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Abstract

Background:

Increasing numbers of long jumpers with lower limb amputations choose to take off from their prosthetic limb. It is not yet known what difference in technique, if any, this requires, or which is more advantageous.

Objectives:

To investigate kinematic differences in long jump technique in athletes with a unilateral transtibial ampution (TT) who take off from their prosthetic limb versus those who take off from their intact limb.

Study Design:

Naturalistic, field-based, observational; independent group, nonparametric comparison.

Methods:

Two-dimensional sagittal plane kinematic analysis was performed on all athletes competing in the men’s Paralympic TT long jump finals. Five athletes took off from their prosthetic limb (TO_prosth) and five from their intact limb (TO_intact).

Results:

No differences were seen between the two groups in terms of jump distance, approach speed or vertical velocity at touch down. While in contact with the take-off board, the two groups gained a similar amount of vertical velocity. However, the TO_prosth group appeared to conserve horizontal velocity by using the prosthesis as a ‘springboard’, minimizing the large hip and knee range of motion displayed by the TO_intact group and athletes in previous studies.

Conclusions:

While differences in technique were observed, no difference was found for jump distance.

Clinical relevance

Athletes choosing to take-off from their prosthetic limb in long jump require a different technique to those who choose to take-off from their intact limb. Knowledge of the correct technique can help reduce excessive training which can lead to injury, particularly in the residual limb.

Keywords

Disability performance technique track and field long jump

Background

The long jump event can be broken down into four main parts for the purpose of biomechanical analysis. First, an approach run which differs in length due to individual preference, the last three steps of which are used to prepare optimal body position for touch-down onto the take-off board. Second, touch-down to take-off where one foot is in contact with the take-off board and the athlete further adjusts body position for optimal take-off position. Third, flight where the athlete tries to adjust body position in the air to delay landing, and lastly, landing technique. Several long jump studies have provided information on the techniques used by athletes with a transtibial amputation (TT) during the approach run and from touch-down to take-off. While these athletes conform to the same long jump model as able- bodied athletes,^1–3 male TT athletes have been found to exhibit a weaker approach speed/distance jumped relationship than their able-bodied counterparts, possibly as a result of having to modify their technique due to the prosthetic limb. TT athletes, even though their approach speed is slower than able-bodied athletes, have been found to touch down onto the take-off board with a disadvantageously high negative vertical velocity resulting in sub-optimal positioning of the body and reduced vertical velocity at take-off. The authors suggested this was associated with taking off from the prosthetic limb prior to touching down onto the take-off board,¹ but to date no studies have reported the effect the choice of take-off limb has on technique.

Previous studies on amputee long jump have included in their analyses a mix of athletes choosing to take off from their intact or prosthetic limb.^2–3 It is not known what effect the choice of take-off limb has on technique and thus whether future studies need to group athletes by take-off limb. It is also not yet known whether recommendations can be made as to which take-off limb should be used to best improve long jump performance.

Individuals with lower limb amputations exhibit asymmetric running patterns, displaying a more flexed knee and hip when touching down and taking off from the prosthetic limb compared to the intact limb.^4–6 They also take longer steps on their prosthetic limb compared to their intact limb on the long jump approach.⁷ A recent study showed that residual shank length does not affect performance for TT athletes taking off from their intact limb, but results remain inconclusive for those taking off from their prosthetic limb.⁸ Thus, it is possible that the choice of take-off limb may make a difference to technique due to constraints of the prosthetic and/or residual limb. The aim of this study was to investigate kinematic differences in long jump technique between athletes with a transtibial amputation who take off from their prosthetic limb and those who take off from their intact limb.

Methods

Subjects

All athletes with a unilateral transtibial amputation and carbon fibre prosthesis participating in the 2004 F44 (long jump) and P44 (pentathlon long jump) Paralympic Games finals were included in the study. If an athlete competed in both competitions, their longest jump was chosen to ensure that they were not included in the analysis twice. Five athletes took off from their prosthetic limb, while five took off from their intact limb. Performance characteristics are presented in Table 1.

Table 1.

Athletes’ best distance jumped and approach speed at the take-off board for the two groups (prosthetic limb and intact limb take off).

