Clinical efficacy and electromyographic analysis of direct current hydrotherapy in the treatment of upper limb peripheral nerve injuries: A randomized controlled trial

Abstract

Purpose

This study aimed to investigate the reparative effect and therapeutic efficacy of direct current hydrotherapy in the treatment of upper extremity peripheral nerve injury to provide a reference for the clinical treatment of peripheral nerve injury in the future.

Method

Between September 2022 and June 2023, 66 eligible patients with upper extremity peripheral nerve injury were enrolled and randomly divided into observation and experimental groups (33 cases each). All participants provided written informed consent; none of them were minors. Based on routine rehabilitation for both groups, the experimental group received additional direct current hydrotherapy. All procedures were performed by professional rehabilitation staff. This study was approved by the hospital ethics committee and was performed in accordance with the Consolidated Standards of Reporting Trials statement. Outcome evaluations, including the action research arm test, Fugl–Meyer assessment, and electromyography, were performed at baseline and 4 weeks after intervention. The primary outcome measure was clinical efficacy, which was classified into cured, markedly effective, improved, and ineffective according to electromyography results.

Results

After 4 weeks of treatment, the experimental group showed a more significant improvement than the observation group (p < 0.05). The total effective rate was 96.7% in the experimental group and 81.8% in the observation group. Treatment was considered clinically effective in patients graded as cured, markedly effective, or improved and as non-effective in those graded as ineffective. The risk difference between the two groups was 0.149, with a 95% confidence interval of 0.004 to 0.294. The effect size (Cohen's h) was 0.52, indicating a moderate-to-large treatment effect.

Conclusion

Direct current hydrotherapy exerts a restorative effect on the peripheral nerves of the upper limbs and has achieved good rehabilitation efficacy, which is worthy of clinical promotion and application.

Registration

This study was approved by the Medical Ethics Committee of Yuyao People's Hospital on 23 September 2022, Yuyao City, Zhejiang Province (Opinion Number: 2022-09-009; Trial registration: ChiCTR, ChiCTR2500110233; Date of Registration: 10 October 2025; https://www.chictr.org.cn/showproj.html?proj=283784).

Keywords

Hydrotherapy direct current water bath therapy peripheral nerve injury upper extremity electromyography

Introduction

Peripheral nerve injury (PNI) refers to structural or functional impairment of peripheral nerves caused by trauma, surgery, or pathological conditions, leading to partial or complete loss of sensory, motor, and autonomic functions.¹ PNI of the upper extremity is common, particularly in young males aged 18–35 years who account for 50%–83% of all patients.² These are most frequently due to motor vehicle collisions, laceration, fractures, and crush injuries.³ In recent years, with the advancement of local manufacturing and industrial development as well as the growing number of transportation vehicles, the incidence of PNI has increased. Such injuries are associated with a high risk of disability and serious social burdens, which can significantly impair patients’ physical function, employment ability, and psychological well-being.⁴ Given the unique anatomical and functional characteristics of upper extremity peripheral nerves, nerve regeneration and functional recovery following upper extremity PNI are complex and slow.⁵ In proximal PNIs, regenerating axons are required to traverse long distances to reach their target tissues, a process that can take months to years. During this prolonged period, the distal nerve stump gradually loses its capacity to support nerve regrowth, whereas target tissues undergo atrophy.⁶ PNIs not only impair motor function and cause sensory loss in specific body regions but also adversely affect brain function and its communication with target organs or muscles. These injuries can exert long-term impacts on behavior, movement, perception, consciousness as well as skin and joint sensations.⁷ Treating PNIs poses significant clinical challenges, which are largely influenced by multiple factors including the location, severity, and type of nerve damage, all of which determine the choice of therapeutic strategies and the potential for functional recovery.⁸

