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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 2  |  Page : 39-46

Dysphagia research in India: A status report


Department of Speech-Language Pathology, All India Institute of Speech and Hearing, University of Mysore, Mysore, Karnataka, India

Date of Web Publication27-Dec-2018

Correspondence Address:
Gayathri Krishnan
Department of Speech-Language Pathology, All India Institute of Speech and Hearing, University of Mysore, Mysore - 570 006, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisha.JISHA_44_17

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  Abstract 


In India, the field of dysphagia is still in its infancy. This study attempted to make a baseline assessment of the status of dysphagia research reported from India in the global scenario. A search in the most popular search engines and databases for research originated in India was conducted. Among the 2436 reports retrieved, 64 reports were included in this study. A two-tier analysis revealed the various characteristics of Indian research, and researchers involved in this science. Initiated less than two decades ago, dysphagia research in India has been on a steady increase. Unfortunately, 23.44% of them remain unpublished and unavailable for other researchers. Although there is a growing interest, dysphagia is still unexplored and has a long way to grow in India. The numerous gaps identified in this study provide a new direction for researchers in dysphagia and also enlighten the Indian researchers about their contribution to the global scenario.

Keywords: Changes, deglutition, growth, Indian research, speech-language pathology, swallowing disorders


How to cite this article:
Krishnan G, Goswami S P. Dysphagia research in India: A status report. J Indian Speech Language Hearing Assoc 2018;32:39-46

How to cite this URL:
Krishnan G, Goswami S P. Dysphagia research in India: A status report. J Indian Speech Language Hearing Assoc [serial online] 2018 [cited 2019 Jan 17];32:39-46. Available from: http://www.jisha.org/text.asp?2018/32/2/39/248017




  Introduction Top


Dysphagia is recent science, a toddler among the rehabilitative sciences practiced in India but much grown and matured in the Western countries. The earliest report of swallowing disorders dates back to James Parkinson,[1] when he profiled the nonmotoric symptoms of Parkinson's disease. To publish a research article solely on dysphagia, it took another century and more.[2] Since then, the field of dysphagia has immensely progressed globally. Realization of scope and importance of dysphagia rehabilitation have drawn many rehabilitation professionals from the West. Increase in demand for expertise to deal with this condition led the professional organizations of developed countries to initiate special board certifications and strict practice guidelines for clinical, research, and advocacy in this science. Specialized laboratories with immense expertise for swallowing rehabilitation, training, and research are established in academic institutions located in these countries. Research outputs from these laboratories are remarkable with a quantifiable number of publications produced by its members at the international platforms.

In the East, growth has been slower compared to the West due to colonization and struggle for an independent and self-sufficient existence. India had initiated the Indian Speech and Hearing Association (ISHA) earlier than Japan, in 1967 (http://www.ishaindia.org.in/). However, the focus of the organization and its members have been exceptionally toward communication disorders while swallowing disorders or dysphagia have been of limited importance. The scene is changing with few speech-language pathologists dedicating their research, and practice interests in dysphagia. These interested professionals often face a lack of expertise and guidance as there are limited background works reported in this science from the Indian population. The actions need to be initiated from scratch and often end up with limited impact, within the country. This study was taken up to understand the “What, How, Why, and Where” of dysphagia research reported from India. Specific objectives of this study were to analyze the following characteristics of research published from India on dysphagia:

  1. Number and availability of reports
  2. Professionals involved
  3. Geographical location
  4. Source and owner
  5. Characteristics studied
  6. Impact factor
  7. Changing trends.



  Methods Top


An all-inclusive literature search in the most popular research databases was done using deglutition, feeding, swallowing, dysphagia, nutrition, and India as search words. These keywords were selected by the researcher in consultation with senior experts and peer groups to include a maximum number of reports that contain any information related to the subject. These databases included both national (IndMed, ISHA Research, and Institutional databases) and international (Turning research into practice, PubMed, Google Scholar, and Medline) collection of research reports. Attempts were made to include Scopus, LILACS, SciELO, and Cape Journals but could not be included due to technical limitations. An additional search of in-house publications of speech and hearing institutes approved by the Rehabilitation Council of India (RCI) was also conducted for the identification of relevant literature. It may be noted that research papers presented at various national and international conference and those published in proceedings of events were not retrieved in this study. Only, the research reports that were published in a journal were considered for inclusion as these are the first and most reliable sources of literature information for any researcher. Details of these reports would provide insight into the contribution of Indian research on dysphagia at a global level. [Figure 1] provides a depiction of the procedure followed for the identification of relevant articles.
Figure 1: Diagrammatic representation of the method followed to identify dysphagia research reports from India