Athlete	Competition	Official distance jumped (m)	Approach sspeed (m.s⁻¹)
Prosthetic limb take off
1	F44	6.68	8.53
2	F44	6.45	8.69
3	P44	6.29	8.37
4	F44	5.72	7.38
5	F44	5.04	7.17
Mean		6.04	8.03
SD		0.66	0.70
Intact limb take off
1	F44	6.20	8.47
2	P44	5.66	7.43
3	P44	5.14	7.98
4	P44	4.78	7.52
5	P44	4.33	7.01
Mean		5.22	7.68
SD		0.73	0.56

SD, standard deviation

Apparatus and procedure

A laser Doppler device (LDM 300 C Sport, Jenoptik Laser, Jena, Germany) recorded approach distance and speed during the run-up of each jump (100 Hz) (see ³ for details). The device was targeted on the torso of the athlete for the duration of their approach run. For each successful jump, speed data at the pre-calibrated point of take-off (the take-off board) were obtained and smoothed (13-point moving average) using Distance Evaluation Sport software (DAS3E v3.9).

Two digital video cameras (Sony, model DCR-TRV33E) were used to record all jumps in the sagittal plane (50 Hz) from the third last step on the approach run to take-off from the board. Prior to competition, a calibration frame was filmed at overlapping intervals along the approach run and board. During competition, the cameras were left running and all athletes’ jumps recorded. Distance jumped was recorded from the competition scoreboard.

The best jump (greatest official distance) for each athlete was selected for two-dimensional kinematic analysis. Video data for each jump from the third last step on the approach run to take-off were manually digitized using eHuman digitizing software (HMA Technology, Inc, Ontario, Canada) and analyzed using a standard 9-segment biomechanical model defined by 18 points.^1–3 Adjustments to the anthropometric data⁹ were made to account for the prosthetic limb.¹ The data were smoothed using a Butterworth fourth order digital filter and a cut-off frequency of 7 Hz. As measurements of the athletes’ heights were not available, each athlete’s estimated height was calculated as the sum of the length of their individual intact segments determined from the coordinates of the digitized data.^3,10

Key events known to be important to long jump technique were identified for each athlete: touch-down (TD) and take-off (TO) for the third last step (3LS), second last step (2LS), last step (LS), touch-down on the take-off board (TD_board), the point of maximum knee flexion while in contact with the board (MKF_board), and take-off (TO_board). Selected kinematic variables were then calculated at each key event: horizontal (H_vel) and vertical velocity (V_vel) of the centre of mass, centre of mass height normalized to estimated height (%H_CM), hip and knee angle, and leg angle (touch-downs only). The hip, knee and leg angles are defined in Figure 1. Hip and knee range of motion (ROM) were calculated as the absolute difference TD–TO for the respective joint angle at each foot contact. Step length and step duration were calculated between 3LS_TD–2LS_TD, 2LS_TD–LS_TD and LS_TD–TD_board. Foot contact times were calculated for the stance phase of each step. ‘Effective distance jumped’ was calculated from official distance jumped plus the toe-to-board distance which was measured from the sagittal plane video one frame before take-off.

Figure 1.

Hip, knee and leg angle conventions.

Statistical analyses

Groups were established consisting of a) those taking off from their prosthetic limb (TO_prosth) and b) those taking off from their intact limb (TO_intact). A Shapiro-Wilks test was used to test the normality of data. Pearson product moment correlation was used to determine the relationship between TO speed (recorded during the approach run) and effective distance jumped. A Wilcoxon test was used to assess differences between steps for each group. A Mann–Whitney U test established differences on each step between those who took off from their prosthetic limb and those who took off from their intact limb. The significance level was set at p<0.05 with trends in the data indicated by 0.05≤p<0.1.

Results

While those taking off from their prosthetic limb had a greater mean jump distance and approach speed (Table 1), there was no significant difference found between the groups. For those taking off from their prosthetic limb (TO_prosth), there was a significant positive relationship (r = 0.943, p = 0.016) between approach speed and distance jumped, while for those taking off from their intact limb (TO_intact), a positive, but non-significant relationship was seen (r = 0.800, p = 0.106) (Figure 2).

Figure 2.

Relationship between approach speed and effective distance jumped for the TO_prosth group (black square) and TO_intact group (white circle). * indicates a significant relationship.

