The Knee 19 (2012) 703–708

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The Knee

Patellofemoral joint stress during running in females with and without

patellofemoral pain
Adam D. Wirtz a, John D. Willson b,⁎, Thomas W. Kernozek b, Di-An Hong b
a
Saint Michael's Hospital, 900 Illinois Avenue, Stevens Point, WI 54481, USA
b
La Crosse Institute for Movement Science, Department of Health Professions, Physical Therapy Program, University of Wisconsin-La Crosse, 1725 State Street, La Crosse, WI, 54601, USA

a r t i c l e i n f o a b s t r a c t

Article history: Patellofemoral pain (PFP) is a common complaint among female runners. The etiology for PFP is frequent-
Received 12 May 2011 ly associated with increased patellofemoral joint stress (PFJS) and altered hip and knee joint kinematics
Received in revised form 30 August 2011 during running. However, whether PFJS during running is increased among runners with PFP is unknown.
Accepted 12 September 2011
The primary aim of this study was to compare PFJS during running among females with and without PFP.
We also compared hip and knee transverse plane kinematics during running due to their potential influ-
Keywords:
Kinetics
ence on patellofemoral contact area and PFJS. Three dimensional hip and knee running kinematics and
Kinematics kinetics were obtained from 20 females with PFP and 20 females with no pain. Patellofemoral joint stress
Gait during running was estimated using patellofemoral contact area and a sagittal plane patellofemoral joint
Knee model previously described. Patellofemoral joint stress, PFJS-time integral, and hip and knee transverse
Hip plane kinematics at the time of impact peak and peak ground reaction force were compared between
groups using a multivariate analysis of variance. The results show that peak PFJS and PFJS-time integral
were similar between groups. Peak knee flexion angle and net knee extension moment were not different
between groups. However, females with PFP demonstrated hip internal rotation that was 6° greater
(P = 0.04) when ground reaction forces were greatest. The extent these results are influenced by com-
pensations for pain is unclear. However, if increased PFJS contributes to the etiology or exacerbation of
PFP, interventions to minimize altered transverse plane hip kinematics may be indicated among runners
who demonstrate this characteristic.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction during stair ascent or descent [5]. To our knowledge it is unknown

Running is a readily accessible and popular mode of exercise. It is
estimated that nearly 36 million people run in the United States alone
[1]. Unfortunately, running has been also associated with several
lower extremity overuse injuries. Patellofemoral pain (PFP) is
among the most common of these injuries in runners, particularly
in females [2–4].
The etiology of PFP has been hypothesized to include increased
patellofemoral joint stress (PFJS) [5–7]. Heino Brechter and Powers
[6] reported that individuals with PFP had significantly higher PFJS
during fast walking, with the PFP group having both peak stress and
integrated stress during the stance phase that were nearly two
times greater compared to healthy controls. However, elevated PFJS
has not been consistently observed across a variety of weight bearing
activities. For example, PFJS was not greater in females with PFP
⁎ Corresponding author at: 4075 Health Science Center, Department of Health Professions,
Physical Therapy Program, University of Wisconsin-La Crosse, 1725 State Street, La Crosse,
WI 54601, USA. Tel.: +1 608 785 8472; fax: +1 608 785 8460.
E-mail address: jwillson@uwlax.edu (J.D. Willson).
if PFJS is elevated among females with PFP during running.
Decreased patellofemoral joint contact area results in an increase
in PFJS for a given quadriceps contraction. Since PFJS has been associ-
ated with the etiology of PFP, it appears important to consider the in-
fluence of hip and knee transverse plane kinematics. Salsich et al. [8]
reported that patellofemoral joint contact area decreases with in-
creased femoral internal rotation among individuals with PFP. Lee
et al. [9] analyzed the influence of fixed rotational deformities of the
femur in cadaveric knees and reported that either 30° of femoral in-
ternal or external rotation increased PFJS by 20–30%. Li et al. [10]
reported that hamstring forces that increase knee external rotation
may further amplify PFJS by 10–24%.
To our knowledge, PFJS during running has not been examined be-
tween females with and without PFP. Therefore the primary purpose
of this study was to compare differences in PFJS during running be-
tween females with and without PFP. Knee and hip transverse plane
kinematics were also compared between groups, based on their po-
tential to increase PFJS. It was hypothesized that female runners
with PFP would demonstrate increased peak PFJS, PFJS-time integral,
and peak hip and knee transverse plane kinematics during stance
compared to females without PFP.