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The search retrieved 2436 reports that were relevant to the literature search. Scrutiny of retrieved reports for duplicates resulted in 1281 articles for the next level of analysis. Manual screening of each of the search result was carried out to exclude articles that had the following criteria:

  1. Did not originate from India
  2. Was not carried out by Indian professionals
  3. Do not provide at least the abstract for review
  4. Did not include human subjects
  5. Did not focus on dysphagia as such
  6. Did not aim at studying dysphagia but rather the cause or other related attributes.


Thus, studies that focused on specific surgical, pharmaceutical methods, studies that merely reported dysphagia within a particular population, and studies that considered dysphagia as one of the outcome measures of medical treatment were excluded from further analysis. The reports were manually scrutinized for duplication and resulted in a total of 64 articles for final inclusion. All the 64 items identified for inclusion were read, reviewed, and various characteristics of the report such as the year of publication, type of publication, citations obtained, type of research, research design followed, focus of the research, location of the study, professionals involved in the study, and its affiliation details were tabulated. The following were the limits within which the review was conducted.

  1. Year of publication: The year in which the article was published in the national or international journal
  2. Type of publication: The characteristics of the journal in which the research report was published (National or International)
  3. Citations obtained: The number of citations received by the report as per Google Scholar Statistics
  4. Type of research: The concept orientation of the research study to basic science or applied science. The study of clinical entity/pathological aspects of swallowing was considered as applied research, and typical swallowing science was included under basic research
  5. Research design: Studies that included single-case observations and statistics were categorized into single-subject designs. These included case studies, case series reports, pre-post comparison studies, and other similar designs which considered data observations from a single individual. Other studies that included group statistics and that involved generalization of results to a population were categorized into group designs. These included experimental designs, quasi-experimental designs, and cross-sectional designs
  6. Research focus: The overall focus of the research report to a description of characteristics/assessment/rehabilitation was tabulated
  7. Location of research: The location of the first author and their affiliation was considered as the location of research
  8. Impact of research: The impact factor reported in the journal website was documented. In case of no updated impact factors available on the journal website, the study was not considered for analysis
  9. Professionals involved: The designation of the authors was reviewed and tabulated as medical/speech-language pathologists/other
  10. Affiliation: The name of the setup was tabulated after which they were classified into medical hospitals/private clinics/academic institutes.



  Results and Discussion Top


Number and availability of reports

The results of web search on most popular database identified only 64 articles reported from India by Indian Researchers that specifically studied dysphagia or its rehabilitation. [Table 1] summarizes the number of articles identified in this area from various sources explored. Majority of relevant Indian reports could be retrieved from Google Scholar. However, the author would like to mention here that PubMed search also retrieved similar results but is not represented here as the reports were duplicates of that retrieved from Google Scholar. Since these duplicates were removed during screening [Figure 1], the same is not represented in [Table 1]. The second most reliable source for Indian research reports on dysphagia is the in-house documentations available from specific institute websites indicating that many researchers have not published their studies on the global library.
Table 1: Number of Indian research works available in national and international database

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Hidden data are hence a significant drawback in Indian research scenario as the in-house publications remain unknown and inaccessible for other researchers globally. The researchers who are aware of the possible institutes and organizations involved in dysphagia research may specifically search for information but many, including this researcher, might miss out on relevant research reports unless it gets published on a widely accessible source. The science of deglutition is still in its early phase, and it is rational to believe that most research carried out in the country is of fundamental nature and probably not interesting to the much progressed global research population. However, there may be interested professionals within the country, who want to take the lead and publishing these “hidden” data can reveal the need of the hour. Unpublished data or data that are made available to a minimal number of researchers is a major hindering factor to progress in dysphagia research in the country. By publishing research reports, not only a research output will be known for its focus area of work, methodology, and organizations where facilities are available but also the researcher. It also boosts awareness among other professionals that further improves team involvement and collaborative works in dysphagia management. Improved accessibility to research would further reduce the wastage of resources and improve work efficiency by avoiding baseless repetitions of already conducted research work.

