York, NY). All data was assessed for normality using the Shapiro-Wilk test, as well as inspecting histograms for the dependent variables. Subjects were divided into two groups based on the median hip-related symptom duration of 36 months within our study cohort and consistent with previous HRP literature. The shorter duration group was defined as experiencing HRP for less than or equal to 36 months, and the long duration group was defined as experiencing HRP for greater than 36 months. When using median splits, it is standard practice to include the median value in the lower category (e.g., ≤ median) to ensure consistency (Royston, 2006). In this study, three individuals had a symptom duration of 36 months and were therefore included in the shorter duration group. This resulted in groups of n=14 (shorter symptom duration) and n=11 (longer symptom duration). Mann-Whitney U tests were used to assess for between-group differences in age, TSK-11 scores, and self-reported hip pain during the SLS, as these variables were not normally distributed. BMI and all TSM-related parameters were normally distributed, and between-group comparisons were made using independent t-tests. Analysis of covariance (ANCOVA) tests were conducted with pain as a covariate as a sensitivity analysis to verify results of the independent t-tests. Fisher’s Exact test was used to assess for between-group differences in sex. Effect size was calculated for each biomechanical parameter using Cohen’s d values (Cohen, 1988), whereby a value of 0 – 0.2, 0.21 – 0.5 and > 0.5 were classified as small, medium, and large effect sizes, respectively. Statistical significance for all analyses was set at an alpha level of 0.05.

RESULTS

There were 14 individuals in the shorter symptom duration group and 11 individuals in the longer symptom duration group. Both groups exhibited similar age, sex distribution, BMI, and TSK scores (Table 1). However, the longer symptom duration group exhibited a 1.75 times higher self-reported hip pain score during the SLS (p=0.025) than the shorter symptom duration group.

Table 1:

Subject Demographics, Tampa Scale for Kinesiophobia (TSK-11), and Self-Reported Hip Pain Scores During the Single Leg Squat (SLS) Task. Age, TSK-11, and Self-Reported Hip Pain Scores Were Assessed Using Mann-Whitney U Tests and are Presented as the Median [Interquartile Range]. BMI Was Assessed Using an Independent T-Test and is Presented as the Mean±Standard Deviation. Sex Was Assessed Using Fisher’s Exact Test and is Presented as a Ratio of Females: Males. TSK-11 is Scored on a Scale of 11 to 44.

Shorter Duration (N=14) Longer Duration (N=11) P-Value
Age (years) 24 [18 – 39] 23 [19 – 29] 0.390
BMI (kg/m2) 26.0 ± 3.6 24.9 ± 4.4 0.527
Sex (Females: Males) 10:4 9:2 0.661
Range of Hip Symptom Duration (months) 3 – 36 40 – 204 X
TSK-11 20 [15 – 40] 18.5 [14 – 34] 0.131
Pain during SLS 2 [0 – 7] 3.5 [1 – 6] 0.025*
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Compared to the shorter symptom duration group, the longer symptom duration group displayed approximately a 33% lower average hip extensor moment during the eccentric (p=0.027, Cohen’s d=0.94) and concentric (p=0.021, Cohen’s d=0.98) phases of the SLS task (Figure 2). The longer symptom duration group exhibited approximately a 10% lower contribution of the hip joint extensor moment to the TSM during the eccentric (p=0.004, Cohen’s d=1.28) and concentric (p=0.004, Cohen’s d=1.25) phases of the SLS task compared to the shorter symptom duration group (Table 2). The longer symptom duration group also demonstrated a statistical trend (p=0.063, Cohen’s d=0.77) towards a higher knee extensor contribution to the TSM during the eccentric phase.

Figure 2:

Figure 2:

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The total support moment (TSM) and individual joint moment profiles during the single leg squat (SLS) task for the shorter and longer duration HRP groups. The vertical bar provides visual separation of the eccentric (0 – 50% squat) and concentric (51 – 100% squat) phases of the SLS task.

Table 2:

Total Support Moment (TSM)-Related Outcomes During the Single Leg Squat Task in the Shorter and Longer Duration Groups. TSM-Related Outcomes Were Assessed Using Independent T-Tests and are Reported as the Mean±Standard Deviation.

