Cameroon geo-ecological zones and surface areas.
\r\n\tThe emergence of novel prion strains in animals, which include the only evidenced zoonotic prion C-BSE causing vCJD in humans, has created an important public health concern. Currently, new threats to human and animals may develop because of the plausible zoonotic properties of scrapie, L-BSE and the recently emerging chronic wasting disease in Europe.
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Drought and flood-related disasters have been more devastating than other natural hazards (volcanoes, earthquakes, landslides, etc.), as far as deaths, sufferings and economical and cultural destructions are concerned. Apart from destructive direct effects, flood and drought events have been followed by secondary, indirect tragedies, such as famine, epidemics, fire, destruction of social networks, etc. [1]. Despite the progress in science and technology, man has remained very susceptible to extreme drought and flood events. Their escalation is facilitated by the continuous development of costly but inappropriate infrastructures, increase in population density, and a rather decrease in the buffering capacities (deforestation, urbanization, drainage wetlands, etc.). Understanding the way people in such areas, especially in SSA perceive these hazards, their experiences and interpretations of patterns of occurrence, coping mechanisms, characteristic factors that drive household and community modus operandi when such anomalies strike are of great imperativeness for the design and implementation of household and community based strategies to curb the effects of floods and droughts; and build more resilient communities.
\nBhavnani and colleagues for instance opine that droughts and floods alone account for up to 80% of the loss of life and 70% of the economic losses in SSA [2]. Frequent floods and droughts conditions have reduced the GDP growth of many African countries [1, 3, 4]; and have as well endangered their development advances [5]. Both water-related phenomena have direct and indirect impacts. Over the last 5 decades, floods and droughts have evolved to become major problems in SSA; causing depletion of assets, environmental degradation, impoverishment, unemployment and forced migrations [2, 5, 6]. Flood has been variously defined but for the purpose of this study we have operationally defined flood as a body of water which rises to overflow land which is normally not submerged [7, 8]. There are mainly five types of floods: river flood, flash flood, inland flood, storm surge, coastal flood [8, 9]. Floods are considered as one of the most frequent global hazards [10]. Floods account for approximately 40% of natural disasters and will possibly become more recurrent and severe due to global warming [11].
\nUnlike floods, droughts are characterized by a slow development, long duration, affects vast areas, and high severity [12]. Furthermore, droughts are expected to become more severe and frequent. This is expected to lead to more water demand, global climate change, and a limited water supply [13]. Based on the nature of water shortages, droughts can be classified into the following four types: meteorological, hydrological, agricultural, and socioeconomic [14]. Among these types, meteorological droughts occur more frequently and regularly than the other three drought types and normally trigger other types of droughts [13].
\nFloods and droughts are now the most frequent types of major disasters. The impacts of climate change are likely to increase their occurrence as they happen to be the most frequent types of major disasters nowadays especially in SSA. In the era of climate change, the reliability on predictability in rainfall patterns has been reduced significantly [15]. The frequency and severity of weather-related events such as floods and droughts have increased unpredictably and shall continue over time.
\nCameroon is one of the SSA countries most hit by these climatic extreme anomalies. It is a country in Equatorial Africa, located on the Gulf of Guinea in Central Africa. It lies between latitude 1°40′ and 13°05′ north and between longitude 8°30′ and 16°10′ east; its area is 475, 412 km2. Cameroon’s beauty and relevance in SSA stems from her extremely diversified landscapes, rich natural resources (petroleum, bauxite, timber and many tropical crops), cultural and ethnic diversity and a multiplicity of climatic and geomorphologic zones. It is not surprising therefore that Cameroon has been nicknamed
Cameroon’s geo-physical location, tectonic history and climate makes her one of the most susceptible countries affected by natural hazards in Africa. The regularity and devastation caused by such hazards along the active Cameroon Volcanic Line (CVL) are becoming more frequent and even more disastrous, affecting livelihood assets including human, social, financial, natural, physical capital [10, 16]. The country is becoming more prone to and persistently hit by floods and droughts but also by mud flows, rock fall, lahars, volcanic eruptions, toxic gas emissions, earth tremors and landslides which occur on a regular annual pattern.
\nDespite her diversity and abundant natural resources, Cameroon is also a victim of several hazards and disasters which have accompanied global climate change. Average temperatures have risen since 1930 [17] and average rainfall has reduced by more than 2% per decade since 1960 [17]. Projected changes in rainfall range from −12 to +20 mm per month (−8 to +17%) by the 2090s [18]. Furthermore, average annual temperatures are predicted to increase between 1.5° and 4.5° by 2100, with a 1.6° to 3.3° rise in coastal zones; and a 2.1° to 4.5° rise in the Sudano-Sahelian region [17]. Average rainfall is predicted to continue to decrease, leading to a prolonged dry season in the Sudano-Sahelian ecological zone. Desert conditions are expected to dominate this area by 2100. It is predicted that Lake Chad will be nearly completely dried up by 2060 [19].
\nIPCC has established that a 2° rise globally will result in a sea-level rise of between 69 cm and 1 m across the world [20]. Cameroon, given its location along the coast is also expected to experience the impacts of sea level rise over the next century. The above-mentioned statistics indicate that Cameroon is highly vulnerable to floods and droughts. Tiefenbacher et al. [21] have argued that such vulnerability presents a serious threat to the development of the leisure sector and in this case would pose serious problems in attaining sustainable development and generates new challenges for achieving the SDGs; and jeopardizes progress already made. The analysis of climate variability impacts in Cameroon indicates consequences in almost all sectors of development, with huge negative impacts on livelihoods especially at household level [19, 22].
\nBurgeoning floods and droughts are expected to inflict adverse effects on many Cameroonian households, given their heavy reliance on agriculture for livelihoods dependence of most households on agriculture [23]. Current agricultural contribution to the country’s GDP could drop by 14% points from 20% now to an estimated 6% in 2025 [16, 22, 24]. This drop will resolve mainly from increased desertification (drought) in the north and higher incidence of flooding in the south and in the north of the country.
\nA fundamental step towards reducing the effects of floods and droughts in Cameroon lies in identifying risk management strategies whose validity supersedes specific geo-ecological zones [16, 24]. In this paper we therefore undertake the agency to understand the array of household determinants of coping with the threats of floods and droughts, the shapers of the peoples’ perceptions, interpretations and experiences to these risks within their daily lives and how all of these tend to shape the way they respond to the threats presented by floods and droughts in their households across the western highlands and the Sudano-Sahelian geo-ecological and socio-cultural areas of Cameroon with the intention to identify drivers that are robust over space and time.
\nCameroon is characterized by five geo-ecological zones with varied landscapes and climates. These are described as Zone I (Sudano-Sahelian); Zone II (High Guinea Savannah); Zone III (Western Highlands); Zone IV (Humid Forest with monomodal rainfall pattern); and Zone V (Humid Forest with bimodal rainfall pattern) [25] (Table 1).
\nSN | \nGeo-ecological zones | \nRegions | \nSurface areas (km2) | \n
---|---|---|---|
I | \nSudano-Sahelian Upland | \nNorth and Far North | \n100,353 | \n
II | \nHigh Guinean savannah | \nAdamawa Region, Mbam Division and Lom and Djerem Division | \n123,077 | \n
III | \nWestern Highlands | \nWest and North West | \n31,192 | \n
IV | \nHumid Rainforest with monomodal rainfall pattern (maritime coast) | \nLittoral and South West Regions | \n45,658 | \n
V | \nHumid Forest with bimodal rainfall pattern (Tropical forest) | \nCentre, South and East Regions | \n165,770 | \n
Total | \n466,050 | \n
Cameroon geo-ecological zones and surface areas.
The current study was carried out in two of the 5 geo-ecological zones; the Sudano-Sahelian upland and the Western highlands. The Sudano-Sahelian zone is located between latitude 7 and 13° north thus covering more than 21% of the national territory. It has a rippling relief with plateaus that have varying altitudes between 500 and 1000 m and plains with altitudes ranging from 200 to 300 m. The area is also characterized by mountains and flood valleys. In addition to the geographical position of the zone, it has a distinctively dry climate as compared to the rest of the country with a single and short rainy season of about 4 months reaching its peak in August and a very severe and lengthy dry season of up to 7 months or more as one progresses up north from the Mandara Mountains. The annual mean rainfall ranges from 400 mm in the northern part to 1100 mm in the southern part of the zone with an average temperature of up to 28° [25].
\nOn the other hand, the Western Highlands is located between latitudes 5°40′ and 7° north and between longitudes 9°45′ and 11°10′ east. The zone is characterized by relief of massifs and mountains. It features several dormant volcanoes, including Mt. Oku and Mt. Bamboutos. A cool temperate-like climate, influenced mainly by mountainous terrain and rugged topography also characterizes the region. Average rainfall is about 2400 mm, temperatures averaging between 23 and 32° [19]. There are two main seasons; the rainy season which starts from mid-March and ends in mid-November and dry season from Mid-November to mid-March. The dry season is characterized by the harmattan with dry air. Forests once largely covered the Western Highlands but because of the influence of anthropomorphic activities the forests were progressively cleared for farmland and grazing, and today, only patches remain. Although small, these patches are recognized as globally important sites for conservation.
\nStudy participants were limited to the study areas; were of both sexes (male and female), aged 20 years and above and had been in the area for at least 10 years; and must have witnessed at least one flood and/or drought event. Data were collected from flood victims in 14 communities of the Western Highlands; and 17 drought-only communities, and 10 floods and droughts affected communities in the Sudano-Sahelian geo-ecological zone.
