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Citation: Lee, S.; Jin, T.-J.; Jin, I.-K.
Methods, Applications, and
Limitations of Somatic Maneuvers for
the Modulation of Tinnitus. Audiol.
Res. 2022,12, 644–652. https://
doi.org/10.3390/audiolres12060062
Academic Editors: Richard Tyler and
Claudia Barros Coelho
Received: 21 October 2022
Accepted: 16 November 2022
Published: 18 November 2022
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4.0/).
Review
Methods, Applications, and Limitations of Somatic Maneuvers
for the Modulation of Tinnitus
Sumin Lee 1, Tae-Jun Jin 1and In-Ki Jin 2,*
1Department of Speech Pathology and Audiology, Graduate School, Hallym University,
Chuncheon-si 24252, Republic of Korea
2Division of Speech Pathology and Audiology, Research Institute of Audiology and Speech Pathology,
Hallym University, Chuncheon-si 24252, Republic of Korea
*Correspondence: inkijin@hallym.ac.kr
Abstract:
The modulation of tinnitus through somatic maneuvers is a well-documented phenomenon
in tinnitus patients with somatic disorders. The purpose of this study was to review the methods,
applications, and limitations of somatic maneuvers. First, 35 somatic maneuvers proposed by various
research groups were summarized according to four body areas (jaw, head and neck, eye, and limbs),
following which their applications and limitations were assessed. Although some studies have shown
that somatic maneuvers can aid in screening for somatic tinnitus and may help alleviate symptoms
with repeated practice, the limited number of studies and inconsistent results among studies make
it difficult to draw definitive conclusions. Therefore, follow-up studies are required to overcome
these limitations and determine whether the treatment of somatic disorders can also aid in alleviating
somatic tinnitus.
Keywords: somatic maneuvers; somatic tinnitus; somatic disorders
1. Introduction
Tinnitus is characterized by the perception of sound in the ear or head regardless of the
influence of external stimuli [
1
]. Generally, the reported prevalence of tinnitus in the adult
population is approximately 10%, although this rate varies from 5.1% to 42.7% depending
on the characteristics of the study group and region [
2
,
3
]. Some patients with tinnitus report
severe pain, which may be accompanied by difficulty thinking and significant impairments
in emotional regulation, sleep, hearing, concentration, and overall quality of life [4–6].
Tinnitus can be classified into various subtypes, and when the cause of tinnitus
among the subtypes is related to the musculoskeletal system of the body rather than
to the ear or hearing loss, it can be classified as “somatic tinnitus” [
7
–
9
]. Although not
observed in all cases, one of the main characteristics of somatic tinnitus is that movement
of or the application of pressure to the causative body part results in the modulation of
tinnitus [8,10–12].
Such modulation has mainly been reported for the jaw, head and neck,
eye, and limb [7,8,11,12].
The modulation of tinnitus due to somatic manipulation is a well-documented phe-
nomenon in patients with tinnitus and somatic disorders [
7
]. Researchers have proposed
various methods for identifying whether somatic manipulation can modulate tinnitus,
which have been termed “somatic maneuvers” [
7
,
11
–
13
]. Several studies have suggested
that these somatic maneuvers are useful when screening for somatic tinnitus and for identi-
fying the true somatic disturbance leading to the condition [11,14,15], which increases the
likelihood that the patient will experience the resolution of symptoms due to the prompt
initiation of direct treatment [
16
–
18
]. Indeed, several groups have reported that alleviating
somatic problems leads to tinnitus relief [16–18].
Although somatic maneuvers have been proven partially useful as screening tools
for diagnosing somatic tinnitus, several limitations remain to be addressed. For example,
Audiol. Res. 2022,12, 644–652. https://doi.org/10.3390/audiolres12060062 https://www.mdpi.com/journal/audiolres
Audiol. Res. 2022,12 645
the control of tinnitus in a specific body area does not always indicate somatic disorders
in that area [
11
,
14
,
19
]. Thus, further research is required to develop methods for improv-
ing the reliability of somatic maneuvers. From a therapeutic perspective, some studies
have suggested that repetitive somatic maneuvers can alleviate tinnitus via neuroplastic
changes, although evidence that somatic maneuvers themselves lead to tinnitus relief is
still lacking [
12
,
16
]. For somatic maneuvers to be useful in clinical practice, further studies
are required to overcome the current limitations of diagnosis and treatment.