Professionals involved

From [Table 2], about half of the dysphagia research is reported by medical professionals that include specialized personnel in the field of Neurology, Gastro-Enterology, Oto-Rhino-Laryngology, and Pediatrics followed by speech-language pathologists. Dysphagia being a multidisciplinary field requires the team efforts of many medical and allied health professionals. It is unfortunate that there is a lack of collaborative work among the professionals who are frequently involved in dysphagia rehabilitation. It may be related to the weaker establishment of the field of dysphagia in this country.
Table 2: Professionals involved in dysphagia research in India

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Dysphagia research is limited to its medical aspects while the rehabilitative aspects dealt by the speech-language pathologists are still unpublished or lacks research evidence. From the author's point of view, the field of speech and hearing is still not well established across the country with relatively less number of professionals working in the land. The vast scope of practice is not explored and established. There need to be clear steps taken to provide an opportunity for this profession to grow. The few academic institutions that produce a qualified workforce in the country focus entirely on communication disorders and almost neglect dysphagia as within their scope of practice, although they are aware of its existence. The relative low emphasizes provided to this subject in theory and practice make very few individuals attracted to take it forward and conduct research and offer rehabilitation services to persons with swallowing disorders in the country. Altogether, it leads to poor awareness and interest among professionals and also negligence, unawareness, and lack of quality health services to the needy. However, it is promising that at least few speech-language pathologists are involved, and they are second only to the medical professionals who are the first choice of consultation for a person with dysphagia for obvious reasons. It will be interesting to know if the persons with dysphagia are referred to the appropriate rehabilitation professionals following their first line of treatment for further management and what are the operating procedures for a person with dysphagia.

Geographical location

[Figure 2] and [Table 3] summarize the geographical locations from which the research reports have originated in India. The state of Karnataka houses 14 institutes approved by the RCI that offers graduate and postgraduate courses in speech and hearing and also has 2346 primary health centers. Government health policy, such as the Karnataka State Integrated Health Policy,[3] has recognized nutrition as an essential aspect of health and paved the way for dysphagia rehabilitation and research to develop in the state. The state of Maharashtra follows Karnataka with five RCI recognized speech and hearing colleges and approximately 34,000 hospitals (as of 2001). Most of the speech and hearing institutes in Karnataka are linked with medical hospitals providing them ample opportunities for delivering dysphagia rehabilitation, which may be a probable reason for the higher number of research outputs from the state of Karnataka. In general, the Southern part of the country (States of Karnataka, Kerala, Tamil Nadu, and Andhra Pradesh) is currently witnessing the growth in the field of dysphagia while dysphagia research is neglected in the Western and Northeastern parts of India. This is in spite of emphasizing placed on nutrition by the National Health Mission, Government of India. The reason for this may be the relatively weaker awareness, lack of expertise, or misplaced focus of the health mission.
Figure 2: Location of research centers in India

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Table 3: Location of dysphagia research centers in India

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Source and owner

Majority of the research originated from medical hospitals (68.75%) and the rest from academic institutes (31.24%). This supports the earlier finding reported in a previous section that majority of professionals involved in dysphagia research are specialized medical professionals. Dysphagia, being a cause and sometimes consequence of medical condition, is a population that is frequently encountered in in-patient facilities. Access to the patient population has been triggering some research in these settings. The speech-language pathologists are the next professionals involved in dysphagia research. The academic institutes may conduct dysphagia research as a part of their criteria for fulfillment of undergraduate and postgraduate courses. This form of research forms the second major contributor of dysphagia research literature in India. Other possible setups for research such as private clinics have not produced any relevant documentation, possibly because they do not have access to the population or due to the lack of facilities for effective dysphagia treatment.