0968-0160/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.knee.2011.09.006
704 A.D. Wirtz et al. / The Knee 19 (2012) 703–708
2. Methods
The study protocol was approved by the university institutional
review board and all subjects provided informed consent prior to par-
ticipation. Using an alpha level of 0.05 a beta level of 0.2, and
expected variability of knee extension moment data during running
in previous studies with similar methodology, 19 participants per
group were determined to be necessary to identify between-group
differences with effect sizes greater than 0.7 [11,12]. All participants
were female runners, 18–35 years old, who ran at least 10 miles per
week and reported their activity level as greater than or equal to 5
out of 10 on the Tegner activity scale (a measure of regular participa-
tion in recreational sports activities that require running or jumping)
[13]. All subjects who were pregnant, reported a known cardiovascu-
lar pathology, had surgery to either lower extremity over the last
12 months or sustained a traumatic injury to either knee joint within
6 months of the study were excluded from participation. Subjects in
the control group had to be free of any lower extremity symptoms
of injury for the last 2 years that prohibited regular participation in
recreational running.
Potential participants with a primary complaint of knee pain dur-
ing running were screened by a licensed physical therapist for specific
criteria to be included in the PFP group. These criteria included a ver-
bal pain score of at least a 3 (moderate) on a 10 point verbal pain
scale during running and squatting, prolonged sitting, ascending or
descending stairs, or jumping. Potential participants must have also
described pain behind or adjacent to the patella and not solely at
the iliotibial band, patellar tendon, or knee-joint line. Knee symptoms
were required to be of insidious onset and present for at least
2 months in duration. Participants with PFP had to report that their
symptoms were exacerbated with manual compression of the patella
into the trochlear groove with the knee in 15° of flexion or with pal-
pation of the medial or lateral patellar retinaculum against the poste-
rior patellar surface. Lastly, participants with PFP were required to
score less than 85/100 on the Anterior Knee Pain Scale [14]. Fifteen
points on this scale has been determined to be the minimum clinically
important difference in comparison to healthy controls [15]. All po-
tential participants were excluded if they presented for screening
tests with signs and symptoms of meniscus or ligament pathology,
were currently receiving supervised treatment for PFP, or reported
symptoms in either foot, ankle, hip or low back that were exacerbated
by running.
Screening of potential participants continued until 20 females
with PFP and 20 healthy females were identified and agreed to partic-
ipate in this investigation. Forty two potential participants with knee
pain were assessed for the above inclusion and exclusion criteria. Ten
of the 20 participants with PFP included in this study reported bilat-
eral symptoms. For these participants, the most symptomatic lower
extremity was chosen for analysis. The right lower extremity of the
healthy control group subjects was used for analysis. All participants
wore the same type of shoe (model 629, New Balance, Boston, MA)
during testing in order to reduce variability that may be caused by
different shoe absorption properties.
2.1. Procedure
Subjects were prepared for 3D motion analysis testing during run-
ning by attaching reflective markers to the leg and pelvis of the involved
limb (PFP group) or right limb (control group). The three-dimensional
coordinates of these markers were used to track the motion of the pel-
vis, femur, shank, and foot, each modeled as a rigid body. Anatomical
markers used to establish the segmental-coordinate systems were
placed over each iliac crest, the greater trochanters, medial and lateral
femoral condyles, medial and lateral proximal tibia, medial and lateral
malleoli, the first and fifth metatarsal heads, and the tip of the shoe.
Tracking markers, which remained in place for all of the running trials,