\nThree Social Science instruments were used for data collection to ensure accurate and reliable data in order to attain the study objective. The combined approach was used in collecting the data. Three instruments (individual questionnaires, Focus Group Discussion (FGDs) guides and In-depth interview guides) were employed in collecting both quantitative and qualitative data to investigate the research question.
\nThis was a structured questionnaire used to collect quantitative data from 2024 different floods and droughts household heads or their representatives. It was developed to understand victims’ perceptions and to identify the factors that influence their adoption of specific coping strategies in situations of floods and/or droughts. Socio-demographic information was collected as well. Questionnaires were administered to respondents on a face to face basis after obtaining their consent. We had two sets of questionnaires designed for the purpose of this study: one for floods victims and the other for drought victims.
\nTo generate qualitative data, 31 FGDs and 99 IDIs were conducted in different floods and droughts communities with household members to capture the general opinion and perception of household members on the hazards and disasters, the consequences of such phenomena in their households and the determinants of their preferred coping strategies. We also sort to understand how experience, cultural factors and location within a certain geo-ecological zone could influence the adoption of formal or informal coping strategies. The data collection instruments in this case were also designed separately to distinctively collect data for droughts and floods.
\nAll quantitative data generated from the questionnaires were entered into a template designed in the Statistical Package for Social Sciences (SPSS version 20.0) (IBM Corp., Armonk, NY, USA). The data were cleaned and later on analyzed using both SPSS and Microsoft Excel 2013.
\nFor qualitative data (FGDs and IDIs), they were recorded in the field using dictaphones (voice recorder) and later on transcribed and typed into a word processing program (Microsoft Word 2013). The transcribed data were analyzed using Nvivo version 11, and themes were established in relation to research objectives. This was to ensure a standardized analysis and interpretation of the qualitative data generated across tools.
\nThis section presents and discusses the socio-economic characteristics of the sample. The discussions are done by comparing results from the Sudano-Sahelian region with those from the Western Highlands. It is worth mentioning that the distribution of respondents across geo-ecological zones indicates that 60% of the from the Sudano-Sahelian zone while 40% was from the Western Highlands. In addition, the sample comprises of victims of both droughts and flood events (45.2% drought victims, 40.7% flood victims and 14.1% both drought and flood victims). More so, while all the respondents in the Western Highlands were flood victims, in the Sudano-Sahelian region, only 0.7% of the respondents witnessed floods alone. 75.7% of the respondents were drought victims, 23.6% had witnessed both droughts and floods.
\nIn general, most of the respondents had attained only primary level of education (65%), seconded by those with secondary level education (21.9%), third by those with no formal education (7.2%) and lastly by those with High school level of education (5.9%). The results are presented in Table 2.
\nGeo-ecological zone | \nDisaster type | \nPrimary (%) | \nSecondary (%) | \nHigh school (%) | \nNo formal education (%) | \nX2 ( | \n
---|---|---|---|---|---|---|
Sudano-Sahelian | \nDrought | \n69.8 | \n18.8 | \n3.4 | \n8 | \n32.423 ( | \n
Floods | \n55.6 | \n22.2 | \n0 | \n22.2 | \n||
Both | \n81 | \n6 | \n2.1 | \n10.9 | \n||
Western Highlands | \nFloods | \n54 | \n31.1 | \n10.1 | \n4.8 | \n11.547 ( | \n
Educational attainment of respondents.
Most respondents had attained only primary school education, irrespective of geo ecological zone. This amounted to 69.8% of droughts victims, 55.6% of flood victims and 81% of both flood and drought victims in the Sudano-Sahelian region (
Over 60% of the entire sample are male, while <40% are female. The distribution in the different geo-ecological zones is presented in Figure 1. In the Sudano-Sahelian region, the males also had the higher proportion as compared to the females among those who witnessed droughts (69.1 and 30.9% respectively,
Sex distribution of respondents.
The distribution in the entire sample according to the marital status of the respondents showed that majority of them were married (76.1%) while 17.7% were still single. In addition, while 4.8% of the respondents were widow(ers), a very small proportion of the respondents (1.3%) had divorced their spouses. Results from the geo-ecological zones are presented in Table 3. These are traditional societies where both boys and girls marry very young and divorce is almost viewed as a taboo. Since it is considered that a woman is married to a family, she is generally considered stilled married to the successor of her husband even after the dead of her real husband. Moreover, men generally remarry upon the dead of their wives because the wives facilitate their household chores which men are essentially not familiar with.
\nGeo-ecological zone | \nDisaster type | \nDivorced (%) | \nMarried (%) | \nSingle (%) | \nWidow(er) (%) | \nChi-square | \n
---|---|---|---|---|---|---|
Sudano-Sahelian | \nDrought | \n0.8 | \n81.9 | \n15.3 | \n2.2 | \n4.6841, | \n
Floods | \n0.7 | \n77.8 | \n22.2 | \n0.0 | \n||
Both | \n0.4 | \n86.7 | \n11.2 | \n1.8 | \n||
Western Highlands | \nFloods | \n1.8 | \n66.4 | \n0.2 | \n22.7 | \n10.308, | \n
Distribution according to marital status.
The results indicate that majority of the respondents in both geo-ecological zones as well as for the different disasters were married (66.4% in the Western Highlands and 81.7% for drought, 77.8% for flood and 86.7% for both flood and drought victims in the Sudano-Sahelian region,
As a livelihood source, most of the respondents were involved in farming activities to sustain their families (60%). However, while 32.1% were business persons, 8.8% of the respondents had salaried jobs. The comparative analysis as presented in Figure 2 also show that most of the respondents rely on farming for their household livelihoods (56.7% in the Western Highlands and 67.9% for drought and 77.8% for flood victims in the Sudano-Sahelian region,
Main occupation of respondents.
For those who witness both floods and droughts, the majority of them were found to rely on their respective businesses for their livelihoods (52.4%) as compared to 43.7% who rely on farming.
\nIn our sample, only a slight difference was observed between Christians and Muslims (48.1 and 48.4% respectively). However, a small proportion of the respondents (3.5%) were African Traditionalists. Figure 3 presents the distribution in the two geo-ecological zones.
\nReligious affiliation of respondents.
From Figure 3, we can infer that most of the victims in the Western Highland region are Christians (91.5%). On the contrary, majority of the respondents in the Sudano-Sahelian region for all disaster types were Muslims (85.2% for both drought and flood victims, 66.7% for flood victims and 76.9% for drought victims,
Geo-ecological zone | \nVariable | \nSample mean | \nDisaster type | \nMean | \nStd. dev | \nStd. error | \n
---|---|---|---|---|---|---|
I | \nAge/years | \n45.41** | \nFloods | \n43.22* | \n22.532 | \n7.511 | \n
Droughts | \n44.13* | \n16.757 | \n0.554 | \n|||
Both | \n49.59* | \n15.284 | \n0.905 | \n|||
Number of years living in the village | \n26.35*** | \nFloods | \n28 | \n8.139 | \n2.713 | \n|
Droughts | \n25.16 | \n11.99 | \n0.396 | \n|||
Both | \n30.14 | \n8.922 | \n0.529 | \n|||
Total household size | \n7.41 | \nFloods | \n8.33 | \n3.122 | \n1.041 | \n|
Droughts | \n7.6 | \n2.933 | \n0.097 | \n|||
Both | \n6.77 | \n2.444 | \n0.145 | \n|||
Income before disaster/FCFA | \n64,990*** | \nFloods | \n87,780 | \n125,300 | \n41,770 | \n|
Droughts | \n66,950 | \n72,440 | \n2390 | \n|||
Both | \n57,975 | \n46,650 | \n2760 | \n|||
Income after disaster/FCFA | \n34,050*** | \nFloods | \n46,330 | \n75,290 | \n25,090 | \n|
Droughts | \n32,290 | \n48,220 | \n1590 | \n|||
Both | \n26,480 | \n23,930 | \n1420 | \n|||
II | \nAge/years | \n43.40** | \nFloods | \n43.40* | \n13.739 | \n0.481 | \n
Number of years living in the village | \n24.5*** | \nFloods | \n24.5 | \n11.575 | \n0.405 | \n|
Household size | \n7.62 | \nFloods | \n7.62 | \n3.024 | \n0.106 | \n|
Income before disaster/FCFA | \n113,390*** | \nFloods | \n113,390 | \n173,040 | \n6060 | \n|
Income after disaster/FCFA | \n63,670*** | \nFloods | \n63,670 | \n95,555 | \n3350 | \n
Age, household size, years in the community and income of respondents.
Significant at 10% level.
Significant at 5% level.
Significant at 1% level.
I = Sudano-Sahelian; II = Western Highlands.
It can be inferred from Table 3 that the age of the respondents was significantly higher among respondents in the Sudano-Sahelian zone than those in the Western Highlands (45.41 ± 16.617 years and 43.4 ± 13.739 years respectively,
This sections first of all looks at the number of times the respondents have witness disaster events in the last decade, before exploring their perceptions with respect to damage of the disasters as well as the severity of the damage. From Table 5, we can infer that more floods have been witnessed in the last decade in the Sudano-Sahelian Zone than in the Western Highlands (5 and 3 respectively,
Disaster | \nGeo-ecological zone | \nMean | \nStd. deviation | \nStd. error mean | \nF-test | \n|
---|---|---|---|---|---|---|
Both | \n\n | Sudano-Sahelian | \n6.68 | \n1.300 | \n.077 | \nNot applicable | \n
Drought | \n\n | Sudano-Sahelian | \n5.99 | \n2.917 | \n.096 | \nNot applicable | \n
Flood | \n\n | Sudano-Sahelian | \n4.89 | \n3.060 | \n1.020 | \n0.000 | \n
Western Highlands | \n3.43 | \n1.615 | \n.057 | \n
Number disasters faced in the last 10 years.