Characteristics studied

Characteristics of research were categorized into various aspects such as clinical or basic research, research designs used, and also the focus of research reported. The descriptive summary of these classifications and the number of included research reports are provided in [Table 4]. There are both basic and applied types of research reported from the country with standard group comparisons as the most common design. Many studies are published based on the unusual presentation of dysphagia which is reported in the form of case studies. A limited number of studies have attempted to explore the measures of swallow across a cross-sectional group of the population, and very few experimental studies on swallowing are reported from India. Few attempts toward the development of assessment, treatment, and quality of life tools can be found in the literature. These tools are mostly developed for in-house use, remain unpublished and are targeted to specific professionals and patients.
Table 4: Characteristics of dysphagia research in India

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Majority of reports focused on a review of a particular topic of interest in the field or else consider describing characteristics of swallowing difficulties in persons with dysphagia when it is associated with a known medical condition. In many of these studies, the focus shifts from dysphagia and moves to the description of the medical condition but was included in the present review as swallowing issues were described in some detail and not wholly kept ignored or unexplained. Many published reports solely focus on characteristics of dysphagia. Development and validation of assessment protocols, methods, and efficiency of specific procedures in detection, identification, and classification of swallowing difficulty have also received attention among professionals working in this science. However, minimum focus toward treatment methods and its efficacy is a concern. It was observed that the bulk of these studies are oriented toward medical treatment and surgical approaches. Very few provide any level of evidence for rehabilitation strategies.

Impact factor

Few National Journals lacked information on updated impact factor, due to which all the reports considered for other sections could not be included in this analysis. Indian researchers are aiming at international and national publications and have successfully published nearly 75% of their work in national and international forums. However, unfortunately, a decent number of works remain unpublished in the in-house repository of the academic institution without marking its impact on the global literature. The reports available are published in good international journals with high-impact factor [Table 5] suggesting acceptance and encouragement of many researchers across the world, and quality of work that has been carried out in India, though limited in number. Few other reports are available in Indian journals that have a lesser impact factor, probably due to limited coverage, availability, and distribution of the journal for reference and citations by other researchers. This is also in concordance with the number of citations made for these Indian research reports by other researchers globally. As calculated from the “Google Scholar” statistics, Indian research in dysphagia published in international journals has received citations 6-folds more than national publications [Table 5]. It may be noticed, that this statistics is only based on “Google Scholar.” There may be high demand for Indian literature in dysphagia if the unpublished works are made available for other interested professionals rather than documenting the same in the in-house repositories.
Table 5: Impact of Indian dysphagia research

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Changing trends

From the data derived from this review, the dysphagia literature originating in India could be divided into two eras as follows: before 2008 and after 2008. The year 2008 seemed to be the igniting year for dysphagia research in India as there was a constant increase in published and unpublished literature from the country. All changes in this study are analyzed in these two eras of Indian literature. The investigated characteristics of these reports across years are presented in [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]. The first report from India appeared in literature in the year 1999, and then there were random appearances in national and international journals [Figure 3]. Since the year 2008, there has been an increasing number of researches reported in the literature. The number of international publications has been increasing since 2008 and so is the unpublished literature. However, the trend of unpublished literature has been changing for good, and some researchers are making their work available globally.
Figure 3: Dysphagia research reports from India across the years

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Figure 4: Type of dysphagia research reported from India across the years

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Figure 5: Research designs reported in Indian Dysphagia Literature across the years

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Figure 6: Focus of dysphagia research reported from India across the years

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Figure 7: Professionals involved in dysphagia research in India across the years

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Figure 8: Dysphagia research conducted in different setups in India across the years

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The kind of dysphagia research carried out in India has always been on the basics of dysphagia rather than the applications of this theoretical knowledge gained [Figure 4]. This trend is understandable as the basic knowledge about the field is to be reestablished in the Indian context to make its implications in the applied field. However, the situations have not changed much over the past 8 years, and the basics are still the interest of Indian research. Probable reasons for this may be the lack of awareness among the ordinary people about the options available for the treatment and management of swallowing difficulties beyond nasogastric tubes and percutaneous endoscopic gastrostomy systems. A part of this awareness should come from the medical professionals who directly deal with persons with dysphagia who may benefit from Swallowing therapy. Adequate and appropriate referral to speech-language pathologists working in the field of dysphagia is necessary not only for rehabilitation of the needy but also for the development of the field of dysphagia in the country as a whole. Lack of service seekers attracts limited speech-language pathologists to work and conduct research in the field and lead to a lack of expertise of professionals involved in dysphagia management. Neglect, unawareness, and lack of demand for quality service hinder applied dysphagia research in India. However, this is not to indicate that dysphagia is uncommon among Indians.