The repair of long-distance nerve defects remains difficult, and autologous nerve transplantation is the gold standard for treating PNIs. However, this method faces has inherent limitations due to limited sources and the risk of scarring.⁹ Currently, there is no unified standard for the treatment of PNIs around the upper limb in clinical practice; treatment mainly includes physical therapy, neurotrophic drugs, acupuncture, and other treatments; however, the treatment effect of these on PNIs around the upper limb remain unsatisfactory.¹⁰ Mecobalamin is commonly used in the adjuvant intervention of various PNIs.¹¹ Clinical studies have shown that electrical stimulation enhances axon growth during nerve repair and accelerates sensorimotor recovery.¹² Direct current stimulation upregulates the expression of key neurotrophic factors, including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and glial cell line-derived neurotrophic factor (GDNF), activates the cyclic adenosine monophosphate (cAMP) signaling pathway, creates a favorable microenvironment for nerve regeneration, and ultimately promotes axonal outgrowth in injured peripheral nerves.¹³ Although there have been substantial advances in direct current water bath therapy in China, few reports are available on its applicability in the rehabilitation treatment for PNIs. Early neurorehabilitation combining electrical stimulation and hydrotherapy improved axonal regeneration and motor function recovery in cats with brachial plexus injury, supporting the synergistic effect of electrical and water-based therapies.¹⁴ This study combined the advantages of hydrotherapy and electrotherapy, adopting direct current hydrotherapy for the treatment of upper extremity PNIs. The therapeutic efficacy was verified through multilevel functional evaluations and electromyography (EMG), and favorable results were achieved.

Data and methods

General information

Sixty-six patients with upper limb PNI who received rehabilitation treatment at our hospital or medical community unit and met the inclusion and exclusion criteria were selected (Figure 1). The participant selection process has been detailed in Figure 2. According to the method of random number table, the patients were randomly divided into the observation and experimental groups, with 33 patients in each group. Basic clinical data on age, sex, and course of disease were collected, and the experimental and observation groups were randomly included according to the method of random number table. During the study, no patient in the test or observation group was excluded or dropped out.

Figure 1.

Flow diagram of patient enrollment.

Figure 2.

Participant timeline.

Sample size calculation was performed using a two-sample independent t-test with a two-sided significance level of α of 0.05 and a power of 0.80. An effect size (Cohen's d) of 0.7 was assumed based on previous studies.¹⁵ The calculated sample size was 25 per group. After accounting for a 15% dropout rate, 29 patients per group were required. Therefore, we enrolled 33 patients per group to ensure adequate statistical power.

Inclusion criteria. Sixty-six patients with PNI of the upper extremity who were hospitalized for rehabilitation treatment in the rehabilitation medicine department within our hospital and the medical community unit were selected. Inclusion criteria were as follows: (a) disease onset 3–6 weeks before enrollment and patient age between 18 and 55 years; (b) sensory loss or absence of sensation in the damaged innervated area on clinical examination, with muscle strength 0–3; (c) EMG findings consistent with incomplete upper limb PNI, including a >30% reduction in motor nerve conduction velocity (MCV) of the affected nerve, fibrillation potentials and positive sharp wave in the affected muscles, reduced motor unit recruitment, and the presence of simple or mixed phase unit action potentials during voluntary contractions; (d) current use of nutritional neurology drugs (mecobalamin tablets, Eisai Pharmaceutical, a tablet per dose (0.5 mg), three times a day); and (e) patient willingness to participate in the study, as demonstrated by the provision of signed informed consent for treatment.

Exclusion criteria. The following exclusion criteria were applied: (a) EMG examination suggesting complete nerve damage requiring surgical treatment; (b) contraindications to electrotherapy such as installation of cardiac pacemakers, acute stage of cardiac infarction, and severe cardiac valvular disease; (c) multiple demyelinating peripheral neuropathy; (d) damage to the anterior horn of the spinal cord; and (e) broken skin, localized infections, or edema.

Criteria for dropping out. The criteria for dropping out were as follows: (a) unable to comply with treatment rules; (b) unable to tolerate the direct current water bath therapy; and (c) treatment discontinuation before completion and voluntary switching to alternative treatment modalities during the study period.

Methods

The observation group was treated with conventional rehabilitation therapy, including conventional physical factor therapy, and the experimental group was treated with conventional rehabilitation therapy + direct current hydrotherapy. The primary outcome measures were MCV and sensory nerve conduction velocity (SCV), as assessed using EMG. The secondary outcome measures included the British Medical Research Council (BMRC) score, action research arm test (ARAT) score, and Fugl–Meyer Assessment (FMA) score. The study complies with the Helsinki Declaration, as revised in 2024.

Observation group

Conventional rehabilitation treatment methods mainly included the following:

1. Protecting the skin wound. During treatment, care was taken to protect the damaged nerves, tendons, bristles and bones; avoid excessive stress; prevent edema and pain induced by treatment; and prevent deformity.