These disasters are known to bring about damages to the asset portfolio of their victims. Presented in Table 6 are some of the negative impacts of the disasters faced by the victims both at household and community levels. The results show mix impacts. For instance while damage to natural environment and livestock at the household level was higher in the Sudano-Sahel region than in the Western Highlands (reported by 91 and 43.8% respectively) loss of property was higher in the Western Highlands than in the Sadano-Sahel region (reported 72.6 and 59.9% respectively).
\nAsset | \nGeo-ecological zone | \nHousehold level | \nCommunity level | \n||
---|---|---|---|---|---|
No (%) | \nYes (%) | \nNo (%) | \nYes (%) | \n||
Damage to natural environment and livestock | \nSudano-Sahelian | \n9 | \n91*** | \n8.1 | \n91.9*** | \n
Western Highlands | \n56.2 | \n43.8*** | \n19.4 | \n80.6*** | \n|
Loss of human life | \nSudano-Sahelian | \n98.2** | \n1.8 | \n90.9 | \n9.1 | \n
Western Highlands | \n97.5* | \n2.5 | \n92.3 | \n7.7 | \n|
Loss of property | \nSudano-Sahelian | \n40.1 | \n59.9*** | \n17.7 | \n82.3** | \n
Western Highlands | \n27.4 | \n72.6*** | \n21.1 | \n78.9** | \n|
Destruction of crops | \nSudano-Sahelian | \n6.6 | \n93.4*** | \n0 | \n100 | \n
Western Highlands | \n2.7 | \n97.3*** | \n0 | \n100 | \n|
Destruction of public infrastructure | \nSudano-Sahelian | \n31 | \n69* | \n0 | \n100 | \n
Western Highlands | \n33.5 | \n66.5* | \n0 | \n100 | \n|
Destruction of worship grounds | \nSudano-Sahelian | \n50.8 | \n49.2 | \n39.5 | \n60.5*** | \n
Western Highlands | \n36.6 | \n63.4*** | \n7.9 | \n92.1*** | \n|
Damage to ancestral links | \nSudano-Sahelian | \n39.7 | \n60.3*** | \n71.1*** | \n28.8 | \n
Western Highlands | \n10.9 | \n89.1*** | \n36.8 | \n63.2 | \n|
Physical injury | \nSudano-Sahelian | \n61.2 | \n38.8*** | \n19.9 | \n80.1 | \n
Western Highlands | \n79*** | \n21 | \n17.8 | \n82.2 | \n|
Increase in sickness and diseases | \nSudano-Sahelian | \n3.1 | \n96.9** | \n8 | \n92*** | \n
Western Highlands | \n6.3 | \n93.7** | \n14.4 | \n85.6*** | \n
Analysis of perceptions of damages caused by disasters.
Significant at 10% level.
Significant at 5% level.
Significant at 1% level.
For the Sudano-Sahel region, the highest three damages are incurred through increase in sickness and diseases (reported by 96.9%), destruction of crops (reported by 93.4%) and damage to natural environment and livestock (reported by 91%). For the Western Highlands, the highest three damages are incurred through the destruction of crops (reported by 97.3%) increase in sickness and diseases (reported by 93.7%) and damage to ancestral links (reported by 89.1%). Details of these as well as the perceptions with respect to damages at the community level can be obtained from Table 5.
\nBase on the level of damage experienced by each household, the respondents provided information on the severity of the damages caused by the disasters both at household and community levels. The results have been summarized in Figures 4 and 5.
\nSeverity of damage at household level.
Severity of damage at community level.
At the household level, a significantly higher proportion of the victims from the Sudano-Sahel region acknowledged the severity of the damage from the disasters to be very high than those from the Western Highlands (74.2 and 30.2% respectively,
The results at the community level with respect to the severity of the damages caused by the disasters are similar with those at the household level. For instance just as was the case at the household level, at the community level a significantly higher proportion of the victims from the Sudano-Sahelian region acknowledged the severity of the damage from the disasters to be very high than those from the Western Highlands (71.8 and 28.6% respectively,
This section presents the different strategies explained to be used by the respondents following disasters and especially the last event. As presented in Table 6, there were some similarities as well as differences in the disaster management strategies employed by the respondents in the Sudano-Sahelian and Western Highlands regions both at household and community levels. For instance it can be inferred that the respondents in both geo-ecological zones did not rely very much on insurance (0% all round) and borrowing from the Bank (1.6% for Sudan-Sahel and 1.3% for Western Highlands at household level and 0% for Sudan-Sahel and 1% for Western Highlands at community level). On the other hand, they reduced their household savings (94.5% for Sudano-Sahelian and 99.1% for Western Highlands at household level and 98.1% for Sudano-Sahelian and 98.5% for Western Highlands at community level), rely on stored food (80.3% for Sudano-Sahelian and 87.2% for Western Highlands at household level), and also rely heavily from help from friends and relatives (77.6% for Sudano-Sahelian and 83.6% for Western Highlands at household level and 62.3% for Sudano-Sahelian and 61.6% for Western Highlands at community level). Details of these and more are presented in Table 7. It is worth mentioning that of all the strategies captured, only insurance premiums was not used by any of the respondents in the study area.
\nStrategy | \nGeo-ecological zone | \nAt household level (%) | \nAt community level (%) | \n
---|---|---|---|
Borrow money from Bank*** | \nSudano-Sahelian | \n1.6 | \n0 | \n
Western Highlands | \n1.3 | \n1 | \n|
Borrow from neighbors*** | \nSudano-Sahelian | \n48.2 | \n0.1 | \n
Western Highlands | \n68.7 | \n19.4 | \n|
Relocation*** | \nSudano-Sahelian | \n40.3 | \n41.9 | \n
Western Highlands | \n56.6 | \n52 | \n|
Assembled at central location*** | \nSudano-Sahelian | \n30.8 | \n33.2 | \n
Western Highlands | \n3.6 | \n0 | \n|
Evacuated by the government*** | \nSudano-Sahelian | \n11.8 | \n24.9 | \n
Western Highlands | \n11.4 | \n3.6 | \n|
Got help from NGOs*** | \nSudano-Sahelian | \n44.2 | \n63.9 | \n
Western Highlands | \n31.2 | \n44.9 | \n|
Reduce household savings*** | \nSudano-Sahelian | \n94.5 | \n98.1 | \n
Western Highlands | \n99.1 | \n98.5 | \n|
Receive help from social groups*** | \nSudano-Sahelian | \n39 | \n19.4 | \n
Western Highlands | \n80.9 | \n49.9 | \n|
Receive help from Church* | \nSudano-Sahelian | \n8 | \n53.2 | \n
Western Highlands | \n10.1 | \n49.9 | \n|
Receive help from friends and relatives** | \nSudano-Sahelian | \n77.6 | \n62.3 | \n
Western Highlands | \n83.3 | \n61.6 | \n|
Receive help from Central government*** | \nSudano-Sahelian | \n66.5 | \n0 | \n
Western Highlands | \n17.5 | \n0.2 | \n|
Receive help from individuals*** | \nSudano-Sahelian | \n12 | \n0.2 | \n
Western Highlands | \n64.7 | \n21.1 | \n|
Insurance support | \nSudano-Sahelian | \n0 | \n0 | \n
Western Highlands | \n0 | \n0 | \n|
Received free medication*** | \nSudano-Sahelian | \n67 | \n51.8 | \n
Western Highlands | \n12.1 | \n25.3 | \n|
Sold family labor*** | \nSudano-Sahelian | \n10.1 | \n69.4 | \n
Western Highlands | \n27.3 | \n92.4 | \n|
Sold household assets*** | \nSudano-Sahelian | \n66 | \n0.1 | \n
Western Highlands | \n74.2 | \n18.7 | \n|
Sold household livestock*** | \nSudano-Sahelian | \n82.2 | \n0.1 | \n
Western Highlands | \n36 | \n21.5 | \n|
Rely on stored food*** | \nSudano-Sahelian | \n80.3 | \n0.1 | \n
Western Highlands | \n87.2 | \n17.1 | \n|
Building of embankment*** | \nSudano-Sahelian | \n62.4 | \n0.4 | \n
Western Highlands | \n6.1 | \n48.7 | \n
Disaster coping strategies.
Significant at 10% level.
Significant at 5% level.
Significant at 1% level.
Presented in Figure 6 is a summary of the above captured strategies. It can be observed from Figure 6 that the respondents in both the Sudano-Sahelian Region and the Western Highlands adopted and implemented mainly informal disaster management strategies in order to cope with the negative effects of the disasters (95.6 and 98.9% respectively,
Main disaster management strategy used by respondents.
We also analysed to identify trends in similarities and differences in the disaster management strategies employed by the respondents from the different disasters faced. The results have been presented in Table 7. Mixed results were also observed here at the household and community levels. For instance the distribution according to insurance (0% all round) show that the respondents did not rely very much on it irrespective of the disaster faced. On the other hand, the distribution in terms of reduced household savings indicate strong reliance among the victims of the different disasters (98.9% for flood victims, and 97.5% for drought victims and 100% for both floods and drought victims at the household level, 99.2% for flood victims, and 93.9% for drought victims and 96.5% for both floods and drought victims at community level). Another important strategy used by the disaster victims is to rely heavily on help from friends and relatives (83.3% for flood victims, and 71.8% for drought victims and 96.1% for both floods and drought victims at the household level, 61.4% for flood victims, and 62.4% for drought victims and 62.5% for both floods and drought victims at community level). Details of these and more are presented inTable 8.