From standard group comparisons and single-case studies before the 2008 era, dysphagia research has progressed immensely toward group designs that include experimental and cross-sectional studies and has started showing varied research designs [Figure 5]. Many researchers also consider review articles and dysphagia resource development as a need. It may be a sign of progress as group designs indicate growth in the number of persons with dysphagia seen by the professional. Studies have progressed from identification and description of random deviated swallows to understanding the characteristics of dysphagia population.

As seen in [Figure 6], the initial research reports focused on describing the symptoms of dysphagia and its assessment procedures as well as developing assessment tools and protocols. Toward the recent, there has been diversity in the focus of attention at multiple levels of dysphagia management that includes identification, feature description, differentiation, assessment methods, protocols, specificity and sensitivity of assessment methods, treatment and management options, techniques, strategies, and also the quality of life. Among these, the description of dysphagia characteristics in specific population and the development of assessment and management resources outweigh others. This is acceptable, considering the fewer number of research reports and the infancy of the field of dysphagia in India. Hopefully, some experimental designs that establish cause-effect relationships and treatment efficacy studies will be aimed in the future as this will aid in the growth of the field at large.

The research was initiated by speech-language pathologists and medical professionals, and they still pursue their work in this field [Figure 7]. Unfortunately, there is very less number of multidisciplinary studies with combined efforts from the two disciplines. Medical professionals have brought their work into limelight compared to speech-language pathologists. Further, other professionals, such as physiotherapists/occupational therapist, have attempted to mark their entry into dysphagia research but have not succeeded much. The multidisciplinary studies have been more frequent in recent years; however, independent disciplines have contributed more to dysphagia research.

The medical hospitals have been and continue to be the most utilized research centers for dysphagia research. This complements the previous finding that the medical professionals are more frequently involved in dysphagia research compared to others. The speech-language pathologists, who mostly work in the academic institutes of the country, are also contributing to the literature in comparable ways. There are no private clinics/bodies that are involved in such research in India probably because they do not have the expertise and facilities. There has been no significant change in the place of origin of dysphagia research reports in India over the past years [Figure 8].

The field of dysphagia and evidence in dysphagia management is sprouting in the country. It needs to grow and bloom and have a long way to go before its efficiency and quality can be measured. The national body of speech-language pathology in India, the ISHA, can play a significant role in the upliftment of this science. Developing a position statement for clinical training and practice of dysphagia rehabilitation in the country is the urgent need of the hour. Setting up the periphery and limits of dysphagia practice in the country can not only bring confidence in professionals interested in deglutition science but also will hallmark this science as within the practical limits of a speech-language pathologist along with other medical and allied professionals. This tagging is necessary for speech-language pathologists to get involved in the team management of dysphagia.

The number of research reports in this subject has been on the gradual rise with a fair amount of citations and references globally. Acceleration in this direction is mandatory for its growth and establishment. Professionals who are working in this area should aim at producing high-quality outputs that can be taken forward at the international level. The professionals involved in this management, medical as well as nonmedical, needs to start making combined efforts for uplifting the quality of life of persons with dysphagia. The focus of the research has been on the basic science of deglutition, and it gradually needs and will call for a shift as the field grows in the country. It indicates that focus should shift from a mere description of symptoms to clinical applications and treatment efficacy studies. Keeping in mind, the differences in size, stature, culture, behavior, and food habits of India compared to other countries, it is also essential to validate the Western findings in the Indian population, and thus replications are no less important.

Such a rise in research reports requires the funding agencies to allocate special grants for less explored sciences such as deglutition. The rehabilitation professionals look up to agencies such as the Department of Science and Technology and the Indian Council of Medical Research for funding options for their research interest. Exclusive funding for projects on deglutition sciences will attract professionals in conducting quality research that will further improve clinical and theoretical knowledge in Indian Scenario. Further, funded research projects will enhance the professional experience and credentials and reflect on national initiatives in dysphagia. The leading originator of such research is the medical centers of the country. Such national-funded projects can encourage multidisciplinary and collaborative research further improving the quality of work.

