Osteopathic technique
HVLA thrust
High Velocity, Low Amplitude · manipulation
What it is
A short, fast, small-range thrust into a joint, after the joint has been positioned and the slack taken up. One technique within OMT.
How it’s done
The patient is positioned so the target joint is localised and the surrounding joints are “locked”. The clinician takes up the slack to the restrictive barrier, then gives one short, fast, small-range thrust. A cracking sound often happens.
HVLA techniques (Gibbons & Tehan)
41 techniques from the book’s contents. LMP = ligamentous myofascial positioning (the book’s term). Step-by-step set-ups are in the book and its videos; they are not reproduced here.
Cervical and cervicothoracic · 21
| No. | Level | Technique | Hold · position |
|---|---|---|---|
| 8.1 | C0–1 | Anterior and superior thrust in a curved plane; contact on occiput | Chin hold · supine · LMP |
| 8.2 | C0–1 | Anterior and superior thrust in a curved plane; contact on atlas | Chin hold · supine · LMP |
| 8.3 | C1–2 | Rotation thrust | Chin hold · supine · LMP |
| 8.4 | C1–2 | Rotation thrust | Cradle hold · supine · LMP |
| 8.5 | C2–7 | Up-slope gliding | Chin hold · supine |
| 8.6 | C2–7 | Up-slope gliding (variation) | Chin hold · supine |
| 8.7 | C2–7 | Up-slope gliding | Cradle hold · supine |
| 8.8 | C2–7 | Up-slope gliding; reversed primary and secondary leverage | Cradle hold · supine |
| 8.9 | C2–7 | Up-slope gliding | Sitting · operator in front |
| 8.10 | C2–7 | Up-slope gliding | Sitting · operator to the side |
| 8.11 | C2–7 | Down-slope gliding | Chin hold · supine |
| 8.12 | C2–7 | Down-slope gliding | Cradle hold · supine |
| 8.13 | C2–7 | Down-slope gliding | Sitting · operator to the side |
| 8.14 | C7–T3 | Rotation gliding | Prone · operator at side of couch |
| 8.15 | C7–T3 | Rotation gliding | Prone · operator at head of couch |
| 8.16 | C7–T3 | Rotation gliding (variation) | Prone · operator at head of couch |
| 8.17 | C7–T3 | Side-bending gliding | Sitting |
| 8.18 | C7–T3 | Side-bending gliding | Sitting · LMP |
| 8.19 | C7–T3 | Side-bending gliding | Side-lying |
| 8.20 | C7–T3 | Side-bending gliding | Side-lying · LMP |
| 8.21 | C7–T3 | Extension gliding | Sitting · LMP |
Before any of these, work through the neck safety screen.
Thoracic spine and rib cage · 8
| No. | Level | Technique | Hold · position |
|---|---|---|---|
| 9.1 | T4–9 | Extension gliding | Sitting · LMP |
| 9.2 | T4–9 | Flexion gliding | Supine · LMP |
| 9.3 | T4–9 | Rotation gliding | Supine · LMP |
| 9.4 | T4–9 | Rotation gliding; short-lever | Prone |
| 9.5 | Ribs 1–3 | Gliding thrust | Prone |
| 9.6 | Ribs 4–10 | Gliding thrust | Supine · LMP |
| 9.7 | Ribs 4–10 | Gliding thrust; short-lever | Prone |
| 9.8 | Ribs 4–10 | Gliding thrust | Sitting · LMP |
Lumbar and thoracolumbar · 7
| No. | Level | Technique | Hold · position |
|---|---|---|---|
| 10.1 | T10–L2 | Rotation gliding thrust; neutral positioning | Side-lying |
| 10.2 | T10–L2 | Rotation gliding thrust; flexion positioning | Side-lying |
| 10.3 | L1–5 | Rotation gliding thrust; neutral positioning | Side-lying |
| 10.4 | L1–5 | Rotation gliding thrust; flexion positioning | Side-lying |
| 10.5 | L1–5 | Rotation gliding thrust; neutral positioning | Sitting |
| 10.6 | L5–S1 | Thrust direction set by the facet joint plane; neutral positioning | Side-lying |
| 10.7 | L5–S1 | Thrust direction set by the facet joint plane; flexion positioning | Side-lying |
Pelvis · 5
| No. | Level | Technique | Hold · position |
|---|---|---|---|
| 11.1 | SIJ | Left innominate posterior | Prone · LMP |
| 11.2 | SIJ | Right innominate posterior | Side-lying |
| 11.3 | SIJ | Left innominate anterior | Supine |
| 11.4 | SIJ | Sacral base anterior | Side-lying |
| 11.5 | Sacrococcygeal | Coccyx anterior | Side-lying |
What is the “crack”?
