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52 (); 21-27
doi:
10.1016/j.jor.2024.02.017

Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty

, , , ,
a Ipswich General Hospital, Queensland Health, Ipswich, QLD, 4305, Australia
b School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, QLD, 4072, Australia
c The CJM Centre, Ipswich, QLD, 4305, Australia
d The Mater Private Hospital, Springfield Lakes, QLD, 4300, Australia
e St Andrew's Ipswich Private Hospital, Ipswich, QLD, 4305, Australia
f RECOVER Injury Research Centre, NHMRC Centre of Research Excellence: Better Health Outcomes for Compensable Injury, The University of Qld, Herston, 4006, Australia
g Physiotherapy Department, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, 4029, Australia

∗Corresponding author: Tristan Pillay. tristan.pillay01@gmail.com

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Total knee arthroplasty (TKA) is commonly performed for the treatment of knee osteoarthritis (KOA). Poor satisfaction continues to be seen after TKA. Whilst reasons for poor patient satisfaction are multifactorial, there is a strong correlation with persistent pain following TKA. Studies have shown an association between local and remote mechanical hypersensitivity, measured using pressure pain thresholds (PPTs), and severity of knee osteoarthritis and functional status. We aimed to determine if the pre-operative PPTs were associated with patient satisfaction following TKA.

A prospective longitudinal study of 77 individuals was undertaken. Regression modelling assessed the relationship between Patient Satisfaction using the Knee Society Score (satisfaction subscale) following TKA for KOA, and PPTs recorded pre-operatively locally and remote to the affected knee, while accounting for potentially confounding patient demographic and psychosocial factors.

Lower PPTs (indicating increased mechanical hypersensitivity) locally and remote to the operative knee were modestly associated with lower patient satisfaction in the short-term (six weeks) following TKA (β 0.25–0.28, adjR2 = 0.14–0.15), independent of demographic or psychosocial influences. However, this relationship progressively diminished in the intermediate and long-term post TKA.

While pre-operative PPT measures may provide some foresight to patient satisfaction post TKA in the short term, these measures appear to provide little insight to patient satisfaction in the intermediate and longer term.

Keywords

Knee osteoarthritis
Patient satisfaction
Knee arthroplasty
Sensory hypersensitivity
Pain pressure threshold
Quantitative sensory testing
1

1 Introduction

Knee osteoarthritis (KOA) is a prevalent cause of pain and reduced quality of life.1–3 For patients with severe KOA who have exhausted non-surgical treatment options, Total Knee Arthroplasty (TKA) is regarded as the ideal treatment thereof.4–6 TKA is the most prevalent joint arthroplasty in Australia and is continuously increasing in frequency5 matching the ever-growing elderly population.7 In 2021, there was a 9% increase in TKA procedures compared to the previous year and a 47% increase compared to 2011.5 The average cost per TKA per patient in Australia is estimated at $AUD 19 000 to $AUD 30 0008 reflecting a significant cost burden on our health system. TKA is generally considered to be successful in improving pain and quality of life,9–13 however, the literature also suggests success rates may be overestimated due to discrepancies between methods of outcome assessment.14,15

Patient satisfaction is a common method of assessing TKA outcomes. Factors underpinning patient reported satisfaction are considered multifactorial.16–18 A principal cause of patient dissatisfaction following TKA is pain persisting more than six months post-surgery.19 The incidence of persistent pain following TKA is reported to be up to 10–34%.20 Studies have attempted to better understand the complexities and predictability of pain pre- and post-TKA.21–28 A better understanding of KOA pain mechanisms and their impact on pain following TKA will ultimately inform better management strategies and improved satisfaction post TKA.

Pressure Pain Thresholds (PPTs) are a measure of quantitative sensory testing (QST), evaluating mechanical sensitivity to pressure and are potentially informative in understanding persistent pain post TKA. Cohorts of KOA patients have been reported to have lower PPT values compared to healthy counterparts.29–36 Compared to healthy individuals, lowered PPTs have been shown in those with advanced KOA both locally as well as remote to the affected knee.36 Furthermore, this cohort of patients undergoing also recorded a relation function of the knee.37 These findings potentially reflect generalised mechanical hypersensitivity in some individuals with advanced KOA but the clinical impact is still in question. While such studies have informed pain mechanisms underpinning KOA, the relationship between mechanical hypersensitivity recorded by PPTs in individuals with KOA and their outcomes following TKA is unknown. Understanding this relationship may be potentially informative to predicting patient dissatisfaction, pain and functional deficits following TKA.19

The aim of this study was to evaluate the relationship between preoperative local and remote PPT measures, and patient satisfaction at incremental stages post TKA for KOA, accounting for potential patient demographic and psychosocial confounding factors. It was hypothesised that lower pre-operative PPTs signifying greater mechanical sensory hypersensitivity would be associated with lower patient satisfaction post-surgery, independent of demographic or psychosocial features.