\nStrategy | \nDisaster type | \nAt household level (%) | \nAt community level (%) | \n
---|---|---|---|
Borrow money from Bank** | \nFloods | \n1.3 | \n1 | \n
Droughts | \n2.1 | \n0 | \n|
Both | \n0 | \n0 | \n|
Borrow from neighbors*** | \nFloods | \n68.8 | \n19.2 | \n
Droughts | \n62.6 | \n0 | \n|
Both | \n1.1 | \n0.4 | \n|
Relocation*** | \nFloods | \n51.6 | \n47.9 | \n
Droughts | \n25 | \n43.4 | \n|
Both | \n96.8 | \n0 | \n|
Evacuated by the government*** | \nFloods | \n11.5 | \n4 | \n
Droughts | \n15.2 | \n32.5 | \n|
Both | \n0.7 | \n0 | \n|
Got help from NGOs*** | \nFloods | \n31.3 | \n45.3 | \n
Droughts | \n38.3 | \n57.7 | \n|
Both | \n63.2 | \n83.9 | \n|
Reduce household savings** | \nFloods | \n98.9 | \n99.2 | \n
Droughts | \n97.5 | \n93.9 | \n|
Both | \n100 | \n96.5 | \n|
Receive help from social groups*** | \nFloods | \n80.6 | \n49.8 | \n
Droughts | \n44.8 | \n24.5 | \n|
Both | \n20 | \n2.8 | \n|
Receive help from Church | \nFloods | \n10.1 | \n50 | \n
Droughts | \n10.2 | \n52.9 | \n|
Both | \n1.1 | \n54.7 | \n|
Receive help from friends and relatives*** | \nFloods | \n83.3 | \n61.4 | \n
Droughts | \n71.8 | \n62.4 | \n|
Both | \n96.1 | \n62.5 | \n|
Receive help from Central government*** | \nFloods | \n17.8 | \n0.2 | \n
Droughts | \n57.6 | \n0 | \n|
Both | \n95.8 | \n0 | \n|
Receive help from individuals*** | \nFloods | \n64.2 | \n21.1 | \n
Droughts | \n14.9 | \n0.2 | \n|
Both | \n2.5 | \n0 | \n|
Insurance support | \nFloods | \n0 | \n0 | \n
Droughts | \n0 | \n0 | \n|
Both | \n0 | \n0 | \n|
Received free medication*** | \nFloods | \n12.6 | \n25.7 | \n
Droughts | \n58.1 | \n47.4 | \n|
Both | \n95.8 | \n65.3 | \n|
Sold family labor*** | \nFloods | \n26.9 | \n92 | \n
Droughts | \n13.1 | \n75 | \n|
Both | \n0.7 | \n51.9 | \n|
Sold household assets*** | \nFloods | \n74 | \n18.4 | \n
Droughts | \n56.4 | \n0 | \n|
Both | \n97.2 | \n0.4 | \n|
Sold household livestock*** | \nFloods | \n36.3 | \n21.2 | \n
Droughts | \n77.5 | \n0 | \n|
Both | \n97.9 | \n0.4 | \n|
Rely on stored food*** | \nFloods | \n80.3 | \n17.1 | \n
Droughts | \n\n | 0 | \n|
Both | \n87.2 | \n0.4 | \n|
Building of embankment*** | \nFloods | \n6.7 | \n48.2 | \n
Droughts | \n53.6 | \n0.5 | \n|
Both | \n91.2 | \n0 | \n
Disaster management strategies adopted by disaster type.
Significant at 5% level.
Significant at 1% level
The Binary Logistic Regression was adopted for this analysis. In this analysis, the dependent variable (Disaster coping strategies) took 1 for Mainly Informal Strategies and 0 for Mainly Formal strategies. 16 explanatory variables were used in the analysis. The attributes of our models as presented in Table 9 and show strong relationships between the dependent and independent variables in the analysis (X2 = 109.423,
\n | Chi-square | \ndf | \nSig. | \n|
---|---|---|---|---|
Step 1 | \nStep | \n110.948 | \n15 | \n.000 | \n
Block | \n110.948 | \n15 | \n.000 | \n|
Model | \n110.948 | \n15 | \n.000 | \n
Omnibus tests of model coefficients.
In addition, the attributes of Table 10 show that our model explains 23.3% of the factors that affect coping strategies among the drought and flood victims in the two geo-ecological zones.
\nStep | \n−2 Log likelihood | \nCox & Snell R square | \nNagelkerke R square | \n
---|---|---|---|
1 | \n416.685a | \n0.053 | \n0.233 | \n
Model summary.
The factors that affect the coping strategies among the drought and flood victims in the two geo-ecological zones are presented inTable 11. The results show that the type of disasters faced, belonging to a social group or network, number of disaster faced, the main occupation of the household head and the number of years living in the community (residence time) positively affected the decisions of the disaster victims to adopt mainly informal disaster coping strategies. On the other hand, the age, educational level, household size, marital status and the sex of the respondents showed negative relationships with adopting mainly informal disaster coping strategies. In addition, both incomes before and after the disasters as well as the per capita income before and after the disasters seem not to be important variables that could be used to differentiate households in terms of disaster coping strategies (B = 0.000 for all four variables). These therefore indicate that the financial/economic status had no influence on the decisions of the disaster victims to adopt one form of disaster coping mechanisms over the other [16, 20, 26, 27].
\n\n | B | \nS.E. | \nWald | \ndf | \nSig. | \nExp(B) | \n
---|---|---|---|---|---|---|
Age* | \n−.058 | \n.012 | \n22.708 | \n15 | \n.000 | \n0.943 | \n
Type of disaster | \n0.190 | \n0.325 | \n0.341 | \n15 | \n0.559 | \n1.209 | \n
Educational level* | \n−1.523 | \n0.602 | \n6.401 | \n15 | \n0.011 | \n0.218 | \n
Geo-ecological Zone | \n−2.114 | \n1.147 | \n3.394 | \n15 | \n0.065 | \n0.121 | \n
Household size | \n−0.040 | \n0.055 | \n0.539 | \n15 | \n0.463 | \n0.961 | \n
Marital status | \n−0.046 | \n0.333 | \n0.019 | \n15 | \n0.890 | \n0.955 | \n
Belong to a group or network | \n18.098 | \n7067.871 | \n0.000 | \n15 | \n0.998 | \n23.64 | \n
Number of disasters faced* | \n0.210 | \n0.064 | \n10.835 | \n15 | \n0.001 | \n1.234 | \n
Main occupation of household head | \n0.116 | \n0.274 | \n0.181 | \n15 | \n0.671 | \n1.123 | \n
Religious affiliations | \n0.675 | \n0.406 | \n2.767 | \n15 | \n0.096 | \n1.965 | \n
Residence time* | \n0.044 | \n0.014 | \n9.708 | \n15 | \n0.002 | \n1.045 | \n
Sex | \n−0.536 | \n0.319 | \n2.831 | \n15 | \n0.092 | \n0.585 | \n
Household income before disaster | \n.000 | \n.000 | \n0.894 | \n15 | \n0.344 | \n1.000 | \n
Household income after disaster | \n.000 | \n.000 | \n1.701 | \n15 | \n0.192 | \n1.000 | \n
Per capita income before disaster | \n.000 | \n.000 | \n2.851 | \n15 | \n0.091 | \n1.000 | \n
Per capita income before disaster | \n.000 | \n.000 | \n1.544 | \n15 | \n0.214 | \n1.000 | \n
Constant | \n−18.243 | \n7067.872 | \n.000 | \n15 | \n0.998 | \n.000 | \n
Regression determinants.
Significant at 10% level
Of significance to this study is the number of disasters faced (B = 0.210,
The number of disasters experienced by households (B = 0.210,
In an area where people roughly share the same way of life, occupation and are subjected to similar shocks, they are likely to employ similar coping strategies when hazards strike as response opportunities and available coping mechanisms are relatively homogeneous [27]. This probably explains why in the research area, the main occupation of the household head affected their household coping strategies. Improving agricultural techniques can therefore enhance the coping capacities of our sampled households to future floods. Improving education to enhance access to off-farm income activities should also be contemplated.
\nThough not significant, belonging to a social group or network showed the strongest contribution to the use of mainly informal disaster coping strategies in this study (B = 18.098,
The probability of the Wald statistics for the variables age and educational level for instance (22.708 and 6.401 respectively) suggests that the disaster victims who are older and more educated are likely to move away from using mainly informal risk management mechanisms to both informal and formal mechanisms. The negative coefficient on education leads us to hypothesize that the more educated a household head is, the more he/she is likely to use formal than informal instruments in managing disasters. These results however contradict the findings in the topical case studies [26, 27, 32]. About 34 for instance in his work in India found education to be a very cost-effective strategy for influencing and implementing schooling decisions in poor households in India. A probable explanation for this is the generally low levels of education observed in the Cameroon case study.