When the joint surfaces are pulled apart quickly, pressure in the joint fluid drops and a new gas cavity forms. That is the sound. It is not a bone going back into place.
Myth vs evidence
Ross, Bereznick & McGill · Spine 2004 · Sørensen et al. · JOSPT 2023
How might it help?
- Leading model: the thrust triggers a nervous-system response (spinal cord and brain) that turns pain down.
- Pain sensitivity drops for a short time, even away from the treated area.
- Honest caveat: in patients, this effect was not clearly better than sham manipulation (low-quality evidence).
Bialosky et al. · JOSPT 2018 · Coronado et al. · J Electromyogr Kinesiol 2012 · Gevers-Montoro et al. · Eur J Pain 2021 · Aspinall et al. · Chiropr Man Therap 2019
Spinal coupling (Fryette’s laws)
Used to set up and name spinal techniques. A teaching model: real lumbar spines often don’t follow it.
Spinal locking
Long-lever HVLA locks the segments around the target so the thrust gathers at one joint. Press Play on each tab to see how.
Evidence by condition
Grades from our HVLA evidence review. HVLA isn’t shown on condition pages yet, so these grades appear only here.
| Condition | Grade | In short |
|---|---|---|
| Chronic low back pain | Grade B Moderate evidence: supported by at least one good study | About as good as other recommended treatments. Small extra benefit for function at 1 month, not at 6–12 months. |
| Acute neck pain | Grade C Limited evidence: indirect or low-quality support only | Helped in 6 small, mixed trials; only minor, short-lived side effects reported. |
| Mechanical neck pain (vs mobilisation) | Grade C Limited evidence: indirect or low-quality support only | No clear advantage over mobilisation for pain, disability or patient-rated change; slightly more neck movement in some directions. 5 small trials, low-quality evidence. |
Cautions
Don’t thrust (absolute)
- Fracture, bone cancer or bone infection at the site
- Osteoporosis
- Joint instability (incl. severe rheumatoid arthritis, Down syndrome)
- Cauda equina or conus signs (e.g. new numbness or weakness)
- Fused joints
- Patient says no
Take extra care (relative)
- Blood thinners or bleeding disorders
- Pregnancy, recent surgery, acute whiplash
- Disc herniation
- Vascular risk (atherosclerosis, clotting risk)
Neck: Before any neck thrust, work through the full neck safety screen below. In short: serious harm is rare, but an early artery dissection can look like ordinary neck pain or headache, so take a careful history, examine, get informed consent and use minimal force in mid-range. Open the neck screen
StatPearls · HVLA lumbar 2023 · StatPearls · HVLA cervical 2022 · Rushton et al. · JOSPT 2023 · Gorrell et al. · BMJ Open 2023 · Church et al. · Cureus 2016
Always check the condition page’s red flags first. Refer-first conditions have no technique cards.
Before a neck thrust: safety screen
Based on the IFOMPT Cervical Framework (2020), an international consensus for manual therapists, reviewed by physiotherapy, osteopathy and chiropractic bodies.
Serious harm after a neck thrust is rare. The bigger danger is missing a problem that is already there: a tear in the wall of a neck artery (a dissection) can feel just like ordinary neck pain or headache in its early stage.
There is no single “safe to thrust” test. Screening is clinical reasoning: a careful history, a physical exam planned around what you heard, then a shared decision with the patient.
IFOMPT Cervical Framework · 2020 · Rushton et al. · JOSPT 2023 · Hutting et al. · Musculoskelet Sci Pract 2018Why we screen: a dissection can already be there
StatPearls · Vertebral artery dissection 2025 · IFOMPT Cervical Framework · 2020 · Thomas et al. · JOSPT 2015Quick checklist, every neck thrust
- History covers vascular risk factors, recent trauma (including recent neck manipulation) and any new or unusual neck pain or headache.
- Asked about brief neurological symptoms now or in the last month: dizziness, vision change, speech or swallowing trouble, numbness, drop attacks.
- Blood pressure measured.
- Neurological and cranial nerve exam done; no upper motor neuron signs.
- Upper neck stability considered (trauma, rheumatoid arthritis, Down syndrome, connective tissue disease).
- No absolute contraindication; relative ones weighed.
- A clear reason for HVLA, and it is the best option compared with mobilisation, thoracic HVLA or exercise.
- Informed consent: risks, benefits and alternatives explained; consent given before treatment and recorded.
- Set-up: mid-range, minimal force, patient supine so you can see their face and eyes; pre-thrust hold checked for comfort.
- Patient monitored during and after, and told which symptoms mean “get help now”.
The 6-step reasoning path
- 1
Patient interview
Any sign of a vascular cause, or another serious problem that rules out neck manual therapy?
Yes → refer (back) to a doctor.