2

2 Material and methods

A prospective longitudinal study assessed the relationship between patient satisfaction (dependent variable) following TKA for KOA, and PPTs recorded local and remote to the affected knee (primary independent variable) pre-operatively, while accounting for other potential confounding factors. STROBE reporting guidelines were followed.38

2.1

2.1 Participants

A sample of convenience of seventy-seven individuals (47 women, 30 men) with advanced KOA scheduled to undergo TKA were recruited in participating hospitals and orthopaedic surgeons’ private rooms. Participants were excluded with a history of prior major knee surgery or relevant concomitant pathology that would alter knee pain and function.

2.2

2.2 Measurements and procedure

Pre-operative measurements were undertaken two weeks prior to the TKA by a single investigator (KJ). This investigator had demonstrated excellent intra-therapist reliability for these measurements.36,39 Demographics including age, gender, and body mass index (BMI) were recorded. Pre-mailed self-reported knee function/expectations and psychosocial questionnaires were completed. PPT measures were recorded, followed by performance of the clinical function test. Participants then underwent their TKA and usual post-operative care. The Patient Satisfaction measure was completed at 6 weeks, 6 months, and 12 months post-operatively.

Dependent Variable - Patient satisfaction was evaluated post-operatively using the Knee Society Score Patient Satisfaction Subscale.40

2.3

2.3 Independent variables - pre-operative measures

Pressure Pain Thresholds (PPT): The primary independent variable of interest were PPTs measured with a digital algometer (Somedic AB, Farsta, Sweden) using a 1 cm2 probe at an application rate of 40 kPa/s. This required patients to depress the switch should pain be felt. A pressure limit of 1000 kPa was utilised to prevent injury.41 If pain was not perceived at this point, the test was ceased.

Knee Pressure Pain Thresholds: Following a familiarisation trial, triplicate recordings were made over 3 different, yet reproducible aspects of the pre-operative knee respectively (Fig. 1). The PPT was deduced as the mean average from these three sites.

Pressure Algometry testing sites at the knee and deltoid.
Fig. 1 Pressure Algometry testing sites at the knee and deltoid.

Deltoid Pressure Pain Thresholds: Triplicate recordings were over the lateral surface of deltoid muscle ipsilateral to the affected knee (Fig. 1). This mean average was recorded as the remote PPT.

The following potentially confounding patient characteristics were recorded pre-operatively to account for these variables potentially impacting the relationship between PPTs and patient satisfaction following TKA.

Patient expectations regarding their knee following TKA was evaluated with the Knee Society Score (Patient Expectations subscale).40

The Knee Society Score (functional subscale) was used to measure the patient-reported knee function.40

Clinical knee function was observed with the 6 - Minute Walk Test (6MWT)42,43 This test aims to assess the distance walked in meters (m) before the pain limits progress, or the total distance walked within 6 min if not halted prior. It is a validated measure of function in patients with osteoarthritis.42,44

2.4

2.4 Psychosocial status

Depression, Anxiety and Stress Scale (DASS-21): The DASS-21 is a validated tool of three self-reported scales designed to assess the negative emotional states of depression, anxiety, and stress. It is used clinically to clarify the locus of emotional disturbance.45,46

Pain Self Efficacy Questionnaire (PSEQ): Is a validated 10-item questionnaire used to assess an individual's confidence in performing activities while in pain47,48.

Pain Catastrophising Scale (PCS): Is a validated scale that consists of 13 questions scored between 0 and 4 that assesses the degree of catastrophising associated with the perception of pain49–51.