\nOur research demonstrates that Cameroon has diverse geo-ecological zones with climate-related hazards and disasters that are specific to some while others cut across. Through a comparative analysis, we differentiate that the Sudano-Sahelian zone is characterized by severe droughts and very deadly floods in both the urban and rural settings while the Western highlands are typified by floods in both the urban and rural settings as well. Further, we gained insights into the different drivers of household determinants of coping with droughts and floods in both geo-ecological zones. Respondents identified Informal coping mechanisms as their major fallback positions and include amongst others; reducing their household savings, relying on stored food and heavy reliance on assistance from friends and relatives. Formal coping strategies were not identified as major drivers at both household and community levels in any of the zones. This explains that building social networks is a very important component in building policies that aim at making households more resilient in these zones.
\nWe also observed that socio-cultural factors and experience with previous disasters influenced the type of strategies people would adopt in subsequent events. The nomadic nature of the Muslim households in the Sudano-Sahelian area elucidates why temporal or permanent migrations will easily be an option in coping with droughts and/or floods. This was not the case with most of the sedentary population of the Western Highlands where most people reported the wish to maintain their residence even after experiencing the floods except in the neighborhoods that have been completely and permanently inundated.
\nIn addition, this was the first of a kind to have witnessed a positive change in income levels of some household members, especially in the Western Highlands where the huge floods have given the opportunity for change in socio-economic activities. Most have now engaged in lumbering and illicit sale of fuel which are considered more economically rewarding than the farming activities they formerly practiced. The presence of water routes now facilitates the transportation of timber from the hinterland to the coast as well as the transportation of fuel from neighboring Nigeria to Cameroon. The energetic male about the ages of 35 and 45 are gainfully employed in this new found economic sector.
\nAbove all, this study is a first step in developing a robust methodology for comparing household determinants for coping with climate-related vagaries within and across multiple geo-ecological zones and within and across hazards/disasters. It serves as a platform for broad-based policy making and implementation not only within Cameroon but across SSA where similar realities abound.
\nAdult scoliosis includes adult idiopathic scoliosis as well as degenerative lumbar scoliosis (DLS). DLS is a de novo scoliosis. It is defined as a lateral curvature of the spine in excess of 10° and a sagittal vertical axis (SVA) of more than 50 mm. in an adult over 50 years of age [1]. The sagittal vertical axis is the horizontal distance from the vertical plumbline dropped from the centroid of C7 to the posterosuperior corner of the sacral end plate.
The prevalence of DLS varies with different studies. The reported rate ranges from 8.3–68% [2, 3, 4, 5]. The marked variation in prevalence reported is possibly a result of the differences in inclusion criteria of the different studies. Kilshaw et al. [6] evaluated the prevalence of lumbar scoliosis using abdominal and kidney–ureter-bladder radiographs on patients over the age of 20 years [6]. The study showed that lumbar scoliosis is more prevalent in women and increases with age [6]. At the ages of between 60 and 69 years, the prevalence was 6%, whereas at the age of 90 years, the prevalence was over 30% [6]. It has, however, to be noted that the study did not differentiate between adult idiopathic scoliosis and DLS and that the radiographs employed were supine films, which might underestimate the Cobb angle and thus the prevalence of lumbar scoliosis. Xu et al. [7] evaluated 2395 Han Chinese over 40 years of age for the presence of DLS, using dual energy X-ray absorptiometry (DEXA) images. They reported a prevalence of 13.3%, with females more commonly affected than males. Also, the prevalence increased with age [7]. Prevalence was reduced with increasing curve severity; over 80% of the patients with DLS had curves in between 10° and 20° [7].
The causes of adult scoliosis are many. Aebi [1] classified adult scoliosis into four different groups, based on their etiologies. Type 1 refers to primary or de novo degenerative lumbar scoliosis. Type 2 refers to adult idiopathic scoliosis (ADIS), and type 3 refers to adult curves with other primary causes. The last type includes two subgroups. Type 3a refers to adult scoliosis caused by spinal or extra-spinal factors, while type 3b refers to those caused by metabolic bone diseases [1]. Thus adult scoliosis patients are not a homogeneous population group. Our present discussion would focus on DLS which is more prevalent than other types of adult scoliosis.
The pathomechanisms of DLS have not been entirely elucidated, though vertebral instability has been proposed to play a role in its pathogenesis [8, 9]. Kobayashi et al. [4], in a study of the prevalence of DLS, proposed that lateral osteophytes present at the endplate which are in excess of 5 mm together with an asymmetric tilt of disc space >3° are risk factors for the development of DLS [4].
The factors initiating the vertebral instability, however, are unknown. Lumbar paraspinal muscle atrophy; facet tropism, which is defined as the angular asymmetry between the left and right facet joint orientation; and osteoporosis have all been implicated in the pathogenesis of the condition [7, 10, 11].
Lumbar multifidus muscle atrophy (LMA) has also been postulated to contribute to vertebral instability [10]. The multifidus muscle is the deepest and most medial paraspinal muscle, adjacent to the facet joint. LMA is common in DLS, particularly on the concave side of the lumbar scoliosis (Figure 1) [12, 13]. Conversely, hyperplasia of the multifidus muscle is evident on the convex side of DLS [14]. Sun et al. [10] investigated the relationship between LMA and various coronal and sagittal radiographic parameters in 144 patients with DLS [10]. They showed that the LMA in the upper and lower vertebral levels adjacent to the apex on the concavity of the lumbar scoliosis correlated positively with the Cobb angle [10]. Conversely, the LMA on the convex side correlated negatively with the lumbar Cobb angle [10]. Sun et al. [10] postulated that LMA may cause vertebral instability and subsequent degenerative changes of lumbar facet joints. Remodeling of articular processes, which includes cartilage degeneration and bone erosion, generally lags behind LMA [10].
Lumbar multifidus atrophy. From the MRI, it is evident that there was marked asymmetric lumbar multifidus atrophy at the level of L3/L4. The fatty infiltration area in the left multifidus was significantly larger than that in the right multifidus.
Facet tropism has also been postulated to increase the risk of vertebral rotatory olisthesis (VRO) and degenerative lumbar scoliosis [11, 15, 16]. Vertebral rotatory olisthesis refers to lateral and rotatory vertebral translation. Facet joints were found to be more angled in a coronal plane on the convex side of VRO than those of the control subjects without VRO [11]. More severe facet tropism is associated with a higher incidence of VRO [11]. The asymmetric facet orientation causes uneven stress distribution across the zygapophyseal tissues and brings about degenerative changes and segmental instabilities [11]. An intraoperative biomechanical study demonstrated that facet tropism contributed to lumbar vertebral instability [17].
The role of osteoporosis in DLS has been controversial, with some studies showing that osteoporosis contributed to DLS, a number showing that DLS caused the osteoporosis, with others showing no correlation between the two [7]. The lumbar scoliosis brought about by vertebral instability may stabilize or progress [8, 9]. In the presence of marked scoliotic wedging of one disc in the early phase of DLS, adjacent discs may compensate by wedging in the other direction to maintain balance, with resultant stabilization or even regression of the lumbar scoliosis (Figure 2) [8].
Mild intervertebral disc wedging in one level is compensated by wedging in the opposite direction to maintain coronal balance. Mild disc wedging was evident in L4/L5 level. The wedging was compensated by disc wedging above (L3/L4) in the opposite direction, balancing the spine.
In other cases, degenerative scoliosis may progress. The increased pressure and shear stress on the facet joints cause alterations within the synovial surfaces of the articular processes with subsequent facet hypertrophy, capsular degeneration, and ligamentous hypertrophy [18]. Also, asymmetric loading of the lumbar facet joints and intervertebral discs may result in spinal deformities occurring in three planes [19, 20], particularly in the presence of decreased bone density. Depending on the number of segments involved, this can also cause segmental or multi-segmental vertebral instabilities. Further instability in the sagittal and coronal planes may result in degenerative spondylolisthesis and rotatory olisthesis, respectively [21]. It has to be noted that rotatory olisthesis is present even in mild lumbar scoliosis of less than 20° [21].
Lumbar VRO is prevalent in L3–L4, followed by L2–L3 and L4–L5. Of all the VRO, L3–L4 laterolisthesis contributes around half of the prevalence [11, 22, 23]. Watanuki et al. [24] proposed that this was related to the mechanical stress at the L3–L4 levels, as the lower lumbar levels are more fixed and the upper lumbar segments are more mobile [24]. The smaller size of the L4 vertebral body may also contribute to the higher incidence of laterolisthesis at L3–L4, as a reduction of 25% of the vertebral cross-sectional area increases mechanical stress by 30% with an applied load, contributing to vertebral instability [25].
To reduce the instability, the body reacts by growing osteophytes (Figure 3). The spondylosis (osteophytes by the end plates) and the spondyloarthritis (degenerative changes of the facet joints) that result, together with the ligamentous hypertrophy, compromise the central spinal canal and the lateral recess and may bring about claudication and nerve root compression symptoms [1].
The osteochondrosis at L4/L5 intervertebral level, together with the bridging osteophyte in the left of L3/L4, stabilized the mild scoliosis curve and maintained coronal balance in this man aged 63 years.
Apart from bone and articular involvement, paraspinal muscle atrophy is prevalent in DLS. Sarcopenia, which is a reduction in skeletal mass, is commonly seen in patients with DLS. Eguchi et al. [26], using DEXA scans to assess the appendicular and trunk skeletal muscle mass, showed that sarcopenia was present in 46.6% of the DLS patients [26]. Sarcopenia is defined as the appendicular skeletal mass index of less than 5.46 kg/m2 [27]. The appendicular skeletal mass index (ASMI) is the sum of the arm and leg lean mass (kg) divided by square of the height (m2) [27]. Studies have also shown that ASMI negatively correlated with pelvic tilt [26], whereas trunk skeletal mass index (Trunk SMI) which is defined as trunk lean mass divided by height2 (m2) significantly correlated with the sagittal vertical axis, pelvic tilt (PT), and lumbar scoliosis [26]. Moreover, trunk SMI correlated positively with bone mineral density (BMD), suggesting that reduction in trunk muscle mass was associated with osteoporosis and sagittal imbalance [26], which is prevalent in patients with DLS.