- 2
Physical exam
Do the findings match your hypothesis from the interview?
No → look for more evidence; consider other hypotheses.
- 3
Indication
Is there a reason to use neck mobilisation or manipulation?
No → advice, other treatment or referral.
- 4
Contraindications and risk factors
Any contraindication, precaution or risk factor for a serious adverse event?
Yes → other treatment or referral.
- 5
Risk–benefit, with the patient
Is mobilisation or manipulation the right treatment for this person?
No → other treatment.
- 6
Treat, then evaluate
Right technique and force; check the effect and how the patient felt.
Serious event → emergency services or doctor. Minor event → rethink with the patient. No benefit → change plan or refer.
1 · History: what raises suspicion
- Neck pain or headache that is sudden and “unlike any other”.IFOMPT Cervical Framework · 2020
- Neck pain or headache that keeps getting worse and isn’t eased by painkillers.IFOMPT Cervical Framework · 2020
- Recent minor trauma or neck strain, including a recent neck manipulation: seen in 64% of dissection patients vs 7% of controls in the 3 weeks before.Thomas et al. · Man Ther 2011 · Thomas et al. · JOSPT 2015
- Brief neurological symptoms in the past month: reported by 67% of dissection patients before admission.Thomas et al. · JOSPT 2015
- Younger adults: in people aged 30–45, dissection may cause 10–25% of strokes.StatPearls · Vertebral artery dissection 2025 · Biller et al. (AHA/ASA) · Stroke 2014
- Family history of dissection, a connective tissue disorder (Ehlers–Danlos, Marfan) or fibromuscular dysplasia.StatPearls · Carotid artery dissection 2022 · StatPearls · Vertebral artery dissection 2025
- Watch while they talk: unsteady gait, poor balance, upper motor neuron or cranial nerve signs, or holding the head as if the neck is unstable.IFOMPT Cervical Framework · 2020
Risk factors: dissection
| Recent trauma | 40–64% |
| Vascular anomaly | 39% |
| Smoker (now or past) | 30% |
| Migraine | 23% |
| High cholesterol | 23% |
| Recent infection | 22% |
| High blood pressure | 19% |
| Oral contraceptive | 11% |
| Family history of stroke | 9% |
Risk factors: non-dissection
| Smoker (now or past) | 65–74% |
| High blood pressure | 53–74% |
| High cholesterol | 53% |
| Migraine | 19% |
| Vascular anomaly | 16% |
| Family history of stroke | 14% |
| Oral contraceptive | 9% |
| Recent infection | 9% |
| Recent trauma (incl. recent OMT) | 7% |
% = share of patients who had the event and had this factor (IFOMPT Tables 2–3). It is not a risk ratio; use it to recognise patterns. No risk factors does not mean no risk: spontaneous dissections often have none.
Pattern: Dissection: often younger, with recent trauma or migraine. Non-dissection events (e.g. atherosclerosis): classic heart and vessel risk factors.
IFOMPT Cervical Framework · 20202 · Symptoms and signs
What a dissection is: inside the artery wall
StatPearls · Vertebral artery dissection 2025 · Biller et al. (AHA/ASA) · Stroke 2014Symptoms in dissection
| Headache | 81% |
| Neck pain | 57–80% |
| Visual disturbance | 34% |
| Pins and needles, arm | 34% |
| Dizziness | 32% |
| Pins and needles, face | 30% |
| Pins and needles, leg | 19% |
Signs: vertebral artery dissection
| Unsteadiness / ataxia | 67% |
| Speech problems | 44% |
| Leg weakness | 41% |
| Arm weakness | 33% |
| Trouble swallowing | 26% |
| Nausea / vomiting | 26% |
| Facial palsy | 22% |
| Dizziness | 20% |
| Droopy eyelid (ptosis) | 19% |
| Loss of consciousness | 15% |
Signs: internal carotid dissection
| Droopy eyelid (ptosis) | 60–80% |
| Arm weakness | 65% |
| Facial palsy | 60% |
| Leg weakness | 50% |
| Speech problems | 45% |
| Unsteadiness / ataxia | 40% |
| Nausea / vomiting | 30% |
| Drowsiness | 20% |
| Loss of consciousness | 20% |
% of patients with that event who had the feature (IFOMPT Tables 4, 6 and 7).
Vertebral artery
Neck pain with headache at the back of the head. Brainstem and cerebellum signs: dizziness, unsteadiness, trouble swallowing or speaking, double vision, vertigo, hearing loss on one side.
StatPearls · Vertebral artery dissection 2025 · IFOMPT Cervical Framework · 2020Internal carotid artery
One-sided neck, face, jaw or temple pain. Horner syndrome (droopy eyelid, small pupil), cranial nerve palsies, pulsing noise in the ear (pulsatile tinnitus).