Tampa Scale of Kinesiophobia (TSK): The TSK is a 17-item questionnaire that uses a 4-point Likert scale to measure patients' fear of movement.52 The TSK has been significantly correlated with measures of disability.53

Interpersonal Support Evaluation List (ISEL): Is a 40-item measure of social support with subscales assessing appraisal support, tangible support, self-esteem support and belonging support.54

CD-RISC Resilience Scale: This is a patient assessed measure for resilience using a 25 item questionnaire, it's psychometric componentry distinguishes between individuals with greater and lesser resilience.55

3

3 Data analysis

All analyses were undertaken using an IBM SPSS Statistics 22 (IBM, New York, USA) package. Descriptive statistics were calculated for all dependent and independent variables. One patient withdrew from the study following the six week outcome session; this participant's data was still included in the statistical analysis up to the six-weeks’ time point.

Hierarchical Regression Analyses were conducted to evaluate the relationship between patient satisfaction post-TKA (three timepoints; six weeks, six months and twelve months, post-operative) (dependent variable) and pre-operative PPTs (primary independent variables), while accounting for potentially confounding patient variables (demographics, expectations, function, and psychosocial variables). Due to the high number of potential confounding variables their univariate relationship with the dependent variable (patient satisfaction) was initially calculated at each timepoint using Pearson correlations. Only those variables with a significant univariate relationship (p < 0.05) with the dependent variable at that timepoint were included in the regression model. Potential multicollinearity impacting the regression models was mitigated in two ways. Firstly, variables identified to have a univariate relationship with the dependent variable were examined for their relationship with each other using Pearson correlations. If any variables were shown to have a strong relationship, then one would be chosen by the investigators to take forward to the final model. Secondly, multicollinearity between independent variables was further assessed in the linear regression models by observing if the Variance Inflation Factor (VIF) values in all models remained <2.

As the knee and deltoid PPT measures were strongly correlated (r = 0.88 p < 0.001)56,57 separate hierarchical regression analyses models were conducted for PPT measures at these sites at each time point. Following recommendations when utilising SPSS software for hierarchical regression analyses participant demographics were entered in the first step to account for their impact on the model. Secondly the relationship between patient satisfaction and the PPT measure of interest was evaluated. In the third step the potential confounding variables shown to have a univariate relationship with patient satisfaction were entered into the model to evaluate their impact on the relationship between patient satisfaction and PPT.

4

4 Results

Table 1 displays the sample characteristics. Table 2 shows the variables with a univariate relationship with the dependent variable (in the direction of higher patient satisfaction) at the six-week (higher pain self-efficacy, lower pain catastrophizing, higher ISEL subscales of appraisal support, self-esteem support and belonging support), six-month (lower pain catastrophizing, higher self-esteem support and belonging support) and twelve-month (higher self-esteem support) timepoints.

Table 1 Characteristics of the participants at baseline (n = 77 unless otherwise stated).
Variables Mean Std. Deviation Minimum Maximum
Demographic
Gender (47 females, 30 males)
Age 65.55 7.79 46 83
BMI 32.19 6.23 16.65 52.65
Psychological and Social
DASS-21
- Depression 6.83 9.3 0 38
- Anxiety 4.84 6.12 0 22
- Stress 8.75 8.99 0 32
PSEQ 40.32 13.55 6 60
PC 16.12 13.25 0 50
TSK 38.7 9.66 21 58
ISEL
- Appraisal support 25.57 4.34 9 30
- Tangible support 26.56 4.26 7 30
- Self-esteem support 22.16 4.99 8 30
- Belonging support 25.23 4.3 9 30
CD-RISC 78.79 16.68 25 100
KSS Satisfaction 15.09 7.33 2 38
KSS Expectation 13.77 1.64 6 15
KSS Function 34.83 14.56 4 68
6 min walking test 165.4 137.39 2.5 459
PPT Operative Knee 355.54 195.68 112.88 1000
PPT Deltoid 326.98 190.91 84 1000
6 weeks KSS Satisfaction 29.9 4.82 16 40
6 months KSS Satisfaction (n = 76) 33.16 5.17 16 40
12 months KSS Satisfaction (n = 76) 35 5.12 20 40
Table 2 Univariate analysis defining the potential variables correlated to the post-operative patient satisfaction.
6 Weeks 6 Months 12 Months
Pearson's Coefficient p Value Pearson's Coefficient p Value Pearson's Coefficient p Value
DASS-21
1-Depression −0.132 0.251 −0.14 0.229 −0.134 0.247
2-Anxiety −0.054 0.640 −0.124 0.287 −0.123 0.29
3-Stress −0.162 0.159 −0.192 0.097 −0.172 0.137
PSEQ .236* 0.039 0.085 0.466 −0.035 0.761
PC −.303** 0.007 −.258* 0.024 −0.165 0.155
TSK −0.089 0.439 −0.136 0.241 −0.086 0.463
ISEL
1-Appraisal support .253* 0.026 0.127 0.275 0.111 0.339
2-Tangible support 0.086 0.456 0.137 0.236 0.117 0.314
3-Self-esteem support .232* 0.043 .236* 0.04 .241* 0.036
4-Belonging support .251* 0.028 .233* 0.043 0.168 0.147
CD-RISC −0.037 0.752 0.007 0.954 0.046 0.695
KSS Satisfaction 0.043 0.708 −0.007 0.951 0.001 0.99
KSS Expectation 0.057 0.623 0.051 0.659 0.139 0.231
KSS Function 0.018 0.878 0.007 0.953 0.022 0.854
6 min walking test 0.188 0.102 0.141 0.223 0.069 0.551