To promote a greater understanding of the value and limitations of conventional
somatic maneuvers among researchers and aid in the development of novel methods,
the present study aimed to review the methods, applications, and limitations of somatic
maneuvers for various body parts (e.g., head, neck, arms, and legs).
2. Materials and Methods
A flowchart of the article selection procedure is shown in Figure 1. We searched
Google Scholar for relevant articles using the following keywords: “somatic tinnitus”,
“somatic tinnitus maneuver”, “somatic tinnitus treatment”, “somatic tinnitus disorder”,
and “somatic modulation”. The search identified a total of 2863 articles, and 416 articles
remained after excluding 2447 duplicates. Among the 416 articles, 396 that were not related
to the topic of this review, non-English articles, animal studies, and non-full-text articles
were excluded. We only reviewed the studies published in English, as this was the only non-
native language common to all researchers, and we were concerned about misinterpreting
papers published in other languages. Finally, 20 articles were selected for this review.
Among them, 13 were reviewed for somatic maneuver methods, and 12 were reviewed for
applications and limitations. Five articles were reviewed for both types of content.
Audiol. Res. 2022, 12, FOR PEER REVIEW 2
Although somatic maneuvers have been proven partially useful as screening tools
for diagnosing somatic tinnitus, several limitations remain to be addressed. For example,
the control of tinnitus in a specific body area does not always indicate somatic disorders
in that area [11,14,19]. Thus, further research is required to develop methods for improv-
ing the reliability of somatic maneuvers. From a therapeutic perspective, some studies
have suggested that repetitive somatic maneuvers can alleviate tinnitus via neuroplastic
changes, although evidence that somatic maneuvers themselves lead to tinnitus relief is
still lacking [12,16]. For somatic maneuvers to be useful in clinical practice, further studies
are required to overcome the current limitations of diagnosis and treatment.
To promote a greater understanding of the value and limitations of conventional so-
matic maneuvers among researchers and aid in the development of novel methods, the
present study aimed to review the methods, applications, and limitations of somatic ma-
neuvers for various body parts (e.g., head, neck, arms, and legs).
2. Materials and Methods
A flowchart of the article selection procedure is shown in Figure 1. We searched
Google Scholar for relevant articles using the following keywords: “somatic tinnitus,” “so-
matic tinnitus maneuver,” “somatic tinnitus treatment,” “somatic tinnitus disorder,” and
“somatic modulation.” The search identified a total of 2863 articles, and 416 articles re-
mained after excluding 2447 duplicates. Among the 416 articles, 396 that were not related
to the topic of this review, non-English articles, animal studies, and non-full-text articles
were excluded. We only reviewed the studies published in English, as this was the only
non-native language common to all researchers, and we were concerned about misinter-
preting papers published in other languages. Finally, 20 articles were selected for this re-
view. Among them, 13 were reviewed for somatic maneuver methods, and 12 were re-
viewed for applications and limitations. Five articles were reviewed for both types of con-
tent.
Figure 1. Flowchart of the article selection procedure.
Figure 1. Flowchart of the article selection procedure.
3. Results and Discussion
In this study, the body parts related to somatic maneuvers were classified into four
groups (jaw, head and neck, eye, and limb), and the somatic maneuver methods used to
assess the modulation of tinnitus were described for each body part, as shown in Table 1.
Audiol. Res. 2022,12 646
Table 1. Somatic maneuver methods for each body part.
Body Parts No. Method References
Jaw
1 Clench teeth together
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Ralli et al. (2016, 2018) [11,23];
Lee et al. (2020) [12]
2 Open mouth with restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Ralli et al. (2016, 2018) [11,23];
Lee et al. (2020) [12]
3 Open mouth without restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Lee et al. (2020) [12]
4 Protrude jaw with restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Ralli et al. (2016, 2018) [11,23];
Lee et al. (2020) [12]
5 Protrude jaw without restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Lee et al. (2020) [12]
6 Slide jaw to left with restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Ralli et al. (2016, 2018) [11,23];
Lee et al. (2020) [12]
7 Slide jaw to left without restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Lee et al. (2020) [12]
8 Slide jaw to right with restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Ralli et al. (2016, 2018) [11,23];
Lee et al. (2020) [12]
Audiol. Res. 2022,12 647
Table 1. Cont.