The centers of dysphagia research are located in metropolitan cities such as Bengaluru, Hyderabad, and New Delhi, indicating that there are needy service seekers and hence it is crucial that full-fledged health centers be set up across the country so that no portion of the population goes unreached. It is also important that these health centers be equipped with a quality workforce of dedicated staffs with the expertise to treat, manage, and rehabilitate the person with swallowing disorders irrespective of age, gender, race, or condition.

It will be interesting to understand the reason for less number of dysphagia research reports from the Indian subcontinent. Among all the studies reviewed for this report, none reported epidemiology of this condition in the country. It is unclear if the lesser number of research initiatives are due to probable differences in the incidence of dysphagia in developing countries (such as India). These differences may exist as there are vast differences in food culture, technological revolutions, and possibly the differences in anatomical dimensions of oropharyngeal structures. If such differences in epidemiology exist, India may be able to offer solutions to the increasing incidence of dysphagia in the West. However, if there are no differences in the incidence of dysphagia between the East and the West, the changes in the Indian population dynamics indicate an immediate need to equip themselves for an aging and dependent population.

Chatterji et al.[4] predict that by 2042, the number of Indians above the age of 60 will outgrow the number of children below 14 years suggesting that Indian society is rapidly aging. From the available population statistics, it can only be interpolated that in another two decades, 34% of the Indian population will be aged above 50 years[5] and that such a change will demand modifications in social, medical, and economic reforms of the country with approximately 34% of the geriatric population experiencing dysphagia.[6],[7] The Indian healthcare system should start accelerating toward equipping themselves with measures to identify, assess, manage, and rehabilitate an aging and possibly dependent population. Research on swallowing and its disorders has its prime importance as preparing for prevention and rehabilitation of this condition can avoid malnutrition, improve overall well-being, and reduce long-term disability in the significant proportion of the Indian population. While some schemes are being implemented for child nutrition, health, and development, the ever-increasing aging population should not be neglected from the same nutrition and well-being. Alleviating dysphagia is one of the quickest routes to a healthy India and national-level missions toward this can make huge differences in the life of persons with swallowing disorders. This one step may improve the overall well-being of an aging population and in turn the quality of life of Indian Society.


  Conclusion Top


Research on dysphagia is still in its early-growing stages with a very gradual rise in the number of published reports, and these are available in Google Scholar and PubMed. There are basic and applied types of research that focuses on identification, assessment, and development of resources. Treatment efficacy studies are scarce from Indian research centers. Medical professionals and speech-language pathologists are frequently involved in these ventures are mostly are localized to specific geographical locations. The overall scene is gradually changing for better research impact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parkinson J. An Essay on the Shaking Palsy. USA: Create Space Independent Publishing Platform; 1817.  Back to cited text no. 1
    
2.
Larsen GL. Rehabilitation for dysphagia paralytica. J Speech Hear Disord 1972;37:187-94.  Back to cited text no. 2
    
3.
The Karnataka State Integrated Health Policy; 2001. Available from: http://www.karnataka.gov.in/..../karnataka-state-integrated-health-policy-2001.pdf. [Last accessed on 2017 May 05].  Back to cited text no. 3
    
4.
Chatterji S, Kowal P, Mathers C, Naidoo N, Verdes E, Smith JP, et al. The health of aging populations in China and India. Health Aff (Millwood) 2008;27:1052-63.  Back to cited text no. 4
    
5.
United Nations Population Division (UN). World Population Prospects: The 2010 Revision. New York: United Nations; 2011. Available from: http://www.esa.un.org/unpd/wpp/index.htm. [Last accessed on 2017 May 05].  Back to cited text no. 5
    
6.
Kawashima K, Motohashi Y, Fujishima I. Prevalence of dysphagia among community-dwelling elderly individuals as estimated using a questionnaire for dysphagia screening. Dysphagia 2004;19:266-71.  Back to cited text no. 6
    
7.
Serra-Prat M, Hinojosa G, López D, Juan M, Fabré E, Voss DS, et al. Prevalence of oropharyngeal dysphagia and impaired safety and efficacy of swallow in independently living older persons. J Am Geriatr Soc 2011;59:186-7.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

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