Screening for potential multicollinearity also demonstrated the ISEL domain subscales to be strongly correlated (r = 0.7–0.76, p < 0.001). Preliminary regression modelling also indicated Variance Inflation Factor values > 2 when all significant ISEL domains (appraisal support, self-esteem support and belonging support) were retained in the model. Therefore, only the self-esteem support subscale was retained in the final model as it demonstrated a consistent univariate relationship with the dependent variable at all 3 timepoints (Table 2).

Subsequent tables report the hierarchical linear regression analyses.

4.1

4.1 Patient satisfaction 6 weeks post TKA and PPTs

Lower patient satisfaction 6 weeks following TKA was associated with lower pre-operative PPTs remotely (β 0.28 (p = 0.03); model adjR2 = 0.15), and similarly (albeit only approaching statistical significance) for PPTs local to the operative knee (β 0.25 (p = 0.06); model adjR2 = 0.14) (Table 3). Older age was significantly related to higher reported satisfaction in both final models (β 0.24–0.25 (p < 0.05). No other demographic or psychosocial variables were significant in the models at 6 weeks post TKA.

Table 3 Patient satisfaction at 6 weeks post-operative: Hierarchical linear regression analyses examining the relationship between patient satisfaction, demographic variables, pressure pain thresholds (PPT) (knee and deltoid), and psychosocial variables. Relationships are expressed as standardised coefficients (β) with progressive model fit expressed as the R2, adjusted R2 (adjR2) and changes in the F statistic (FChange).
Variables Knee PPT Deltoid PPT
β Model Summary β Model Summary
Step 1 Demographic variables
Age 0.29** R2 = 0.12adjR2 = 0.09FChange = 3.4* 0.29** R2 = 0.12adjR2 = 0.09FChange = 3.4*
BMI 0.04 0.04
Gender −0.21 −0.21
Step 2 PPT Measures
Age 0.33** R2 = 0.18adjR2 = 0.14FChange = 5.34* 0.32** R2 = 0.19adjR2 = 0.14FChange = 5.72*
BMI 0.1 0.05
Gender −0.07 −0.05
PPT 0.29* 0.3*
Step 3 Psychological variables
Age 0.25* R2 = 0.22adjR2 = 0.14FChange = 1 0.24* R2 = 0.23adjR2 = 0.15FChange = 1.31
BMI 0.09 0.06
Gender −0.07 −0.04
PPT 0.25 0.28*
PSEQ 0.07 0.08
PCS −0.11 −0.13
ISEL 3 0.08 0.08
4.2

4.2 Patient satisfaction 6 months post TKA and PPTs

There was no significant association between patient satisfaction 6 months following TKA and pre-operative PPTs either local to the operative knee (β 0.2 (p = 0.16); model adjR2 = 0.04) or remotely (β 0.14 (p = 0.3); model adjR2 = 0.02) (Table 4). No demographic or psychosocial variables were significant in the models at 6 months post TKA.