were positioned as a cluster of three markers on the rearfoot of the shoe,
a cluster of four markers on the posterior shank, a cluster of four
markers on the lateral thigh, and three markers for the pelvis on each
anterior superior iliac spine and at the L5–S1 interspace. The knee
joint center was assumed to be the midpoint of a line between the fem-
oral condyle markers. Ankle joint center was assumed to be the mid-
point of a line between the two ankle malleoli markers. The hip joint
center was identified using a Newton iterative spherical fitting algo-
rithm on data recorded during a standing trial where the instrumented
leg was moved in a prescribed fashion prior to the running trials [16].
During this trial, participants stood on their contralateral leg while mov-
ing their free leg through two arcs of approximately 80° hip flexion and
two arcs of 50° hip abduction. Following both the standing calibration
trial and hip center movement trial, each of the anatomical markers
were removed.
All participants were asked to run along a 20 m runway between
3.52 and 3.89 m/s as indicated by the forward velocity of the sacral
marker in the lab coordinate system prior to contact with the force
platform. After at least five practice trials, five trials were collected
for further analysis. During each trial, marker data were collected at
120 Hz using eight Eagle digital cameras (Motion Analysis Corpora-
tion, Santa Rosa, CA, USA) positioned around the runway. These
marker trajectories were digitally filtered at 12 Hz using a low pass,
fourth order Butterworth recursive filter. Ground reaction forces
were recorded at 1080 Hz by a force platform (Model 4080, Bertec
Corporation, Columbus, OH) flush with the surface of the runway.
Ground reaction force data used in the calculation of joint moments
using the inverse dynamics approach were digitally filtered at 12 Hz
using a low pass, fourth order Butterworth recursive filter based on
the recommendations of Bisseling and Hof [17]. The original ground
reaction force data were then digitally filtered at 50 Hz using a low
pass, fourth order Butterworth recursive filter in order to identify
the peak vertical force impact transient and peak vertical ground re-
action force for each trial.
Hip and knee joint kinematics and joint moments during the
stance phase for each running trial were calculated with Visual 3D
software (C-Motion Inc, Rockville, MD) using sequence of rotations
where hip and knee flexion–extension were calculated first, followed
by abduction–adduction, and internal–external rotation, respectively.
Joint kinematic conventions were defined using the right hand rule.
Kinematic data were not normalized to the static neutral trial. In
other words, 0° corresponded to an erect posture at the hip and knee.
Kinematic and kinetic variables of interest included peak knee ex-
tension moment, peak knee flexion angle, and hip and knee trans-
verse plane angle at the vertical impact transient and at the peak
ground reaction force (GRF) during the stance phase of each running
trial. Hip and knee transverse plane joint angles were compared be-
tween groups at the peak impact transient because this event occurs
early during stance phase and kinematic differences in females with
PFP may be especially apparent in shallow knee flexion angles [18].
Transverse plane hip and knee joint kinematics were compared at
peak vertical ground reaction force because this event occurs near
midstance of running when knee flexion and knee extensor moment
values are greatest. Kinematic rotations that decrease patellofemoral
contact area during this time may significantly increase PFJS. Kine-
matic dependent variables of interest were identified using custom
software (LabView 8.6, National Instruments, Austin, TX). The aver-
age of these variables of interest from all five running trials were cal-
culated and used for analysis.
2.2. Patellofemoral joint stress
Patellofemoral joint stress (PFJS) during running was calculated
by dividing estimated patellofemoral joint reaction force by estimat-
ed patellofemoral contact area. Patellofemoral joint reaction force
was estimated using a biomechanical model previously described by
 A.D. Wirtz et al. / The Knee 19 (2012) 703–708 705