Patients are generally over 50 years of age. Clinical presentation is variable. Onset is generally gradual, though it can be sudden, after a day’s work, repetitive bending of the low back, poor sitting posture, or prolonged standing.
Most of the patients complain of low back pain, radiculopathy, and claudication [28]. Liu et al. [28], in a study of the clinical features of 112 patients with DLS treated surgically, found that 77% of them complained of low back pain, 90% complained of radiculopathy, and 48% complained of neurogenic intermittent claudication. Only 3% of them had neurological symptoms [28]. The symptoms can present singly or in combination [28].
Low back pain is generally diffuse. It is often located in the apex and concavity of the curve and at the junction between two curves [28]. The severity of the pain varies with different curve types, with thoracolumbar, lumbar, and lumbosacral curves being more painful than thoracic curves. A compensatory hemicurve is the least painful, except for the left compensatory lumbosacral hemicurve [29, 30, 31]. Pain is also localized on the iliac crest and the coccyx, where the tendons of the lumbar paraspinal muscles insert [1]. Rarely, the lowest ribs impinge on the iliac crest and cause pain [1]. In the presence of a reduced lumbar lordosis or a complete loss of the natural lumbar curve, the muscle pain is generally greater. This is not unexpected as the lumbar paraspinal muscles have to contract continuously to maintain coronal and sagittal spinal balance.
Whether the extent of the pain is related to the magnitude of the curve and coronal balance has not been clearly elucidated as yet [29, 32]. A number of studies have shown that Cobb angles in excess of 45° are associated with more pain [33]. Other studies, however, have shown that the magnitude of the curve was not related to the pain [29, 34].
The impact of coronal balance on low back pain is likewise controversial. Some studies showed that a coronal imbalance in excess of 4–5 cm. is associated with more pain and reduction in function in un-operated scoliosis patients [32, 35]. Further trunk shift is a predictor of surgery in patients with DLS [35]. Other studies, however, did not show such an association [36].
Radiculopathy is common in patients with DLS. Many studies have attempted to investigate the relationship between the scoliosis curve, VRO, and the nerve roots involved [28, 37, 38]. In a study evaluating 47 male and 65 female DLS patients with a mean age of 54.7 years, Liu et al. [28] showed that L3 and L4 nerve roots are generally compressed on the concave side of the scoliosis [28]. Conversely, L5 and S1 nerve roots are more commonly afflicted on the convex side of the scoliosis [28].
Liu et al. [37] evaluated the site of nerve root irritation in 22 DLS patients [37]. They identified three zones (Figure 4) where the nerve root could be compressed or irritated. These included the lateral recess zone, the foraminal zone, and the extra-foraminal zone [37]. The lateral recess zone refers to the zone where the nerve root passes from the thecal sac to the entrance of the foramen; the foraminal zone refers to the interval canal beneath the pedicle, and the extra-foraminal zone refers to the zone outside the lateral border of the pedicle [37]. They found that the L3 and L4 nerve roots are more commonly compressed in the foraminal and extra-foraminal zones in the concavity of the scoliosis curve. Conversely, L5 and S1 nerve roots are more commonly affected by a lateral recess stenosis on the convex side [37].
The magnified view of the spinal canal and the intervertebral foramina. Nerve root irritation can occur in (a) the lateral recess zone, (b) the foraminal zone, and (c) the extra-foraminal zone; (d) is the sagittal diameter of the spinal canal. Spinal stenosis can result from narrowing of the sagittal diameter of the spinal canal or that of the lateral recess, when they are known as lumbar spinal stenosis and lateral lumbar spinal stenosis, respectively.
Gardner et al. [38] evaluated different patterns of lumbar spinal stenosis with lateral subluxation in patients with DLS and had similar findings [38]. They showed that the pattern of nerve root compression varies with the types of lateral subluxation, viz., the open subluxation and closed dislocation. Open subluxation refers to subluxation where the disc is open on the side where the vertebra above is slipping. The wedge is open on the convexity of the curve (Figure 5). Conversely, closed dislocation is present when the disc is closed on the side where the vertebra above is slipping [23]. Gardner et al. [38] showed that open subluxation commonly affects L3 and L4 levels. When present, it causes contralateral lateral recess and foraminal stenosis. Closed dislocation, on the other hand, is generally seen on the concavity of the curve, causing an ipsilateral pattern of stenosis [38, 39]. L1 and L2 are the most frequently involved [38].
VRO was evident at Ll, L2, and L3 levels. L1 translated tangentially to the right, with no disc wedging. L2 similarly translated to the right though to a smaller extent, with disc closing on the right, which was the concavity of the lumbar curve. This is defined as closed dislocation. L3, on the other hand, slipped to the left. The disc wedged open on the side of curve convexity. This is termed open subluxation.
In a study of a cohort of 78 patients with DLS and spinal canal stenosis, Ferrero et al. [39] demonstrated that foraminal and lateral stenosis were most frequently observed on the concavity of the distal lumbosacral curve. L5 radicular pain was significantly more frequent in the presence of compensatory lumbosacral hemicurve [39].
In view of the different patterns of vertebral instability and compensatory curve patterns, it is understandable that the clinical presentation of DLS varies. Nerve root irritation may be single or multilevels, causing pain in different dermatomes [40, 41].
It is interesting to note that the side of radicular pain frequently corresponded to the side of coronal shift. Patients with right truncal coronal shift more frequently present with right radicular pain; similarly, patients with left coronal shift more commonly present with left radicular pain [39]. The mechanism involved was not clear, though it was found that in 69% of the cases, the truncal coronal shift was associated with the side of the lumbosacral counter-curve (i.e., C7 is shifted to the convex side of the main lumbar curve) [39].
With progression of the condition, pain generally involves the buttock as well as the leg, causing neurogenic claudication symptoms which are worse with standing and walking and are relieved with sitting or stooping. The condition is a result of lumbar spinal stenosis brought about by impingement of nerves emerged from the spinal cord. Studies have shown that the symptoms vary over time in different patients. Symptoms tended to improve in 15% of the patients. In 40% of the patients, the condition tended to deteriorate during the initial 2–3 years of follow-up, and in 45% of the patients, the condition remained stable [42, 43].
Compression of nerve roots is common, with reported incidence varying from 47–78% [44, 45]. The incidence of cauda equina compression with apparent bladder and rectal sphincter problems, however, is low [1].
Central spinal stenosis is generally seen at the junction between two curves. In the study by Ferrero et al. [39], 70% of the cohort had central stenosis at the junction between the main lumbar curve and the lumbosacral hemicurve. Central spinal stenosis also occurs in the concavity of the main lumbar curve and at the junction between the main thoracic curve and the lumbar curve [39].
Many studies have shown adult scoliosis tends to progress, with the rate of progression higher in DLS than ADIS [46].
DLS tends to progress irrespective of the magnitude of the curve (Figure 6) [46]. A study reported the rate of progression of scoliosis in patients with DLS to be 1.64° per year (0.77–3.82°) [7], while another study reported an increase of 3° per year in a cohort of 200 people over the age of 50 years [47]. The radiographic risk parameters are similar to that of ADIS and include apical vertebral rotation ≥ III, a Cobb angle >30°, lateral vertebral translation >6 mm., and L5 above the intercristal line, which is the line joining both iliac crests [9, 47].
Progression of degenerative lumbar scoliosis in a postmenopausal woman 70 years of age. In the year 2003 (a), the left lumbar scoliosis measured 30°. It increased to 35° in year 2009 (b). After the patient was prescribed Fosamax by his medical practitioner, the curve stabilized, as can be seen in the radiograph in 2017 (c).
The physical evaluation aims at the differential diagnosis of the condition as well as to identify the nerve root(s) involved. The findings depend on the severity of the condition and if there are signs of neurological involvement. In the presence of neurological claudication, patients generally walk with an antalgic gait (gait to avoid or reduce pain), with the trunk listing forward to widen the spinal canal and to reduce the compression on the nerve roots. In more severe cases, the patients may walk with flexed hips and knees [48]. With progression of the condition, the walking distance reduces. Not uncommonly, the patient reports a reduction in height, which averages 4–24 cm. in 1–22 years [49].
Inspection from the back generally shows a hump in the low back with the concavity on the opposite side. Generally pelvic obliquity occurs; Radcliff et al. [50] reported a pelvic tilt in 87% of patients with DLS [50, 51]. Patients with a single lumbar curve were more likely to have a higher pelvis contralaterally (79%), as a compensatory mechanism to maintain coronal trunk balance [50]. Patients with a lumbar curve and a compensatory lumbosacral hemicurve did not display consistent pelvic obliquity compensatory patterns [50].
In the presence of marked pelvic obliquity or pelvic tilt, apparent leg length discrepancy becomes evident, with the leg ipsilateral to the lumbar convexity appearing shorter [50] and the posterior superior iliac spines being unlevel. The coronal spinal imbalance can be determined by measuring the distance from C7 to the vertical line extended from the gluteal cleft. The distance measured in mm. represents the coronal shift (Figure 7). In the presence of a single thoracolumbar or lumbar curve, the spine is generally decompensated to the side of lumbar convexity.