Table 4 Patient satisfaction at 6 months post-operative: Hierarchical linear regression analyses examining the relationship between patient satisfaction, demographic variables, pressure pain thresholds (PPT) (knee and deltoid), and psychosocial variables. Relationships are expressed as standardised coefficients (β) with progressive model fit expressed as the R2, adjusted R2 (adjR2) and changes in the F statistic (FChange).
Variables Knee PPT Deltoid PPT
β Model Summary β Model Summary
Step 1 Demographic variables
Age 0.06 R2 = 0.01adjR2 = −.031FChange = 0.25 0.06 R2 = 0.01adjR2 = −0.03FChange = 0.25
BMI −0.07 −0.07
Gender −0.04 −0.04
Step 2 PPT Measures
Age 0.09 R2 = 0.06adjR2 = 0.002FChange = 3.36 0.08 R2 = 0.03adjR2 = −0.03FChange = 1.42
BMI −0.02 −0.06
Gender 0.08 0.05
PPT 0.25 0.17
Step 3 Psychological variables
Age 0.01 R2 = 0.11adjR2 = 0.04FChange = 2.23 −0.01 R2 = 0.1adjR2 = 0.02FChange = 2.71
BMI −0.04 −0.07
Gender 0.06 0.04
PPT 0.2 0.14
PCS −0.12 −0.15
ISEL 3 0.17 0.17
4.3

4.3 Patient satisfaction 12 months post TKA and PPTs

Patient satisfaction 12 months post TKA was not associated with pre-operative PPTs local to the operative knee (β 0.17 (p = 0.22); model adjR2 = 0.02) or remotely (β 0.09 (p = 0.5); model adjR2 = 0.002) (Table 5). Higher self-esteem support (ISEL domain 3) was significantly related to higher patient satisfaction at 12 months post TKA in both models (β 0.24–0.25 (p < 0.05).

Table 5 Patient satisfaction at 12 months post-operative: Hierarchical linear regression analyses examining the relationship between patient satisfaction, demographic variables, pressure pain thresholds (PPT) (knee and deltoid), and psychosocial variables. Relationships are expressed as standardised coefficients (β) with progressive model fit expressed as the R2, adjusted R2 (adjR2) and changes in the F statistic (FChange).
Variables Knee PPT Deltoid PPT
β Model Summary β Model Summary
Step 1 Demographic variables
Age −0.003 R2 = 0.003adjR2 = −0.04FChange = 0.06 −0.003 R2 = 0.003adjR2 = −0.04FChange = 0.06
BMI 0.02 0.02
Gender −0.05 −0.05
Step 2 PPT Measures
Age 0.02 R2 = 0.03adjR2 = −0.03FChange = 1.94 0.01 R2 = 0.008adjR2 = −0.05FChange = 0.4
BMI 0.05 0.02
Gender 0.04 −0.001
PPT 0.19 0.09
Step 3 Psychological variables
Age −0.03 R2 = 0.08adjR2 = 0.02FChange = 4.11* −0.05 R2 = 0.07adjR2 = 0.002FChange = 4.52*
BMI 0.008 −0.02
Gender 0.04 0.01
PPT 0.17 0.09
ISEL 3 0.24* 0.25*
5

5 Discussion

Results showed that lower PPTs both locally at the knee and remotely at the deltoid recorded pre-operatively have an association with lower patient satisfaction in the short-term (six weeks) following TKA, even when potentially confounding influences were accounted for. However, this relationship at six weeks was relatively modest (β 0.25–0.28, adjR2 = 0.14–0.15) and was lost at intermediate and longer term follow up. The six-week outcome is potentially important to the clinician and the health system as it may allow the focussed pre-emptive use of resources by indicating which patients would benefit from more regular formal clinical review. Additionally, this finding carries useful prognostic information for patients regarding how their early rehabilitation is likely to progress. Rehabilitation has not been shown to affect the overall outcome of TKA surgery, this may be because it is currently lacking sufficient focus.58 The findings of lowered PPT at the deltoid as well as the knee suggests preoperative central sensitisation in some patients, potentially affecting the early recovery phase following TKA. It is plausible that after performing the TKA the central sensitisation process may take up to six months to normalise. Most importantly when a surgeon examines a pre-operative patient with KOA who displays significant pain during palpation of the knee, they should not be concerned that this finding will ultimately impact post-TKA satisfaction.