Body Parts No. Method References
9 Slide jaw to right without restorative pressure
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21];
Won et al. (2013) [14];
Kim et al. (2013) [22];
Lee et al. (2020) [12]
10 Retract jaw
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
An et al. (2011) [21]
Head and Neck
11 Head in neutral position, with resistance to a force
applied by the patient to the occiput
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
12 Head in neutral position, with resistance to a force
applied by the patient to the forehead
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
13 Head in neutral position, with resistance to a force
applied by the patient to the vertex
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Kim et al. (2014) [22];
Ralli et al. (2016) [21]
14 Head in neutral position, with resistance to an
upward force applied by the patient to the mandible
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20];
Kim et al. (2014) [22];
Ralli et al. (2016) [21]
15 Head in neutral position, with resistance to a force
applied by the patient to the right temporal bone
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
16 Head in neutral position, with resistance to a force
applied to the left temporal bone
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
Audiol. Res. 2022,12 648
Table 1. Cont.
Body Parts No. Method References
17 Left mastoid attachment of the sternocleidomastoid Won et al. (2013) [14];
Lee et al. (2020) [12]
18 Right mastoid attachment of the
sternocleidomastoid
Won et al. (2013) [14];
Lee et al. (2020) [12]
19 Forward flexion of the neck Ralli et al. (2016) [21]
20 Backward flexion of the neck Ralli et al. (2016) [21]
21 Turn head to the right Ralli et al. (2016) [21]
22 Turn head to the left Ralli et al. (2016) [21]
23
With the head turned to the right, resist maximal
torsional force applied by the examiner to the right
zygoma
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
24
With the head turned to the left, resist maximal
torsional force applied by the examiner to the left
zygoma
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Kim et al. (2014) [22];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
25
With the head turned to the right and tilted to the
left, maximally resist full force applied by the
examiner to the left temple (left
sternocleidomastoid)
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
Head and Neck
26
With the head turned to the left and tilted to the
right, maximally resist full force applied by the
examiner to the right temple (right
sternocleidomastoid)
Levine et al. (2003, 2007) [13,19];
Abel and Levine (2004) [20];
Won et al. (2013) [14];
Ralli et al. (2016) [21];
Lee et al. (2020) [12]
Eye
27 Movement of eye horizontally Sanchez et al. (2007) [16];
Simmons et al. (2008) [25]
28 Movement of eye vertically Sanchez et al. (2007) [16];
Simmons et al. (2008) [25]
29
Movement of eye diagonally to the upper and lower
corners of the visual field Simmons et al. (2008) [25]
Limb
30
Locking the patient’s flexed fingers of the two hands
together and pulling them apart as forcefully as
possible
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20]
31
Right shoulder abduction against resistance applied
by the patient
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20]
Audiol. Res. 2022,12 649
Table 1. Cont.
Body Parts No. Method References
32 Left shoulder abduction against resistance applied
by the patient
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20]
33
Flexion of the right hip against resistance applied by
the patient
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20]
34 Flexion of the left hip against resistance applied by
the patient
Levine (1999) [7];
Sanchez et al. (2002) [24];
Levine et al. (2003) [13];
Abel and Levine (2004) [20]
35
Abduction of both hips against resistance applied by
the patient
Levine (1999) [7];
Sanchez et al. (2002) [24]
3.1. Somatic Maneuver Methods
Generally, the modulation of tinnitus occurs with the movement of or application
of pressure to body parts such as the jaw, head and neck, eye, and limbs (e.g., [
7
,
14
,
21
]).
Somatic maneuvers require the patient to perform a specific motion under the guidance
of the examiner, who then assesses whether modulation has occurred. Maneuvers may
be performed with the patient or examiner applying pressure, and all somatic maneuvers
are carried out for several seconds to ensure that the patient can recognize any change in
tinnitus symptoms. When the modulation of tinnitus is observed after a specific maneuver,
further testing is suspended until the tinnitus volume has returned to baseline [11].