Approach velocities

There was a difference in horizontal velocity of the centre of mass (H_vel) between the two groups on the third last step of the approach only (Figure 3), the TO_prosth group tending to be faster at TD (p = 0.076) and faster at TO (p = 0.034). No differences were seen between steps for the TO_prosth group, while the only between step difference seen for the TO_intact group was that they were slower (p = 0.043) taking off from their LS than from their 2LS.

Figure 3.

Horizontal velocity of the centre of mass from 3LS_TD to TO_board for the TO_prosth group (black square) and TO_intact group (white circle). * indicates a significant difference and (*) a trend towards a difference. Between group differences seen at 3LS_TD (p = 0.076) and 3LS_TO (p = 0.034). Within group difference seen between 2LS_TO and LS_TO (p = 0.043) for the TO_intact group.

No group differences in vertical velocity of the centre of mass (V_vel) on the approach run were seen (Figure 4). Both groups showed a reduction (p = 0.042 for the TO_intact group; p = 0.074 for the TO_prosth group) in V_vel between 2LS_TO and LS_TO.

Figure 4.

Vertical velocity of the centre of mass from 3LS_TD to TO_board for the TO_prosth group (black square) and TO_intact group (white circle). * indicates a significant difference and (*) a trend towards a difference. Within group differences seen between 2LS_TO and LS_TO for the TO_prosth (p = 0.074) and TO_intact (p = 0.042) groups.

Both groups gained a similar amount of vertical velocity while in contact with the take-off board (Table 2). The TO_intact group however, lost almost double the amount of horizontal velocity of the TO_prosth group (TD_board–TO_board). This loss was seen to be greatest in the first part of the take-off phase (TD-MKF) where there was a trend towards a group difference (p = 0.091).

Table 2.

Mean ± SD velocity (m.s⁻¹) changes while in contact with the take-off board. * indicates a significant difference between the groups p < 0.05, (*) a trend towards a difference between groups 0.05≤p<0.1.

Group		TD-TO	TD-MKF	MKF-TO
TO_prosth	H_vel (loss)	0.36	0.30 (*)	0.10
	SD	0.21	0.12	0.12
	V_vel (gain)	2.52	1.68	0.84
	SD	0.46	0.63	0.60
TO_intact	H_vel (loss)	0.62	0.60 (*)	0.14
	SD	0.36	0.29	0.05
	V_vel (gain)	2.54	1.60	0.94
	SD	0.66	0.63	0.43

Relative centre of mass height

No group differences were seen in terms of relative centre of mass height (%H_CM) (Figure 5). Both groups exhibited a trend towards a lower (p = 0.080) %H_CM at TD_board than they had at LS_TD. The TO_prosth group also exhibited a trend towards a lower (p = 0.080) %H_CM at TD_board than at 2LS_TD, and had a higher (p = 0.043) %H_CM at LS_TO than at 2LS_TO.

Figure 5.

Relative centre of mass height (%H_CM) from 3LS_TD to TO_board for the TO_prosth group (black square) and TO_intact group (white circle). * indicates a significant difference and (*) a trend towards a difference. Within group differences seen between LS_TD and TD_board for both groups (p = 0.080). Also, between 2LS_TD and TD_board (p = 0.080) and 2LS_TO and LS_TO (p = 0.043) for the TO_prosth group.

Joint angles

No joint angle differences were seen between the groups while they were in contact with the take-off board (Table 3). On 3LS, there was a trend towards the TO_prosth group (intact limb stance) having a more extended knee (p = 0.083) and smaller leg angle (p = 0.076) at touch-down, and a more extended knee (p = 0.074) at take-off than the TO_intact group. On 2LS, the TO_prosth group (prosthetic limb stance) had a more flexed knee (p = 0.009) at touch-down, with a trend towards a more flexed hip angle (p = 0.076) at take-off compared to the TO_intact group. On LS, the TO_prosth group (intact limb stance) had a smaller leg angle (p = 0.023) at touch-down and a more extended knee (p = 0.047) and hip (p = 0.028) at take-off than the TO_intact group. Thus, both groups exhibited a more ‘upright’ position touching down onto their intact limb, and a more flexed position touching down onto their prosthetic limb.

Table 3.