Salem and Powers [19] which has also been used to estimate PFJS Table 2
during walking, resisted squatting, and stair climbing in other previ- Comparison of mean (SD) estimated patellofemoral joint stress (PFJS) variables be-
tween females with and without PFP during the stance phase of running.
ous studies [5,6,20]. This model uses tibiofemoral sagittal plane
angle and net joint moment data obtained using inverse dynamics PFP group Healthy group P value⁎ Effect size
as input variables. Internal knee extension moment data during the Peak PFJS (MPa) 9.6 (2.5) 8.5 (2.2) 0.14 0.47
stance phase of each running trial was divided by the effective lever PFJS-time integral (MPa s) 236.4 (66.4) 218.5 (87.0) 0.47 0.23
arm for the quadriceps as a function of knee flexion angle to obtain PFP = patellofemoral pain.
quadriceps force. The effective lever arm of the quadriceps is based ⁎ Univariate between-subjects effects (α = 0.05).
on cadaver data presented by van Eijden et al. [21] as represented
by the equation presented by Salem and Powers [19]. Patellofemoral
joint reaction force was then calculated by multiplying calculated
quadriceps force by the ratio of patellofemoral compression force to
quadriceps force as a function of knee flexion angle presented by
van Eijden et al. [21] and represented mathematically by Salem and
Powers [19].
Patellofemoral contact area during weight bearing may differ
among females with PFP compared to females without PFP during
weight bearing activities, particularly at shallow knee flexion angles
[6,18,22]. Thus, the estimated patellofemoral contact area as a func-
tion of knee flexion angle was unique for each group. Patellofemoral
contact area for females with and without PFP was obtained from
data reported by Connolly et al. [22]. In this previous study, contact
area was determined at 15°, 30°, and 45° knee flexion using magnetic
resonance imaging as subjects lay supine with the quadriceps con-
tracted at 10% maximum voluntary force. These data were then line-
Fig. 1. Patellofemoral joint stress for females with and without PFP during the stance
arly interpolated to provide patellofemoral contact area as a function phase of running. Shaded areas represent standard error of the mean at each time
of knee flexion angle for each group. Patellofemoral joint reaction point. The dotted lines represent time of vertical impact peak and peak ground reaction
force was divided by this group-specific patellofemoral contact area force, respectively.
to estimate PFJS during running. Dependent variables of interest
based on the PFJS model included peak PFJS and the PFJS-time inte-
Transverse plane hip kinematics measures were not different between groups at
gral during the stance phase of running.
the time of their vertical impact peak (Table 3, Fig. 2). However, females with PFP dem-
onstrated 6° of greater hip internal rotation at their peak vertical GRF (P = 0.04,
ES = 0.68).
2.3. Statistical analysis Differences in transverse plane knee kinematics between groups were not statisti-
cally significant at either peak vertical force impact transient or peak vertical GRF
Each dependent variable was first compared between groups using (Table 3, Fig. 3). However, female runners with PFP demonstrated nearly 5° greater
knee external rotation in comparison to the control group at the time of their vertical
a multivariate analysis of variance (MANOVA) with a familywise
impact peak (P = 0.13, ES = 0.48) (Table 3).
alpha=0.05. Follow-up univariate tests were performed between groups Peak knee flexion angle was similar between groups (Table 3, Fig. 4). Similarly, no
when statistically significant MANOVA results were identified. All statisti- difference in peak knee extension moment between the PFP group and the control
cal procedures were performed in SPSS (version 13, SPSS Inc., Chicago, IL). group were observed (Fig. 5).