2. Exercise ability training. Exercise was performed with joint range of motion training as much as possible under pain-free conditions. Muscle strength training was performed according to each patient’s muscle strength, with simultaneous comparison with the healthy side. When the muscle strength of the affected nerve–innervated muscle was graded 0–1, passive movement was performed. When muscle strength was graded 2–3, power exercises, active exercises, and equipment-based exercises were performed. When muscle strength was graded 3–4, resistance exercises and other training methods were performed. At the same time, the patient was provided training to improve speed, endurance, agility, and coordination. The training intensity was based on the healing and stress-bearing capacity of the patient's tendons and bones. The number of repetitions was gradually increased; however, care was taken to ensure that the exercise regimen was not too exertive as to cause excessive fatigue. Coordination and movement mode training was given to strengthen the ability of the core muscles, and practice upper limb chain movement under posture control, such as the training of sitting upright and throwing objects.

3. Upper limb functional training for different injuries. Abduction and dorsal extension of the thumb; adduction and abduction of each finger; finger and palm function training of the thumb; wrist and finger extension exercises of the affected limb assisted by the healthy limb; forearm rotation function training; and interphalangeal, metacarpophalangeal, and wrist joint flexion function training were performed for radial nerve injury. Therapeutic functional activities included typing and playing various computer games using keyboards. For median nerve injury, the following exercised were performed: passive-to-active flexion of finger joints, thumb-to-palm exercises, wrist flexion and lateral wrist movements, pronation and supination of the forearm, and extension and flexion of the elbow joint. Therapeutic functional activities included fine grasping exercises, including embroidery, writing, and painting, and gross functional training activities such as pottery making, dough kneading, and keyboard games. For ulnar nerve injury, training mainly focused on abduction and adduction of the fingers (syndactyly), and the muscles innervated by the ulnar nerve were trained using methods such as fingerboard, paper clamping, and paper tearing.

4. Sensory remodeling training. This training was provided to patients with sensory loss, hyperesthesia, and hyperesthesia to achieve sensory desensitization and sensory re-education. Other treatments, such as tactile training, were used to improve the patient’s ability to distinguish a variety of forms, texture, size, weight, and temperatures. Visual compensation was provided when necessary to prevent and treat the neglect of the affected limb. In principle, training progressed from large to small and from easy to difficult.

5. Joint mobilization surgery. For patients with joint and tendon contractures, moderate joint loosening and related techniques were used. Athletic training was conducted 2 times a day, 5 days a week for 4 weeks.

Experimental group

Using the Trautwein butterfly-shaped bath and the limb-separated direct current bath, the affected limb was treated using direct current hydrotherapy. The direct current hydrotherapy treatment was conducted 5 days a week, once daily for 20 min during each session for a total of 4 weeks; routine rehabilitation training was performed after each direct current hydrotherapy session (Figure 3).

Figure 3.

Flow chart of the study design and intervention protocols.

Observation indicators

Basic function evaluation. The basic function was assessed according to the evaluation method for limb motor and sensory function proposed by the BMRC.

ARAT. This test includes four categories of assessment content: (a) grasp (6 items); (b) pinch (4 items); (c) hold (6 items); and (d) gross motor skills (3 items), with a total of 19 sub-items. Each item was scored from 0 to 3 points, with 0 indicating the inability to complete the action, 3 indicating normal completion of the action, and a maximum score of 57 points. The higher the score, the better the recovery of upper limb motor function.

FMA for functional assessment of the upper extremity. This method was used to assess flexion of the shoulder, elbow, wrist, and fingers and consists of 33 sub-items on a 3-point scale (0–2) with a maximum total score of 66.

Neuromuscular electrical activity assessment using EMG.

(a) Cured. No abnormalities detected on EMG, and MCV and SCV have normalized;

(b) Markedly effective. No/only slight denervation potentials on EMG, regeneration potentials visible, motor units showing a mixed pattern, and normal MCV and SCV;

(c) Improvement. Denervation and regeneration potentials are present on EMG, motor units decrease and show a simple mixed pattern, and MCV and SCV slow down;

(d) Ineffective. No significant changes observed after treatment.

Evaluation time. Both groups of patients underwent a basic functional assessment at the time of enrollment, including basic function assessment, the ARAT, and the FMA Upper Limb Function Assessment. All assessments were conducted by the same rehabilitation physician who has received professional training but does not participate in treatment. Both groups of patients underwent EMG examination at the time of enrollment and after 4 weeks of treatment.