Mean ± SD lower limb angles (degrees) on the approach run and take-off board. Bold values indicate prosthetic limb stance. * indicates a significant difference between the groups p < 0.05, (*) a trend towards a difference between groups 0.05≤p<0.1. Within-group differences are indicated by the paired symbols #,°,†,x, and trends towards a difference indicated by (symbol).

Group		3LS_TD	3LS_TO	2LS_TD	2LS_TO	LS_TD	LS_TO	TD_board	MKF	TO_board
TO_prosth	Hip angle	161.5	189.5	156.0(*)(°)	174.0#	155.6x	189.0*#	162.8x(°)	163.6	173.4
	SD	0.7	9.6	4.9	4.3	5.3	6.4	3.6	3.5	9.3
	Knee angle	163.0(*)	158.0(*)	147.8*†°	144.6(#)	156.6†	151.0*(#)	157.0°	144.0	152.2
	SD	1.4	3.2	2.6	5.3	2.7	8.2	5.2	12.9	16.2
	Leg angle	4.0(*)		10.20†		5.60†x		15.00x
	SD	0.0		4.0		2.5		5.0
TO_intact	Hip angle	158.0	179.0	154.6(*)	180.4	151.0	178.0*	158.4	167.6	182.0
	SD	5.6	2.0	5.7	5.3	11.5	2.5	6.5	12.1	9.2
	Knee angle	154.3(*)	153.0(*)	156.4*	154.0†	147.8	140.2*†	159.2	146.6	168.6
	SD	3.0	1.7	4.6	11.1	9.8	12.4	6.6	6.4	6.3
	Leg angle	10.3(*)		8.4(x)		10.2#		15.8#(x)
	SD	4.0		4.0		2.1		3.7

This posture difference was also observed between steps for both groups. For the TO_prosth group, a more extended knee (p = 0.042) and smaller leg angle (p = 0.043) on LS_TD (intact limb stance) compared to 2LS_TD (prosthetic limb stance), along with trend towards a more extended knee (p = 0.080) and a more extended hip (p = 0.043) at LS_TO compared to 2LS_TO was seen. For the TO_intact group, a more extended knee (p = 0.043) angle on 2LS_TO (intact limb stance) compared to LS_TO (prosthetic limb stance) was seen.

At TD_board, no significant group differences in posture were seen. The TO_prosth group displayed a trend towards a more extended hip angle (p = 0.083) and greater leg angle (p = 0.043) at TD_board compared to LS_TD. As such, when touching down onto the board they were leaning back with a more outstretched leg than on the previous step. They also exhibited a more extended knee (p = 0.043) and trend towards a more extended hip (p = 0.074) at TD_board compared to 2LS_TD, even though both of these steps were performed on their prosthetic limb. For the TO_intact group, a greater leg angle (p = 0.043) at TD_board was seen compared to LS_TD. The TO_intact group also exhibited a trend towards a greater leg angle (p = 0.078) on TD_board than 2LS_TD even though both of these steps were performed on their intact limb.

Hip ROM was smaller (p = 0.011) for the TO_prosth group on the 2LS (prosthetic limb stance) compared to the TO_intact group (intact limb stance) (Table 4). On the take-off board hip ROM was also smaller during TD-MKF (p = 0.034) and MKF-TO_board (p = 0.008) for the TO_prosth group compared to TO_intact group. Knee ROM was smaller (p = 0.009) for the TO_prosth group from MKF-TO_board on the take-off board compared to the TO_intact group. Thus while in contact with the take-off board, the TO_prosth group exhibited reduced knee and hip ROM compared to the TO_intact group.

Table 4.

Mean ± SD hip and knee ranges of motion (ROM, degrees) on the approach run and take-off board. Bold values indicate prosthetic limb stance. * indicates a significant difference between the groups p < 0.05, (*) a trend towards a difference between groups 0.05≤p<0.1. Within-group differences are indicated by the paired symbols #,†, and trends towards a difference indicated by (symbol).