Coronal imbalance and sagittal imbalance are evident in this man aged 62 years old. He complained of radiculopathy localized to the right anterior thigh. The radiograph (a) showed a right lumbar scoliosis with a mild compensatory left thoracolumbar scoliosis. Though the sagittal imbalance was not significant (b), there was a reduction in sacral slope and thoracolumbar lordosis.
In patient with DLS, sagittal imbalance is more significant clinically than coronal imbalance [52]. Loss of lumbar lordosis is generally evident with patients leaning forward [48]. In cases with spinal stenosis, patients may flex their hips and knees to compensate for the sagittal spinal imbalance. In long standing cases, contracture of the hips may result, which can be assessed by the Thomas leg raise test [53].
The physical examination can also be used to identify the pain driver. Tenderness is generally elicited at the junction between two major curves, including the junction between the thoracic and lumbar curves and between the lumbar curve and the compensatory lumbosacral hemicurve. Also, pain can be elicited at the apex of the thoracolumbar or lumbar curves [33] and on the iliac crest where the tendons of the lumbar paraspinal muscles attach [1]. A neurological examination which consists of the assessment of motor strength, reflexes, sensation, and gait also needs to be performed, to assess the extent of neurological involvement and to rule out other possible causes of back pain.
Radiographic examination usually involves taking erect posteroanterior and lateral full spine radiographs. This enables the evaluation of the regional spinopelvic parameters as well as global spinal balance. Sagittal spinal balance has been reported to be positively associated with health-related quality of life (HRQOL) [32, 35].
A frontal radiograph generally depicts a thoracolumbar or lumbar scoliosis, which is generally shorter than that seen in ADIS, involving only a few vertebral segments. Additionally, vertebral body deformities are less severe than that of ADIS [54]. Of interest is that the majority of lumbar curves with a convexity to the right had apexes above L2 and those with convexities to the left had apexes below L2 [55]. The authors, however, did not offer any explanation for the findings [55].
Depending on the degree of the DLS, radiographic features differ. In the early stages, mild lumbar intervertebral wedging may be present, and compensation in the form of wedging to the opposite direction may be seen in the upper vertebral levels [8].
With progression of the condition, vertebral instability in the form of a translatory shift may be evident [39]. Very often, lateral vertebral translation or laterolisthesis is accompanied by vertebral rotation, when it is known as VRO. VRO most often affects the L3 and L4 levels and less commonly L2–L3 and L4–L5. Of note is that 50% of the VRO occurs at the junction between the main lumbar curve and the compensatory lumbosacral hemicurve [39]. VRO also occurs at the apex of the main lumbar curve and at the junction between the thoracic curve and the lumbar curve [39]. Open subluxation tends to occur on the convexity of the main curve, while closed dislocation tends to occur at the junction between the scoliosis curves [39].
In late stage DLS, osteophytosis may be seen in the vertebral end plates in the concavity of the lumbar scoliosis. Large bridging osteophytes provide stability to previously unstable vertebrae. Also evident are signs of disc degeneration, facet arthrosis, and spinal stenosis [4]. The possibility of lateral recess stenosis and central spinal stenosis may also be discerned from the frontal radiographs. The Cobb angle and the apical vertebral rotation need to be measured, as they are related to the risk of curve progression and back pain. A lumbar scoliosis in excess of 30°, an apical vertebral rotation in excess of 33%, and lumbarization increase the propensity for curve progression and the incidence of back pain [34].
Pelvic obliquity is common in DLS [50]. From the radiograph, the coronal balance may also be determined. It is the distance between the vertical lines extended from the mid sacrum (central sacral line, CSL) to mid C7. When it is in excess of 4 cm, it is associated with deterioration of pain and function scores in adult scoliosis patients [32, 35]. Of importance is that Ferrero et al. [39] reported that the side of radicular pain corresponded to the side of coronal shift in 70% of the subjects [39].
Lateral spinal radiography generally reveals a reduction of lumbar lordosis and sagittal imbalance. This is important as regional spinopelvic parameters and global spinal balance have been found to be associated with clinical outcome. A study showed that pelvic incidence-lumbar lordosis (PI-LL) mismatch ≥10° and pelvic tilt ≥22° were reported to correlate with disability [56].
Sagittal spinal imbalance is common in patients with DLS. One of the commonly used parameters is the sagittal vertical axis, which is the distance between the vertical line dropped from C7 and the posterosuperior angle of the sacrum. It is noteworthy that a SVA ≥7 cm. is associated with clinical symptoms [32]. The finding was supported by other studies [36, 56]. In mild and moderate spinal malalignment, patients with DLS tend to incline the trunk forward and tend to develop a posterior pelvic shift to maintain balance and to provide relief from neurologic symptoms, especially in the presence of concomitant degenerative spondylolisthesis [48].
In the presence of claudication and neurological symptoms, computed tomography and magnetic resonance imaging (MRI) may be indicated for diagnosis, monitoring, and follow-up. When decreased BMD is suspected, bone density measurement using a DEXA scan or radiofrequency echographic multi spectrometry (REMS) method is indicated. Computed tomography generally shows signs of facet arthropathy and spinal stenosis, including central spinal stenosis, lateral recess stenosis, and foraminal stenosis.
Magnetic resonance imaging of the lumbar spine is used to assess the soft tissues of the spine, including the spinal cord and tissues within the spinal canal. It is also useful for the assessment of the degenerative changes of disc and facets as well as to assess the extent of spinal stenosis. Recent studies have shown that bone marrow edema was associated with low back pain [57, 58]. In a study of 120 DLS patients, Nakamae et al. [57] found that bone marrow edema was associated with low back pain (Figure 8) and that the bone marrow edema score was positively associated with low back pain severity [57]. Bone marrow edema was often seen in the concavity of the curve [57]. Buttermann et al. [58] found that the painful scoliosis which was located at the apex of the scoliosis curve or at the lumbosacral junction was associated with a higher frequency of end plate inflammatory changes [58]. The study showed that the end plate changes demonstrated a bimodal distribution, with peaks at L2–L3 and L5–S1 [58].
Bone marrow edema is evident just below the inferior end plate of L2 and superior end plate of L3 in the left.
MRI may also reveal a reduction in muscle mass in the lumbar paraspinal muscles in patients with DLS [59, 60] as paraspinal muscles are involved in the stability of the lumbar spine; Barker et al. [59] suggested that their atrophy was associated with lumbar instability [59]. The percentage of fat infiltration areas in paraspinal muscles was significantly higher on the concave side than the convex side. Further the asymmetry of the multifidus muscle change is positively correlated with the lumbar curvature, lateral vertebral translation, and apical vertebral rotation [60].
Studies showed that BMD was lower in DLS patients than normal controls [7]. Also, BMD was found to correlate negatively with the Cobb angle [61]. Patients with DLS and Cobb angle ≥20° had lower BMD than those with curves less than 20° [7]. A low BMD was associated with increased risk of curve progression. Thus assessment of BMD is of importance in DLS patients.
BMD can be assessed using either the DEXA or the REMS methods. Though DEXA is the gold standard in the assessment of BMD, it has to be noted that DEXA is prone to errors, which includes wrong inclusion of vertebrae and positioning of patient [62]. In the presence of DLS, the spinal BMD could be falsely elevated [62], as the degenerative changes, such as aortic calcification, vertebral osteophytes, facet degeneration, end plate sclerosis, and vertebral rotation, may all have artificially elevated readings obtained from a standard anteroposterior lumbar DEXA scan [63], causing errors in clinical management. A study by Pappou et al. [62] study showed that the falsely elevated scores increased with Cobb angles in excess of 22.5° [62]. The viable alternative for conducting a BMD evaluation of patients with DLS are the hip DEXA values [62]. Alternately, REMS measurement can be used. It relies on a machine algorithm and takes into consideration the entire bony profile including the vertebral microarchitecture, compact bone to trabecular bone mineral density ratio, and collagen index, thus reducing the many errors that are associated with the DEXA measurement [64, 65].
The body composition of the patient needs to be evaluated, when sarcopenia or loss of muscle mass with aging is suspected. Recent studies have shown that 46.6% of patients with DLS had reduced muscle mass involving the extremities and the trunk [26]. The trunk SMI was found to be significantly negatively correlated with sagittal vertical axis, pelvic tilt (PT), lumbar scoliosis, and apical vertebral rotation, suggesting that the reduction in trunk muscle mass was related to the stooped posture, pelvic retroversion, and lumbar scoliosis [26].
Patients with DLS generally seek treatment for pain and disabilities, instead of deformities [52]. Conservative treatment is generally indicated, and this often involves methods to control or relieve pain, such as epidural injection, non-steroidal anti-inflammatory drugs, analgesics, traction, electrotherapies, dry needling, manipulation, mobilization, and deep tissue massage. These methods can generally provide relief, though temporarily [66, 67]. A systematic review concluded that there was only level IV evidence in support of the effectiveness of physical therapy, chiropractic care, and bracing in the treatment of adult scoliosis patients and level III evidence for steroid injection [66]. The long-term successful rate of conservative treatment of symptomatic adult scoliosis was only 27% [68, 69].
The poor outcomes of the above interventions are not unexpected, as the treatments were directed towards pain relief, but not the deformities and the global imbalance that are causing the symptoms [69]. Treatment approaches that target spinal deformities yielded better results in terms of reduction in pain and disability ratings in ADIS patients [70, 71, 72, 73, 74, 75, 76]. Yet, it has to be noted that many of the studies targeted younger cohorts who suffered from ADIS rather than DLS. Further for patients who are in pain or have difficulties performing exercises, a spinal brace may be indicated. It stabilizes the spine, improves the sagittal imbalance, and reduces the load in the lumbar spine. de Mauroy et al. [77] have shown that a spinal brace is able to stabilize progressive curves in 80% of the adults with scoliosis [76].