Our review of somatic maneuvers related to jaw movement revealed that changes in
tinnitus can be confirmed during the clenching of the teeth (maneuver 1) or when opening
the mouth as wide as possible with or without the self-application of restorative pressure
(maneuvers 2, 3). Similarly, the modulation of tinnitus can be assessed during the protrusion
of the jaw with and without the self-application of restorative pressure (maneuvers 4, 5),
following which additional assessments can be performed by having the patient slide their
jaw to the left or right, with and without restorative pressure (
maneuvers 6–9
). Lastly,
instructing the patient to retract their jaw (maneuver 10) can aid in identifying whether jaw
movement can modulate tinnitus.
Several studies also described somatic maneuvers for the head and neck. First, with
the patient’s head in a neutral position, the examiner can aid the patient in determining
whether the modulation of tinnitus occurs during resistance to the self-application of
force to the occiput, forehead, vertex, jaw, right temporal bone, and left temporal bone
(
maneuvers 11–16
) in sequence. The patient then moves the head to position it as close to
the shoulder as possible. If the movement is performed to the left, the left mastoid naturally
contacts the left sternocleidomastoid muscle (maneuver 17). The patient then moves their
head to the right, and the right mastoid naturally contacts the right sternocleidomastoid
muscle (maneuver 18). Changes in tinnitus are then assessed by asking the patient to bend
the neck forward, backward, left, and right (maneuvers 19–22) in sequence. Thereafter,
modulation is assessed as the patient resists the maximal torsional force exerted by the
examiner on the right zygoma, with the patient’s head turned to the right and left, respec-
tively (maneuvers 23, 24). The final motion is performed with the patient’s head turned to
the right and tilted to the left, allowing the examiner to resist the respective force applied to
the left and right temples as much as possible (maneuvers 25, 26). Each maneuver is held
for approximately 5 s to allow for the adequate assessment of tinnitus modulation.
Somatic maneuvers related to eye movements are also performed under the guidance
of an examiner. The patient first moves their eyes horizontally (maneuver 27) and vertically
Audiol. Res. 2022,12 650
(maneuver 28), followed by diagonal movement (maneuver 29). In each case, the maneuver
is performed with a hold of at least 1 s in each direction.
Several studies also described somatic maneuvers related to the limb. The first move-
ment involves locking the flexed fingers of the patient’s two hands together and pulling
them apart as forcefully as possible (maneuver 30). Then, the patient spreads their right and
left arms away from the center of their body in sequence (maneuvers 31, 32), followed by
right and left shoulder abduction against resistance applied by the patient. The effects of hip
movement on tinnitus are assessed with the patient in the supine position. First, each knee
is bent to allow for the forward lifting of the leg (maneuvers 33, 34).
Maneuvers 33 and 34
involve the flexion of the right and left hips against resistance applied by the patient, respec-
tively. In this case, the examiner can assist the patient to ensure that body movements are
performed correctly. Finally, the leg is lifted to the side to allow the patient to observe the
modulation of tinnitus during the abduction of both hips against resistance
(maneuver 35).
3.2. Applications and Limitations of Somatic Maneuvers
3.2.1. Screening for Somatic Tinnitus
Several studies have suggested that the modulation of tinnitus can be observed during
somatic maneuvers in the affected area in patients with somatic disorders accompanied
by tinnitus [
17
,
23
,
26
]. Vielsmeier et al. (2011) compared the effects of somatic maneuvers
on tinnitus in patients with and without temporomandibular disorders (TMDs) and the
observed modulation of tinnitus in 50% and 21% of patients in these two groups, respec-
tively, indicating a significant difference [
17
]. Ralli et al. (2016) reported that 79.67% of
310 patients with TMDs or neck dysfunction accompanied by tinnitus experienced the
modulation of tinnitus when somatic maneuvers were performed in the same region [
23
].
In a study of 608 patients with tinnitus, Ward et al. (2015) also noted that patients with
somatic tinnitus reported that the clear modulation of tinnitus had a higher rate of somatic
disorders, such as TMDs, than those with non-somatic tinnitus [26].