Our findings also showed older age to be correlated with higher satisfaction in the early stage (6 weeks) post-surgery, somewhat mirroring the impact of PPT measures. The literature concerning the impact of age on outcome following TKA is inconsistent, some studies59–63 report younger age is associated with worse post-operative pain and dissatisfaction while others64–67 show poor results linked to older age.

Interestingly, our regression modelling suggested that only one psychosocial variable, specifically the self-esteem support subscale of the ISEL, had a significant relationship with patient satisfaction and only at 12-month follow-up. This domain has not been investigated previously in this regard. ISEL as a perceived measure of availability of social support, has previously been shown to buffer the pathological effect of stressful life events.54 Although pain sensory sensitisation and psychosocial factors do not necessarily evaluate the same construct, they were an important inclusion into the modelling due to their previous link with outcomes following TKA and their proposed role in central sensitisation.68 There is significant evidence in the literature highlighting the association between psychological variables and post-operative outcomes following total joint replacement69 as well as post-operative pain in general.70

Among the other psychological factors we investigated, were pain self-efficacy, and pain catastrophizing, which revealed a univariate correlation to the post-operative patient satisfaction but failed to show any predictive value on hierarchical regression analysis. This contrasts with some previous evidence on the influence of these psychological factors within 12 months of TKA71–74 but not the long term outcome which is still with limited or conflicting evidence.69 Psychological parameters have a complex interaction with the outcome of TKA and their reported influence may vary depending on study methodology and quality.

To our knowledge, this is the first study to incorporate pain threshold measures with such a comprehensive battery of psychosocial and clinical function factors in a hierarchical regression model to investigate the predictive capacity of pain thresholds in determining outcome following TKA. Rakel et al.25 was the only group who included limited psychological factors (anxiety, depression and pain catastrophizing) with their QST measures. We acknowledge that the pain sensory measure we used is only one of many available pain sensory measures. The literature has shown preliminary evidence that preoperative PPTs have some predictive value in TKA outcome.26,27 However, the findings of this study suggest that pressure pain thresholds seem to have limited value in predicting the post-operative outcome in the medium to long-term following TKA.

There are some limitations of our study, particularly the use of only one modality of QST, it may be worth evaluating other modalities in future studies. It could be postulated that performing QSTs so close to surgery may have affected our results due to psychological stress in the perioperative period, but we feel our data is appropriately representative of the pain in patients with advanced KOA prior to surgery. We did not cease the analgesia taken by the OA group prior to QST in order to best mimic the pain state in their normal daily life, this might also have affected their pain perception process. We were also limited to a participant sample of convenience in this study although they seemed representative of a typical TKA population. Participants in this study had a mean age of 65.65 ± 7.79 years which is only slightly younger on average than the mean age for TKA in Australia at 67.2 years,5 and a mean BMI of 32.91 ± 6.23 consistent with previous studies.74,75 Due to exclusion of certain demographics such as race and socioeconomic status, these findings may be more difficult to apply to more specific population groups.

6

6 Conclusion

Our findings suggest that mechanical hypersensitivity does not negatively impact patient satisfaction post-TKA at 6 and 12 months. However, when it is present surgeons should be aware that is associated with lower patient satisfaction in the first 6 weeks after surgery. Patients with this clinical finding may benefit from closer post-operative review. At 12 months patient satisfaction was significantly associated with the ISEL self-esteem subscale, further study of this finding may provide a means of rationalising pre-operative screening questionnaires.

Participant consent in-line with ethical requirements

Our protocol to proceed with our studies received the appropriate Institutional Review Board approval by Institutional Human Research Ethics Committee (WMSBHSD Protocol 25-9 and GPH HREC Protocol 12/27) and all participants provided written informed consent prior to participating. The appropriate certificate is available upon request.

Funding

This project was supported by a Queensland Health – Health Practitioner Research Scheme Grant.

CRediT authorship contribution statement

Michael McAuliffe: Conceptualization, Methodology, Writing – Original and Review, Supervision. Tristan Pillay: Conceptualization, Writing – Original and Review, Data curation, Visualisation. Khalid Jaber: Conceptualization, Methodology, Investigation, Writing – Original. Michele Sterling: Data curation, Formal analysis, Supervision, Writing – Review. Shaun O'Leary: Conceptualization, Writing – Original and Review, Data curation, Formal analysis.

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