Many case reports and case series studies have reported that scoliosis-specific exercises (SSE) and multi-modal rehabilitation reduce pain, disability, and curves in patients ADIS [70, 71, 72, 73, 74, 75, 76]. Yet, only a few studies have targeted patients with DLS. Daily side plank exercises on the side of curve convexity for 3–22 months were reported to reduce the curves significantly in 30% of the patients with ADIS and DLS [70]. The study, however, did not evaluate the impact of the exercises on pain and disabilities [70]. A prospective pilot study by Ng et al. [72] showed that 9 months of scoliosis-specific exercises at home reduced the thoracolumbar or lumbar curves in over 30% of the ADIS and DLS subjects [72]. Also, our unpublished study showed that 6 weeks of SSE reduced pain and disability ratings of subjects with ADIS and DLS.
While many studies have addressed the coronal curves in ADIS and DLS patients, very few studies have addressed the impact of SSE on the sagittal profile of patients [72]. The effects of SSE on the sagittal profile of this group of patients are thus uncertain. Additionally while SSE may be indicated in the management of patients with DLS, our experience has shown that many older patients had difficulties in mastering the Schroth exercises or the scientific exercises approach to scoliosis (SEAS). They had difficulties in coordinating breathing together with the corrective movements needed. A number of patients encountered problems holding the spine in an erect position, while other patients had increased low back pain soon after the exercises, despite normal spine DEXA scores. This was possibly a result of the DEXA over-estimating the spinal BMD scores when the patient was actually osteopenic. Instead of focusing on corrective exercises, the patients may need to be instructed to adopt corrective postures during daily activities as they are easier to master.
In the presence of a left lumbar curve, the patient can stand, with his or her right knee flexed to lower the right pelvis. Alternately, the patient can raise the left heel. This raises the left pelvis [78]. Either way, this lowers the right sacrum, in relation to the left, and reduces the lumbar scoliosis. This may enable the patient to stand longer. To further reduce the left lumbar curve or reverse the curve, the patients could side shift to the left [78]. Conversely, in the presence of a right lumbar curve, the patient should reverse the above postures.
Yet, it is difficult to maintain the correct standing posture during ambulation, unless the patient learns how to level the pelvis. Patients with a left thoracolumbar or lumbar curve needs to contract the right hip abductor to bring the pelvis to the midline and level it (Figure 9) while derotating the left lumbar curve forward [51] (Figure 10). Similarly, patients with right thoracolumbar or lumbar curves need to derotate the right lumbar curve forward while contracting the left hip abductors [51]. The patient then learns to walk with the gluteus medius contracted.
Contraction of the gluteus medius would level the pelvis. (a) The patient was standing naturally. The right pelvis can be seen shifted to the right and was higher, with pelvis obliquity. (b) Contraction of the right gluteus medius leveled the pelvis. The patient was instructed to learn walking in this corrected position.
This patient with left thoracolumbar scoliosis can derotate the left lumbar spine forward during daily activities.
When sitting, the patient needs to maintain the lumbar lordosis, as forced thoracolumbar lordosis was found to reduce double major curves [79]. In the presence of a loss of lumbar lordosis, the patient may be advised to wear a wearable lumbar cushion at all times, though its effects in single thoracolumbar or lumbar curve have not to date been investigated. It is also crucially important that the patient refrains from adopting postures or activities that reinforce the faulty scoliosis pattern (Figure 11).
Patient should refrain from faulty habitual postures, which would aggravate the scoliosis. (a) Frontal lumbar radiograph showed a right lumbar scoliosis, with apex at L2 in a female patient with ADIS. (b) When sitting on the floor, he habitually flexed her left hip and knee, increasing the right lumbar scoliosis. (c) When she flexed her right hip and knee, however, the lumbar curve reduced. Yet, the latter posture should also be discouraged, as lumbar lordosis was not maintained.
Functional leg length discrepancy is common, as compensation in patients with DLS. Prescription of a sole lift, in the presence of an apparent LLD, but not anatomical LLD, may induce a compensatory lumbosacral hemicurve, instead of reducing the main lumbar curve [51]. Patients should preferably be advised to contract the gluteus medius on the side of higher pelvis to level the pelvis [51], to flex the knee on this side to lower the pelvis or to raise the heel of the leg ipsilateral to the convexity of the lumbar curve [78] to raise the pelvis.
Spinal bracing has been advocated in the management of adult scoliosis, to halt progression of curves, restore sagittal balance, and treat pain and disability. The effectiveness of braces, however, has been controversial [77, 80]. A number of studies opined that spinal braces do not halt curve progression. Any benefits of pain relief are offset by the deconditioning of the lumbar paraspinal muscles [80].
Recent studies, however, have shown that spinal bracing is effective in reducing pain and halting curve progression (Figure 12) [77, 80]. A study which used a lordosing bivalve polyethylene overlapping brace to treat 158 adults with spinal deformities for over 5 years showed that 24% of the curves improved by ≥5°, 56% of the curves stabilized, and 20% worsened by ≥5° [77]. The findings were supported by a long-term follow-up study of 22 years [80]. It was shown that brace wear reduced the progression of curves in both ADIS and DLS patients [80]. The yearly progression for curves in patients with DLS reduced from 1.47° to 0.24° per year [80]. de Mauroy [77] suggested that the brace treatment not only is palliative but also helps to stabilize the lumbar spine in lordosis [77].
The man aged 73 years of age complained of right anterior thigh pain with intermittent claudication. The lumbar radiograph and MRI (a) showed a right thoracolumbar scoliosis (b) with a reduction in thoracolumbar lordosis (c) and mild sagittal imbalance. The patient was treated by exercises that increased the thoracolumbar lordosis and a lordotic spinal brace. (d) Despite that the patient was non-compliant and wore the brace only at home for 4 hours daily, the brace treatment increased the walking distance from 10 minutes to around 30 minutes.
Apart from SSE to reduce the scoliosis angles, patients should be encouraged to perform exercises to improve muscle mass, as sarcopenia is prevalent in patients with DLS [26].
Many studies have shown that physical exercises, proper nutrition, and optimal hormonal homeostasis are the three pillars to fight or treat (pre)-sarcopenia [81, 82]. Physical exercises should consist of resistance and endurance exercise training (50% resistance training and 50% endurance training). They should be performed at least three times a week [83]. Resistance exercise training aims at improving muscle strength, muscle mass, and BMD and optimizing the hormonal milieu [81], whereas endurance exercise training targets at improving the cardiovascular function, increasing the insulin sensitivity and the anti-inflammatory effects, as well as maintaining the endocrine milieu [81, 83]. Thus patients with DLS should also be encouraged to take up a regular exercise program. Nourishment with optimal protein intake is also important. Patients should take 25–30 g of protein with essential amino acids daily [82]. Supplements should include long-chain omega 3 fatty acids and antioxidants (e.g., polyphenols such as hydroxytyrosol, resveratrol, epigallocatechin 3 gallate, curcumin, quercetin) and vitamin D [81, 84]. Ideally, vitamin D should be dosed to attain a serum level of 30 ng/L [82]. Depending on the hormonal level, testosterone and creatine may also be prescribed to treat the (pre)-sarcopenia [82].
Reduction in BMD is common in patients with DLS. A study by Eguchi et al. [26] showed that trunk skeletal muscle mass correlated positively with BMD [26]. The presence of sarcopenia would thus be indicative of osteoporosis [26]. Depending on the BMD, treatment by medication and/or nutritional supplementation may be required. Pharmacological agents are indicated in the presence of a moderate or high risk of fracture. Common medications prescribed for postmenopausal osteoporosis include estrogen, estrogen + progestin, bisphosphonates, selective estrogen receptors modulators (SERMS), the denosumab, calcitonin, and teriparatide. Each of them has different indications and contraindications [85]. Whether these medications help stabilize or halt the progression of DLS has however not been studied to date. Clinically, however, the author has seen cases of rapidly progressing DLS controlled by administration of bisphosphonates.
Together with pharmacological agents, nutritional supplements such as calcium, vitamin D3, vitamin K2, and silica and abstinence from alcohol and smoking are indicated [86]. Recent studies have demonstrated that calcium supplementation is associated with a low bone calcium content with a parallel increase in vascular calcium content [86] and that low BMD is correlated with an increased cardiovascular mortality [87, 88]. The calcium paradox is speculated to be related to vitamin K2 deficiency [89]. It is thus prudent to advise patients with DLS and osteoporosis to take vitamin K2 along with a calcium supplement.
When conservative treatment fails to provide pain relief or control the symptoms, the patient needs to be referred for surgery, particularly in the presence of neurological signs and symptoms [90], as the outcome of surgery has been reported to be superior to conservative treatment [48], albeit with a much higher risk of complications.
When treating patients with DLS, we should not only target symptomatic relief, but it is also necessary to address the underlying aggravating or risk factors of the condition. Physiotherapy, manipulation, and needling can be used to treat pain, together with spinal bracing. Scoliosis-specific exercises should be prescribed, and corrective postures should be encouraged during daily activities to improve the sagittal and coronal spinal imbalances. In the presence of sarcopenia and decreased BMD, resistance exercise training and nutritional supplements are also indicated.
The author declares no conflict of interest.
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