4. Discussion
3. Results

Subjects from both groups were similar with respect to age, height, weight, and
BMI (Table 1). Subjects in the PFP group on average had slightly lower self-reported ac-
tivity levels and ran five fewer miles per week than the control group (Table 1).
Significant multivariate effects were found when all dependent variables were con-
sidered together (Wilks'λ = 0.44, F (14,25) = 2.31, P = 0.033). Slightly greater PFJS
(ES = 0.47) and PFJS-time integral (ES = 0.23) values were found for the PFP group com-
pared with the control group during running (Table 2, Fig. 1). However, follow-up univar-
iate analysis revealed these differences were not statistically significant.
The primary purpose of this study was to compare PFJS during
running between female runners with and without PFP. Transverse
plane hip and knee joint kinematics may also affect PFJS but are not
included in this PFJS model. Thus, our secondary purpose was to com-
pare these kinematic variables between groups. Previous studies have
used these methods to model PFJS among individuals with and

Table 3
Comparison of mean (SD) kinematic and kinetic variables between females with and
Table 1 without PFP during the stance phase of running.
Comparison of mean (SD) anthropometric and demographic characteristics for runners
in the PFP and healthy groups. PFP group Healthy group P value⁎ Effect size

Peak knee extensor moment 1.30 (0.2) 1.27 (0.2) 0.70 0.12
PFP group Healthy group
(Nm/kg m)
Age (years) 21.3 (2.6) 21.6 (4.4) Peak knee flexion angle (°) 43.9 (5.0) 41.8 (4.1) 0.16 0.46
Height (m) 1.7 (0.1) 1.7 (0.1) Hip IR at impact peak (°) 3.0 (11.9) − 2.0 (8.7) 0.14 0.48
Weight (kg) 62.9 (7.7) 61.8 (9.2) Hip IR at peak vGRF (°) 3.7 (10.7) − 2.4 (7.2) 0.04 0.68
BMI 22.1 (1.9) 21.7 (1.9) Knee IR at impact peak (°) − 3.2 (11.8) 1.6 (8.0) 0.13 0.49
Miles/week 15.6 (8.1) 20.6 (10.9) Knee IR at peak vGRF (°) 2.3 (9.6) 4.3 (7.5) 0.48 0.23
Years running 4.1 (3.1) 4.8 (3.5)
PFP = patellofemoral pain, IR = internal rotation, vGRF = vertical ground reaction
Tegner score 5.9 (0.8) 6.9 (1.5)
force; negative values represent external rotation.
BMI = body mass index, PFP = patellofemoral pain. ⁎ Univariate between-subjects effects (α = 0.05).
706 A.D. Wirtz et al. / The Knee 19 (2012) 703–708
Fig. 2. Hip internal rotation angle for females with and without PFP during the stance
phase of running. Shaded areas represent standard error of the mean at each time
point. The dotted lines represent time of vertical impact peak and peak ground reaction
force, respectively.
Fig. 3. Knee internal rotation angle for females with and without PFP during the stance
phase of running. Shaded areas represent standard error of the mean at each time
point. The dotted lines represent time of vertical impact peak and peak ground reaction
force, respectively.
without PFP during walking and stairs. In addition, several previous
studies have compared hip and knee transverse plane rotation be-
tween individuals with and without PFP. However, to our knowledge,
this is the first study to simultaneously compare PFJS and transverse
plane hip and knee joint kinematics in females with and without PFP.
Patellofemoral joint stress and PFJS-time integral were not differ-
ent between groups of females with and without PFP during running.
Fig. 4. Knee flexion angle for females with and without PFP during the stance phase of
running. Shaded areas represent standard error of the mean at each time point. The
dotted lines represent time of vertical impact peak and peak ground reaction force,
respectively.
Fig. 5. Knee extension moment for females with and without PFP during the stance
phase of running. Shaded areas represent standard error of the mean at each time
point. The dotted lines represent time of vertical impact peak and peak ground reaction
force, respectively.
Heino Brechter and Powers [5] also reported no significant difference
in peak PFJS or PFJS-time integral during stair ascent and descent be-
tween individuals with PFP and a control group. However, these same
authors did find increased PFJS and PFJS-time integral among partici-
pants with PFP while walking [6]. They concluded that individuals
with PFP may adopt compensatory strategies to maintain stress levels
within a comfortable range during activities likely to induce pain,
such as negotiating stairs. Running is traditionally associated with
pain among patients with PFP and therefore it is possible that similar
compensatory strategies were used by females with PFP in the cur-
rent study to decrease PFJS.
There are at least two reasons to believe our data provide an un-
derestimate of PFJS during running, particularly for females with
PFP. First, our PFJS estimate during running is calculated using only
sagittal plane inputs such as net knee extension moment and knee
flexion angle. Transverse plane kinematics known to decrease patel-
lofemoral contact area are not accounted for in this model and may
be more apparent among those with PFP [12,23]. Second, quadriceps
muscle force is estimated using net knee extension moments by this
model. As such, co-contraction of the knee flexors during running
will underestimate quadriceps muscle force at any given net knee ex-
tensor moment. Females with PFP may simultaneously contract ham-
strings and quadriceps during running to a greater extent than
females without PFP, which would decrease the PFJS estimate for
this group using this model [24]. Comparison of PFJS between females
with and without PFP during running using modeling techniques to
account for knee flexor muscle activity appear justified [25,26].
Our results suggest that peak PFJS is particularly high during run-
ning. Peak PFJS among individuals with and without PFP using these
methods is reported to range from 2 to 6 MPa during walking and
from 5 to 7 MPa during stairs [5,6]. Peak PFJS in this study exceeded
8.5 MPa during running, which is at least 40% greater than each step
during walking and 20% greater than each step on stairs. The high