Efficacy evaluation criteria

(a) Cured. No abnormalities on EMG, and normalization of MCV and SCV;

(b) Markedly effective. No/only slight denervation potentials on EMG, regeneration potentials visible, motor units show a mixed phase, and MCV and SCV are normal;

(c) Improved. Denervation and regeneration potentials are present on EMG, motor units decrease and show a simple mixed phase, and MCV and SCV slow down;

(d) Ineffective. No significant change observed after treatment.

Statistical analyses

All experimental data were statistically analyzed using the Statistical Package for Social Sciences (SPSS) software (version 27.0) and expressed as mean ± SD. Normality and homogeneity of variance were tested first. Independent-sample t-test and one-way analysis of variance (ANOVA) were used for between-group comparisons, and paired t-test was used for within-group comparisons before and after treatment. Non-parametric tests were used for non-normally distributed or ordinal data, and chi-square test was performed for enumeration data. A p-value <0.05 was considered statistically significant.

Results

Basic patient information

There was no significant difference in age, sex, and course of disease between the two groups (p > 0.05), indicating comparability (Table 1).

Table 1.

Comparison of the general data of patients in the two groups.

Group	Number of cases	Male	Female	Age	Day of illness
Experimental group	33	18	15	41.64 ± 9.447	32.18 ± 7.278
Observation group	33	19	14	39.03 ± 8.52	32.27 ± 5.281

Evaluation of the ARAT and FMA scores

Compared with before treatment, after 4 weeks of treatment, the basic functions of both groups of patients showed significant improvement, with significant increases in the ARAT and FMA scores (p < 0.05). Compared with the conventional rehabilitation treatment group, the group receiving direct current water bath therapy showed a more significant improvement in scores (p < 0.05).

Comparison of the pre- and post-treatment basic function assessment scores between the two groups of patients (excellent defined as 3 points, good as 2 points, normal as 1 point, and poor as 0 point). There was no statistically significant difference between the experimental and observation groups before treatment; both treatments were beneficial to the patients. Compared with the observation group, the experimental group had a lower p-value, indicating greater treatment effectiveness (Table 2).

Table 2.

Comparison of the basic function assessment scores before and after treatment in the two groups of patients.

Group	Pretreatment	Post-treatment	p-value (within-group)	Effect size (d)	95% Cl	p-value (between-group)
Experimental group	1.091 ± 0.678	1.848 ± 0.508	<0 . 001	1 . 278	0.783 to 1.773	0.704 (baseline)
Observation group	1.512 ± 0.712	1.424 ± 0.502	0 . 003	0 . 135	−0.321 to 0.591	0.002 (post-treatment)

Bolded values are Cohen’s d effect sizes, and the two within-group p-values were <0.05, showing that the treatment achieved significant efficacy in both groups.

CI: confidence interval.

Comparison of the ARAT scores before and after treatment between the two groups of patients. After treatment, both groups showed significant improvements in the measured index compared with those at baseline (all p < 0.05). The experimental group exhibited a moderate treatment effect, with an effect size (Cohen's d) of 0.69 and a 95% confidence interval (CI) (CI: 0.13 to 1.25). In contrast, the observation group showed a small effect size (d = 0.33, 95% CI: −0.19 to 0.84). At baseline, there was no significant difference between the two groups (p = 0.983). Although the post-treatment value was higher in the experimental group than in the observation group, the between-group difference did not reach statistical significance (p = 0.123) (Table 3).

Table 3.

Comparison of the ARAT scores before and after treatment in the two groups of patients.

Group	Pretreatment	Post-treatment	p-value (within-group)	Effect size (d)	95% Cl	p-value (between-group)
Experimental group	26.39 ± 9.666	30.76 ± 7.874	0.020	0.69	0.13 to 1.25	0.983
Observation group	26.21 ± 7.457	27.91 ± 6.907	0.024	0.33	−0.19 to 0.84	0.123

CI: confidence interval; ARAT: action research arm test.

Comparison of the FMA scores between the two groups of patients before and after treatment. There was no statistically significant difference in the FMA scores before and after treatment between the experimental and observation groups; both groups demonstrated improvement in upper limb nerve injury, with the experimental group demonstrating a better therapeutic effect than the observation group (Table 4).

Table 4.

Comparison of the FMA scores before and after treatment in the two groups of patients.