However, other studies have reported that somatic maneuvers are not sensitive to
somatic tinnitus. Sanchez et al. (2002) compared the tinnitus modulation rate in 68 patients
with tinnitus who had craniomandibular disorders and 53 patients who had no symptoms
of somatic disorders [
24
]. The modulation of tinnitus was observed in 67.6% of those
with somatic symptoms and 62.3% of those without somatic symptoms, and there was no
significant difference between the groups [
24
]. An et al. (2011) also reported no significant
difference in the rate of somatic modulation between patients with somatic tinnitus (n= 24)
and patients with sensorineural tinnitus (n= 21) [
21
]. Abel and Levine (2004) also noted
that 60.5% of participants without tinnitus heard sounds similar to tinnitus during somatic
maneuvers [20].
Although some studies have partially demonstrated that somatic maneuvers can be
used to screen for somatic tinnitus, their application in this area may be limited due to
inconsistencies in the results of previous studies (e.g., [
17
,
21
,
23
,
24
]). Therefore, additional
research is required to identify the most reliable methods for somatic tinnitus screening
using somatic maneuvers.
3.2.2. Improvements in Tinnitus via Repetitive Somatic Maneuvers
Some researchers have focused on improving tinnitus using somatic maneuvers.
Sanchez et al. (2007) proposed that training using repetitive somatic maneuvers can con-
tribute to tinnitus relief based on the principle of neuroplasticity. In their study,
38 patients
with tinnitus engaged in nine muscle contraction trainings twice a day for a total of
2 months
. Although patients reported no changes in tinnitus during daily life, the loudness
of tinnitus decreased during somatic maneuver training in 42.9% of participants [
16
]. In
addition, Sanchez and Pio (2007) reported the resolution of symptoms in a patient with
gaze-evoked tinnitus with a history of surgery for vestibular schwannosis who performed
repeated eye movements for 14 weeks [
27
]. However, as only a limited number of stud-
Audiol. Res. 2022,12 651
ies have demonstrated improvements in tinnitus via training involving repeated somatic
maneuvers, their value remains unclear at this time [28].
Several studies have suggested that the direct treatment of somatic disorders is ef-
fective in alleviating somatic tinnitus. Michiels et al. (2016) reported that 6 weeks of
multimodal cervical therapy, including manual therapy, exercise therapy, and home ex-
ercise, resulted in significant improvements in 20 of 38 patients with cervical somatic
tinnitus [
29
]. In addition, Wal et al. (2020) reported that 9 weeks of lifestyle guidance, facial
treatment, and physical therapy significantly reduced tinnitus functional index scores in a
cohort of 40 patients with temporomandibular somatosensory tinnitus [
30
,
31
]. Wright and
Bifano (1997) described improvements in tinnitus in patients with TMDs who had been
treated with a variety of approaches, including self-care guidelines to avoid muscle pain,
splint and jaw stretching exercises, postural training and medication, and consultation
with a psychologist. In their study, 52 of 93 patients reported tinnitus resolution, and 30%
(28 patients) exhibited significant improvements after TMD treatment [32].
4. Conclusions
Currently, the etiology of somatic tinnitus seems unclear. Some studies have reported
that diseases such as TMDs, cervical spine disorder, Paget’s disease of the bone, and restless
legs syndrome are mainly accompanied by somatic tinnitus, but more studies are needed to
confirm the relationship between these diseases and somatic tinnitus [
17
,
33
–
35
]. This study
reviewed the methods, applications, and limitations of somatic maneuvers for assessing
the modulation of tinnitus during movement or the application of pressure. Although
some studies have shown that somatic maneuvers can aid in screening for somatic tinnitus
and may help alleviate symptoms with repeated practice, the limited number of studies
and inconsistent results among studies make it difficult to draw definitive conclusions.
Therefore, follow-up studies are required to overcome these limitations and to determine
whether the treatment of somatic disorders can also aid in alleviating somatic tinnitus.
Author Contributions:
Conceptualization, I.-K.J.; methodology, all authors; software, S.L. and T.-J.J.;
validation, all authors; formal analysis, S.L. and T.-J.J.; investigation, S.L. and T.-J.J.; resources, S.L. and
T.-J.J.; data curation, all authors; writing—original draft preparation, all authors; writing—review and
editing, I.-K.J.; visualization, S.L. and T.-J.J.; supervision, I.-K.J.; project administration, I.-K.J.; funding
acquisition, I.-K.J. All authors have read and agreed to the published version of the manuscript.
Funding:
This research was funded by the National Research Foundation of Korea (NRF) grant
funded by the Korea government (MSIT) (No. 2022R1H1A2091291).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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