Group		3LS_TD-TO	2LS_TD-TO	LS_TD-TO	TD-TO_board	TD-MKF	MKF-TO_board
TO_prosth	Hip ROM	30.0	18.0*†	33.4†	10.6*†	2.8(#)	9.8(#)
	SD	7.1	2.0	7.4	9.3	1.9	7.3
	Knee ROM	4.0	4.4	6.4	11.6	13.0	8.2*
	SD	4.2	3.4	6.1	7.9	10.2	5.0
TO_intact	Hip ROM	21.0	25.8*	27.0	23.6*	9.2(†)	14.4(†)
	SD	6.6	3.6	10.0	12.0	8.4	19.6
	Knee ROM	2.0	9.2	7.6	9.4	12.6(#)	22.0*(#)
	SD	2.6	5.5	4.6	6.6	5.0	4.2

For between steps, the TO_prosth group hip ROM was greater (p = 0.043) on the LS (intact limb stance) than both the 2LS and TD–TO_board (prosthetic limb stance). This group also exhibited a trend towards a larger hip ROM (p = 0.068) during MKF-TO_board compared to TD-MKF on the take-off board. The TO_intact group also exhibited a trend towards a larger hip (p = 0.078) and knee ROM during MKF-TO_board compared to TD-MKF.

Step lengths, durations and foot contact

The only difference in step length between the two groups was observed when stepping 2LS–LS (Figure 6). Here, the TO_prosth group tended to have a longer step length (p = 0.076) (stepping from prosthetic onto intact limb) than the TO_intact group (stepping from intact to prosthetic limb). No differences were seen between the two groups in terms of step time duration.

Figure 6.

Step length on the approach run for the TO_prosth group (black) and TO_intact group (white). * indicates a significant difference and (*) a trend towards a difference. Between group differences seen at 2LS–LS (p = 0.076). Within group differences seen between 3LS–2LS (p = 0.068) and 2LS–LS (p = 0.043) for the TO_prosth group.

For between steps, the TO_prosth group had a longer (p = 0.043) 2LS–LS (prosthetic–intact limb) than LS–TD_board (intact–prosthetic limb) and a trend towards a shorter (p = 0.068) 3LS–2LS (intact–prosthetic limb) compared to both 2LS–LS and LS–TD_board. No significant differences were noted between steps for the TO_intact group and no differences were seen for either group in terms of step time duration.

Foot contact time was shorter for the TO_prosth group on their LS (p = 0.006) and tended to be shorter on their 3LS (p = 0.068) – both intact limb stance – compared to the TO_intact group (Figure 7). For between steps, the TO_prosth group had a trend towards a shorter foot contact time (p = 0.083) on LS (intact limb stance) compared to 2LS. For the TO_intact group, a shorter foot contact time (p = 0.038) was seen on their 2LS (intact limb stance) compared to their LS.

Figure 7.

Foot contact times on the approach run for the TO_prosth group (black) and TO_intact group (white). For the TO_prosth group (black), 3LS occurs on the intact limb, 2LS on the prosthetic limb, LS on the intact limb and TD–TO on the prosthetic limb. For the TO_intact group (white), 3LS occurs on the prosthetic limb, 2LS on the intact limb, LS on the prosthetic limb and TD–TO on the intact limb. * indicates a significant difference and (*) a trend towards a difference. Between group differences seen at 3LS_TD–TO (p = 0.068) and LS_TD–TO (p = 0.006). Within group differences seen between 2LS_TD–TO and LS_TD–TO for TO_prosth group (p = 0.083) and TO_intact group (p = 0.038).

Discussion

The aim of this study was to investigate kinematic differences in long jump technique between athletes with a transtibial amputation who take off from their prosthetic limb and those who take off from their intact limb. As both groups exhibited similar postures and foot contact times when touching down onto the prosthetic limb, technique differences were seen on each step. While there was no significant difference found for official jump distance or approach speed between the groups, the TO_prosth group jumped an average of 0.82 m further. The fact the difference was not significant was likely due to the low number of athletes in each group.

The lack of difference in running speed between the two groups is not unexpected as all athletes were competing at a similarly elite level. The horizontal approach velocity pattern is similar to that reported previously for both male and female long jumpers with a lower limb amputation.^1-3 It has previously been reported that elite TT long jumpers have a greater negative vertical velocity at TD_board than elite able-bodied athletes.¹ While negative vertical velocity at touch-down was greater in the current study compared to elite able-bodied athletes¹¹, no significant difference in vertical velocity at TD_board was seen between the groups (mean ± SD TO_prosth = -0.20 ± 0.1 m.s⁻¹, TO_intact = -0.26 ± 0.23 m.s⁻¹). If the residual limb/prosthesis was responsible for a lack of control at TD_board, a greater disparity in negative vertical velocity would likely have been seen. Thus taking off from the prosthetic limb does not appear to be a disadvantage in terms of lack of control of the residual limb.