PFJS during running may substantiate why the incidence of PFP is par-
ticularly high among runners and why PFP symptoms do not tend to
be self-limiting among athletes who remain active in their sport [27].
Females with PFP demonstrated 6° greater hip internal rotation dur-
ing running at the time of peak vertical ground reaction force. Increased
hip internal rotation during running for females with PFP is consistent
with several previous studies [18,23,28,29]. For example, Souza and
Powers [28] reported that females with PFP demonstrated over 7° in-
creased average hip internal rotation during the stance phase of run-
ning compared to females without PFP. Using weight bearing MRI
data, Souza et al.[18] also reported that females with PFP demonstrated
increased internal rotation at 0°, 15°, and 45° of knee flexion compared
to a control group. Increased hip internal rotation during the time of
 A.D. Wirtz et al. / The Knee 19 (2012) 703–708
peak vertical ground reaction force while running may reduce patellofe-
moral contact area when patellofemoral joint reaction forces are great-
est, leading to significantly elevated PFJS. However, it is worth noting
that the minimal detectable difference (MDD) using this methodology
to determine peak hip transverse plane kinematics during running is es-
timated to be 8.8° [30]. Hip internal rotation differences relative to the
control group mean exceeded the MDD for six PFPS participants
(30%). Therefore, although PFP group mean hip internal rotation was
statistically greater than the control group and a moderate effect size
was found, increased hip internal rotation was greater than the range
of potential measurement error among only a minority of females
with PFP.
Females with PFP demonstrated 4.8° greater knee external rota-
tion at the time of the vertical impact peak than females without
PFP. These results are consistent with a previous report of 4.3° greater
knee external rotation during running, jumping, and single leg squats
[12]. Three females with PFPS demonstrated increased knee internal ro-
tation during running which contributed to unexpectedly high
within-group variability and a statistically insignificant between-group
comparison. Using kinematic reliability estimates previously reported,
the MDD for peak knee transverse plane kinematics during running is
4.5° [30]. Seven females with PFP (35%) demonstrated knee external
rotation values that exceeded the MDD relative to the control group
mean. Among these participants with PFP we can be 95% confident
that this greater knee external rotation was not due to random mea-
surement error. Such females who run with greater knee external ro-
tation magnitudes may experience 10–24% greater PFJS during each
step [10]. However, greater knee external rotation was not a univer-
sal finding among females runners with PFP. This supports the pre-
mise that there may not be a single predominant mechanism of
injury for PFP.
Sagittal plane differences in knee mechanics during running
among females with PFP were not observed in this study. Peak knee
extension moment was similar between groups, which is consistent
with previous studies during walking and running [6,12,31]. Likewise,
peak knee flexion angle was similar between groups agreeing with
several previous investigations during a variety of weight bearing ac-
tivities [5,6,32,33]. If increased PFJS contributes to the etiology or ex-
acerbation of PFP, interventions that focus on sagittal plane knee
mechanics during running may have limited therapeutic effect. Clini-
cians may pose interventions that reduce transverse plane rotations
of the hip and knee joints (and increase patellofemoral contact
area) as potentially more valuable in the treatment of PFP.
There are several notable limitations for this study. First, contact area
estimates were based on MRI data obtained for females with and with-
out PFP as they maintained an isometric contraction of 10% maximal vol-
untary force [22]. Actual contact area for subjects in our study may have
been different and would significantly affect PFJS estimates. However,
the age, height, and weight of the females in our study were very
similar to the females used for our contact area estimate. Second, the
case–control design used in this study prohibits determination of
whether PFP group running mechanics were a cause or effect of pain.
Prospective studies are necessary to indentify running mechanics that
contribute to PFP as well as compensatory changes that are most often
employed after the onset of symptoms. Third, all participants ran in
standardized footwear, regardless of their usual footwear or foot type,
to minimize potential effects due to differences between shoe types.
The change in footwear may have facilitated altered kinematics among
participants not accustomed to the characteristics of the standardized
shoes. Fourth, female participants in this study were 18–35 years old,
and our findings may not be generalizable to males or females of differ-
ent ages and activity levels. Finally, skin movement artifact may have
influenced the position of motion analysis markers during running, lead-
ing to random hip and knee joint kinematic error for both groups.
In conclusion, PFJS calculated using a sagittal plane model is simi-
lar among females with and without PFP during running. Altered hip
707
and knee transverse plane kinematics during running may increase
PFJS and appear present among some females with PFP. Future stud-
ies that account for the influence of hip and knee transverse plane ki-
nematics on PFJS during dynamic activities appear to be justified.
Funding source
None.
Conflict of interest statement
No authors have any financial or personal relationships with other
people or organizations that could inappropriately influence their work.
Acknowledgements
The authors acknowledge Kaitlin Strauss and Dan Thour for their
assistance with data collection and analysis.
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