Group	Pretreatment	Post-treatment	p-value (within-group)	Effect size (d)	95% Cl	p-value(between-group)
Experimental group	28.12 ± 8.609	33.42 ± 7.778	<0.001	0.66	0.16 to 1.16	0.959
Observation group	28.36 ± 6.113	31.85 ± 5.783	<0.001	0.59	0.10 to1.08	0.319

CI: confidence interval; FMA: Fugl–Meyer assessment.

Comparison of the MCV and SCV on the injured side of the nerves between the two groups of patients before and after treatment. There was no statistically significant difference in the MCV or SCV before and after treatment between the experimental and observation groups; both experimental and observation groups demonstrated improvement in upper limb nerve injury, with the experimental group showing better efficacy than the observation group (Table 5).

Table 5.

Comparison of motor conduction velocity (MCV) and sensory conduction velocity (SCV) on the injured side of the nerves before and after treatment in the two groups of patients.

Group	Index	Pretreatment	Post-treatment	p-value (within-group)	Effect size (d)	95% Cl	p-value (between-group)
Experimental group	MCV	28.62 ± 9.01	39.24 ± 10.13	<0.05	1.12	0.62 to 1.62	0.918
Experimental group	SCV	27.38 ± 8.77	39.74 ± 8.47	<0.05	1.43	0.91 to 1.95	0.954
Observation group	MCV	27.77 ± 8.06	32.78 ± 9.04	<0.05	0.57	0.08 to 1.06	0.007
Observation group	SCV	27.70 ± 6.79	31.86 ± 8.10	<0.05	0.54	0.05 to 1.03	0.001

CI: confidence interval.

Comparison of the efficacy between the two groups

A group of 33 patients received hydrotherapy, with 3 showing significant improvement, 29 showing improvement, and 1 patient demonstrating a decrease in both MCV and SCV after treatment. In the group using conventional rehabilitation methods, 1 patient showed significant improvement, 26 showed improvements, and 6 experienced a decrease in both MCV and SCV after treatment, with no response to the treatment. For efficacy evaluation, treatments given to patients graded as cured, markedly effective, or improved were considered clinically effective, whereas those provided to patients graded as ineffective were considered non-effective. The overall effective rate for the hydrotherapy group was 96.7%, whereas that for the conventional treatment group was 81.8%. The hydrotherapy method was superior to the conventional rehabilitation method (p < 0.05), and no significant adverse reactions were observed in any patient during the treatment period (Table 6).

Table 6.

Comparison of the efficacy between the two groups (n(%)).

	n	Markedly effective	Improved	Ineffective	Efficient (%)
Experimental group	33	3	29	1	96.7
Observation group	33	1	26	6	81.8
p-value value	—	—	—	—	0.034

Discussion

Several studies have demonstrated the therapeutic efficacy of direct current therapy in PNI repair. This study innovatively combined direct current therapy with hydrotherapy and achieved favorable clinical outcomes. The present study demonstrated that the total effective rate was 96.7% in the experimental group receiving direct current hydrotherapy combined with conventional rehabilitation, which was significantly higher than 81.8% in the observation group receiving conventional rehabilitation alone (p < 0.05). These results are consistent with previous studies reporting that direct current hydrotherapy can improve clinical efficacy in patients with PNI.¹⁶ No significant between-group differences were observed in baseline functional, ARAT, and FMA scores or electromyographic indexes (p > 0.05), indicating that the two groups were comparable at enrollment. After 4 weeks of intervention, functional scores, including basic functional ability as well as ARAT and FMA scores were improved in both groups, suggesting that both rehabilitation regimens contributed to functional recovery in patients with upper extremity PNI. Notably, improvements in the experimental group were more obvious than those in the observation group, indicating that direct current hydrotherapy further enhances motor and functional recovery.

Electromyographic findings revealed that the MCV and SCV of the injured side were increased in both groups, indicating gradual recovery of injured peripheral nerves. In the experimental group, only one patient exhibited poor cooperation and emotional instability during treatment, leading to relatively limited improvement in functional scores and decreased MCV and SCV values. In the observation group, six patients exhibited no obvious improvement in MCV and SCV and were classified as ineffective. These results suggest that direct current hydrotherapy provides better promotion of nerve conduction recovery. In addition, no obvious adverse reactions were observed in either group during the entire treatment period, confirming that the combined intervention is safe and well-tolerated.

Notably, this study is limited by its relatively small sample size, lack of blinding, and a relatively short follow-up duration, which restrict the generalizability and robustness of the findings. Therefore, although the present results suggest that the experimental intervention yields more pronounced functional benefits, these preliminary findings should be interpreted with caution and require verification in larger, randomized, blinded, long-term follow-up studies.