High negative vertical velocity at TD_board stems from lowering the %H_CM between LS and TD_board. To avoid this or to reduce the negative vertical velocity as much as possible, able-bodied long jumpers tend to lower their CM on 2LS-LS either by taking a longer step or increasing knee flexion.^{10, 12–14} It has been shown previously that TT athletes do not only lower their %H_CM 2LS–LS, but also continue to lower it from LS–TD_board.² There were no significant differences between groups in terms of %H_CM from 2LS–TD_board, with both groups lowering their %H_CM significantly from LS–TD_board. This was despite using different take-off limbs which suggests that there is no disadvantage for athletes with a transtibial amputation to take-off from their prosthetic limb. On the contrary, as landing onto, and taking off from, their intact limb (LS) should not be a problem, athletes who take off from their prosthetic limb could be purposefully decreasing their %H_CM between LS–TD_board thereby creating a greater negative vertical velocity in order to gain an advantage from rapidly loading and unloading their carbon fibre prosthetic foot.

Both groups exhibited a different body posture at TD_board than at TD on the previous steps. This posture was similar to that used by elite able-bodied long jumpers – a more extended hip and knee and greater leg angle.^10–12,14 What the groups did next, however, showed a marked difference in technique while on the take-off board. The vertical velocity gain TD–TOboard was similar for both groups, yet less than has been previously reported for elite TT,¹ and able-bodied¹¹ male athletes. However, the TO_prosth group lost half the amount of horizontal velocity TD–TO_board as the TO_intact group. The only way in which the TO_prosth group could conserve so much of their horizontal velocity for the same gain in vertical velocity is through the function of the prosthetic limb. The carbon fibre prosthetic sports feet used by these athletes act as a passive ‘spring’, allowing the material to be loaded and returning a substantial amount of stored energy when unloaded. The more the spring is loaded, the more energy can be returned. It is important to note though, such a passive ‘spring’ cannot return more energy than is stored during loading, nor can it return more energy than a human foot.¹⁵ Thus while this indicates a technique difference, it cannot be concluded that it is a technique advantage.

Another difference in technique used during TD–TO_board was observed. For the TO_prosth group, hip ROM was significantly smaller, less than half that of the TO_intact group, indicating that those who take off from their prosthetic limb do not need to rely heavily on the hip muscles to compensate for the partial loss of the limb observed during walking, running and jumping.^1,4,15–16 Interestingly, the groups showed a very similar knee ROM TD–TO_board, but the TO_prosth group exhibited significantly less knee ROM MKF-TO_board indicating that they may be stiffening their knee and using their prosthetic limb more like a ‘springboard’ than relying on the hip and knee extension seen in the TO_intact athletes. Due to these differences, it is recommended that TT long jumpers be grouped by take-off limb in future studies.

A limitation of the study was the low subject numbers involved. However, as the athletes were filmed during competition finals and there were no semi finals, it was not possible to perform this study with a larger cohort of athletes. Even with such small numbers, significant differences and technique differences between the two groups were noted. While these present results should be used as preliminary findings on which to base further research, the results of this study provide useful insights into differing long jump techniques due to choice of take-off limb, where little data has previously been reported.

Conclusions

Differences in long jump technique are seen depending on whether the prosthetic or intact limb is used at take-off. The TO_prosth athletes ‘stiffen’ their knee and use their prosthetic limb as a ‘springboard’, avoiding having to increase hip ROM, a compensation seen in TO_intact athletes. It is not known, however, which technique is more advantageous. Further study where athletes swap take-off limb for comparison purposes is recommended. In addition, future studies should group TT long jumpers according to choice of take-off limb.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that there is no conflict of interest.

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Effect of take-off from prosthetic versus intact limb on transtibial amputee long jump technique

Abstract

Background:

Objectives:

Study Design:

Methods:

Results:

Conclusions:

Clinical relevance

Keywords

Background

Methods

Subjects

Apparatus and procedure

Statistical analyses

Results

Approach velocities

Relative centre of mass height

Joint angles

Step lengths, durations and foot contact

Discussion

Conclusions

Footnotes

Funding

Conflict of interest

References