Shorter Duration (N=14) Longer Duration (N=11) P-Value Effect Size Adjusted P-Value†
Eccentric Phase
TSM (Nm/kg) 1.77 ± 0.2 1.67 ± 0.5 0.496 0.28 0.491
Hip Extensor Moment (Nm/kg) 0.60 ± 0.2 0.40 ± 0.2 0.027* 0.94 0.039*
Knee Extensor Moment (Nm/kg) 0.65 ± 0.2 0.74 ± 0.2 0.373 0.37 0.344
Ankle Plantarflexor Moment (Nm/kg) 0.52 ± 0.1 0.53 ± 0.1 0.756 0.13 0.953
% Hip Contribution 32.96 ± 8.7 21.98 ± 7.5 0.004* 1.28 0.007*
% Knee Contribution 36.22 ± 10.0 43.60 ± 8.1 0.063 0.77 0.041*
% Ankle Contribution 30.82 ± 9.1 34.42 ± 10.2 0.381 0.36 0.594
Concentric Phase
TSM (Nm/kg) 2.18 ± 0.3 2.01 ± 0.6 0.375 0.37 0.291
Hip Extensor Moment (Nm/kg) 0.82 ± 0.3 0.55 ± 0.2 0.021* 0.98 0.032*
Knee Extensor Moment (Nm/kg) 0.76 ± 0.2 0.81 ± 0.3 0.599 0.22 0.856
Ankle Plantarflexor Moment (Nm/kg) 0.60 ± 0.1 0.65 ± 0.1 0.369 0.37 0.491
% Hip Contribution 36.32 ± 8.7 26.25 ± 6.2 0.004* 1.25 0.013*
% Knee Contribution 34.66 ± 9.0 39.07 ± 7.4 0.222 0.51 0.344
% Ankle Contribution 29.03 ± 8.4 34.69 ± 10.0 0.155 0.59 0.182
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†

p-values obtained from ANCOVA utilizing pain as the covariate.

DISCUSSION

The purpose of this study was to analyze whether self-reported hip pain during a SLS task, kinesiophobia, and TSM-related parameters during the eccentric and concentric phases of an SLS task differ based on symptom duration in individuals with HRP. It was hypothesized that individuals with a longer symptom duration would report higher hip pain and kinesiophobia and exhibit differing TSM-related parameters during the SLS compared to individuals with a shorter symptom duration. We found that subjects with a longer symptom duration had lower average hip joint extensor moments and lower hip joint contribution to the TSM during both the eccentric and concentric phases of the SLS, as well as higher hip pain during the SLS task than subjects with a shorter symptom duration. However, both groups exhibited high levels of kinesiophobia. This similarity in severity in fear of movement, yet significantly higher levels of self-reported hip pain during the SLS task, may suggest that the alterations observed in lower extremity mechanics within the longer symptom duration group may be associated with more severe hip-related pain as opposed to fear of movement. However, as both groups exhibit similar severity of fear of movement, we cannot make definitive conclusions on the effects of kinesiophobia on lower extremity mechanics in individuals with HRP. Further investigation is required to determine the association between kinesiophobia and SLS squat mechanics in order to better understand the relationship between psychological health factors and duration of hip-related symptoms in individuals with HRP.

Prior work has shown that the SLS task is a more challenging and sensitive task compared to the double-limb squat task when assessing lower limb mechanics in individuals with FAIS, the most common form of HRP (Malloy et al., 2019). In addition, individuals with FAIS exhibit lower peak hip joint extensor moments during a SLS task, and these alterations in hip extensor moments may suggest a mechanism to reduce hip extensor muscle activity and reduce contact forces at the hip (Malloy et al., 2019). Our study results indicate that those with a longer symptom duration exhibited lower average hip extensor moments during both the eccentric and concentric phases of the SLS task compared to those with a shorter symptom duration. Although the overall TSM did not differ between the groups during either the eccentric or concentric phases of the SLS task, the longer symptom duration group exhibited a lower hip joint contribution to the TSM during both phases of the SLS task. The lower hip joint contribution to the TSM is related to the lower hip extensor moment produced by the longer symptom duration group during both the eccentric and concentric phases of the SLS. Similar to previous work in the FAIS population (Malloy et al., 2019), these individuals with longer symptom duration may be reducing hip extensor muscle activity to reduce hip joint contact forces during the SLS. The longer symptom duration group also indicated a statistical trend towards a larger knee joint contribution to the TSM during the eccentric phase of the SLS. The large effect size (Cohen’s d=0.77) supports the potential clinical relevance of the higher knee joint contribution to the TSM during the eccentric phase of the SLS in those with longer symptom duration. This larger knee joint contribution during the eccentric phase may suggest that individuals with longer symptom duration experience larger deficits in eccentric hip extensor muscle function compared to the individuals with shorter symptom duration. The larger deficit in eccentric hip extensor muscle function may require a larger role of the quadriceps musculature in assisting with deceleration of the center of gravity during the eccentric phase of the SLS task in individuals with longer symptom duration. Overall, these alterations in lower extremity joint kinetics during the SLS task, as determined by the TSM analysis, suggest variations in movement patterns in those with a longer symptom duration compared to those with shorter symptom duration.