Conclusion

PNI of upper limbs often occurs in conditions, including trauma, tumors, burns, electrical injuries, and viral infections. PNI often leads to impaired sensory motor function.¹⁷ It can easily lead to dysfunction in patients, which can seriously affect their work and quality of. If a younger individual loses their ability to work after nerve damage, it not only poses challenges in their professional life but also reduces social participation, thus affecting their mental health. Currently, there is no unified and standardized clinical treatment for managing the dysfunction caused by PNI. Motor and sensory re-education as well as neurotrophic therapy are common alternatives; however, functional recovery after PNI is sometimes unsatisfactory.¹⁸

Synaptic stripping is a significant cause of functional loss following PNI. After PNI, microglial cells in the spinal cord become activated and proliferate. Once activated, the microglia migrate toward the damaged ventral horn and interpose themselves between the cell bodies of the ventral horn and the detaching synapses. This phenomenon, in which microglia “lift” these synapses, is referred to as synaptic stripping. This process can lead to the withdrawal of la axons and their synapses from the ventral horn. Although motor and la axons can reinnervate muscles, la axons cannot return to the ventral horn. Thus, individuals with this type of PNI exhibit deficits in high-force motor tasks due to the absence of la axons.

The effects of direct current hydrotherapy combined with traditional physical factors in treating dysfunction after PNI are derived from three aspects: (a) hydrotherapy; (b) direct current; and (c) functional exercises. Direct current hydrotherapy can exert the therapeutic effects of a hydrotherapy bath and can be superimposed on the effects of direct current. The effects of hydrotherapy are as follows: (a) it uses warm water, which applies chemical, mechanical, and thermal massage to the body, thereby improving blood circulation, relieving pain and tension, and relaxing the muscles;¹⁹ (b) water exercise therapy provides a low-impact treatment environment, reduces the burden on joints and bones through buoyancy, and can effectively improve joint range of motion and joint function;²⁰ (c) direct current in water can also use the plasticity of water flow, water temperature, and other characteristics to administer comprehensive treatment on severely damaged nerve tissue, thereby accelerating the establishment of microcirculation in the nerve tissue, promoting local tissue blood circulation, and further repairing the nerve tissue. The effects of direct current therapy include the following: (a) conditioning with electrical stimulation increases the speed of regeneration and axonal elongation, which is critical for early distal reinnervation; and (b) electrical stimulation can increase the regenerative capacity after repair of chronic nerve lesions.^21,22

During the treatment process, we also observed that patients’ psychological states exerted a significant impact on limb function recovery. Patients who cooperated for treatment achieved greater improvements in functional scores; correspondingly, more obvious progress in the SCV and MCV was observed on electromyographic examinations in these patients. In contrast, patients with poor treatment compliance were likely to develop treatment resistance, which was more unfavorable to their recovery process.

Thus, direct current hydrotherapy is effective in the treatment of upper extremity PNI and exhibits good safety in patients. After 4 weeks of treatment, both experimental (conventional rehabilitation combined with direct current hydrotherapy) and observation (conventional rehabilitation alone) groups showed significant improvements in upper limb function (p < 0.05); notably, the experimental group achieved more significant improvements than the observation group (p < 0.05), with the total effective rate reaching 96.7% in the experimental group versus 81.8% in the observation group. Additionally, no significant adverse reactions occurred in either group during the entire treatment period. Therefore, direct current hydrotherapy is worthy of clinical promotion and application for the rehabilitation of upper extremity PNI.

Trial status

Protocol version number and date:v1.0, 9 October 2020

Recruitment start time: 23 September 2022

Recruitment end time: 30 June 2023

Footnotes

Acknowledgments

The authors wish to thank Doubao AI for providing language editing and polishing services for this manuscript.

ORCID iD

Qilei Yang

Ethics approval and consent to participate

All human participants included in this study signed informed consent statements. This study has been approved by the Medical Ethics Committee of Yuyao People's Hospital, Opinion number 2022-09-009.

Authors’ contributions

Qilei Yang wrote the main manuscript text, prepared figures 1–3 and table 1–6. Feng Gao designed the experiment, completed the experiment, collected and organized the data. All authors reviewed the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Internal funding, It was funded by the hospital where the author works.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of data and materials

The datasets used and/or analyzed in this study are available from the corresponding author of this project upon reasonable request.

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