Individuals with HRP exhibit lower extremity muscle dysfunction (Casartelli et al., 2011; Frasson et al., 2020; Harris-Hayes et al., 2020; Kierkegaard et al., 2017; Nepple et al., 2015), and the alterations observed in the hip extensor moment within the longer symptom duration group may be due to the presence of more severe hip extensor muscle dysfunction. Similar to prior work in the FAIS population (Malloy et al., 2019), these individuals with longer symptom duration may have developed a pain compensatory strategy in which they adapted their movement patterns to minimize hip muscle activation to minimize hip joint loading during the SLS task. Although we did not directly assess hip muscle function (i.e., electromyography, strength testing), the TSM analysis performed in this study provided an indirect measure of eccentric and concentric hip muscle function during dynamic activity and the corresponding impact on lower extremity kinetics in individuals with HRP. These findings suggest the need to further investigate the direction of the relationship between mechanics and pain, as well as the potential moderating role of kinesiophobia in this relationship.

Our study data should be interpreted with caution as we used the median symptom duration to separate study participants into the shorter and longer symptom duration groups. Even individuals in the shorter symptom duration group still reported chronic hip pain, ranging in duration from 3 to 36 months. Future studies should explore individuals within the acute symptom range (< 3 months duration). In addition, our sample size is relatively small and does not allow us to draw definitive conclusions related to the duration of HRP on lower extremity mechanics during the SLS. Another limitation of the current study is that biomechanics data were not collected for a healthy, asymptomatic control group, and therefore, we cannot infer the impact of symptom duration on SLS-related mechanics compared to a population without HRP. In addition, a between-limb comparison was not performed as these individuals with HRP may alter their movement patterns in the asymptomatic limb due to the presence of unilateral HRP. We also did not obtain radiographic imaging of the pelvis/hips and therefore specific morphologic-related hip conditions, such as FAIS and hip dysplasia, exhibited by our study participants could not be determined.

CONCLUSIONS

In conclusion, individuals with a longer HRP symptom duration exhibited altered lower extremity mechanics and worse hip pain during the SLS compared to those with shorter symptom duration. The results of this study have the potential to guide future work in this population and suggest the need to further investigate the direction of the relationship between mechanics and pain, as well as the potential moderating role of kinesiophobia in this relationship. Additionally, these findings suggest that the TSM-based analysis performed in our study was sensitive enough to detect alterations during the SLS task in those with a longer symptom duration and provides insight into potential biomechanical targets for future interventions to optimize hip joint mechanics and to mitigate hip pain in individuals with HRP.

HIGHLIGHTS.

  • Individuals with longer hip symptom duration had more pain during movement

  • Individuals with longer hip symptom duration had more detrimental squat mechanics

  • Both groups reported high kinesiophobia which may or may not impact squat mechanics

FUNDING

This work was funded by the American College of Sports Medicine Mid-Atlantic Regional Chapter (MARC-ACSM) Early-Stage Investigator Award and West Virginia University Research and Scholarship Advancement (RSA) Grant. KNJ is funded by NIH Award (K23-AT011922). MAS is funded by NIH Award (K01-AG073698).

Footnotes

CRediT AUTHOR STATEMENT

Holly M. Stanze: Conceptualization, Methodology, Software, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Visualization Bethany J. Wilcox: Software, Formal Analysis, Data Curation, Writing – Review & Editing Anthony A. Mangino: Formal Analysis, Writing – Review & Editing Michael A Samaan: Conceptualization, Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Supervision Kate N Jochimsen: Conceptualization, Methodology, Investigation, Resources, Data Curation, Writing – Review & Editing, Supervision, Project Administration, Funding Acquisition

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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