Biller et al. (AHA/ASA) · Stroke 2014 · StatPearls · Carotid artery dissection 2022 · IFOMPT Cervical Framework · 2020Other vascular problems that can look like neck pain or headache
| Giant cell arteritis | Temple headache, scalp tenderness, jaw or tongue pain when chewing, vision change |
| Reversible cerebral vasoconstriction | Severe “thunderclap” headaches |
| Subarachnoid haemorrhage | Sudden severe headache, stiff neck, light sensitivity, vomiting, one-sided weakness |
| Jugular vein thrombosis | Neck pain, headache, fever, swelling at the angle of the jaw |
| Carotid atherosclerosis or aneurysm | Pain and tenderness over the carotid (carotidynia), TIA |
3 · Physical exam
Blood pressure
Measure it properly. There is no single cut-off: stroke risk rises the higher it goes. A sudden high reading can be a sign of acute artery injury. If it’s newly high, advise them to see their GP. In dissection patients under 38, high blood pressure was not linked.
Neurological and cranial nerve exam
Look for upper motor neuron signs and cranial nerve palsies. Parts of the exam have at least moderate reliability. A normal exam does not rule out a dissection.
Carotid artery
Listen (auscultate) rather than pressing on both sides, which can trigger a vagal reaction. A pulse that differs side to side, a pulsing swelling (aneurysm) or a bruit is significant. The vertebral artery can’t be checked this way. A normal result doesn’t rule anything out.
Refer
If the history and exam support a vascular cause, refer for immediate medical assessment, following local policy. Work-up uses duplex ultrasound, CT angiography or MR angiography.
Positional (VBI) tests, e.g. sustained rotation
Not recommended as a screening test- The IFOMPT framework removed provocative positional tests in 2020: they can’t predict who is at risk.IFOMPT Cervical Framework · 2020
- Accuracy is poor: 4 low-quality studies, sensitivity 0–57%, specificity 67–100%.Hutting et al. · Man Ther 2013
- The extension–rotation test had 0% sensitivity for reduced vertebral artery flow.Côté et al. · J Manipulative Physiol Ther 1996
- In healthy people, test positions and sustained rotation didn’t change blood flow inside the skull (transcranial Doppler).Moll et al. · J Man Manip Ther 2023 · Hutting, Kranenburg & Kerry · Musculoskelet Sci Pract 2020
The debate
- The other view: Thomas and Treleaven argue the tests check whether backup (collateral) blood flow is enough in certain head positions, so they may still have a place.Thomas & Treleaven · Musculoskelet Sci Pract 2020
- The StatPearls cervical HVLA chapter (2022) still advises a vertebral artery test before neck manipulation, while noting its accuracy is doubtful.StatPearls · HVLA cervical 2022
What IFOMPT keeps: put the patient in the pre-thrust position first and hold it, checking comfort and any unusual response. This is a comfort check, not proof of safety.
IFOMPT Cervical Framework · 20204 · Upper neck instability
- Think about it after trauma, and in rheumatoid arthritis, Down syndrome or connective tissue disease. All of these are on the absolute list below.StatPearls · HVLA cervical 2022
- Rheumatoid arthritis: 10.4% of 240 patients had atlantoaxial subluxation; a third of those with neck involvement had no neck pain.Alp et al. · Musculoskeletal Care 2024
- Down syndrome: in 80 adults, 11.2% had atlantoaxial and 17.5% atlanto-occipital instability on X-ray, but only 3.8% had symptoms.El-Khouri et al. · World Neurosurg 2014
- Tests: the membrane tests had the best accuracy, but no instability test has been checked in primary care. Sharp–Purser in rheumatoid arthritis: specificity 96%; sensitivity 88% when the slip was over 4 mm.Hutting et al. · Phys Ther 2013 · Uitvlugt & Indenbaum · Arthritis Rheum 1988
5 · Contraindications to neck HVLA
Don’t thrust (absolute)
- Acute fracture or dislocation
- Acute soft-tissue injury or ligament rupture
- Instability (incl. rheumatoid arthritis, Down syndrome)
- Acute myelopathy
- Chiari malformation
- Ankylosing spondylitis
- Joint fused by surgery or disease
- Recent surgery
- Osteoporosis
- Infection (e.g. osteomyelitis)
- Tumour or bone metastasis
- Connective tissue disease
- Vertebral artery abnormality or vascular disease
- Anticoagulant therapy
- Patient says no
Stop and reason it through (relative)
- Acute disc herniation
- Acute whiplash
- Hypermobility syndromes
- Any symptom made worse by neck movement
- Dizziness or vertigo
- Drop attacks
- Double or blurred vision, visual disturbance
- Trouble speaking (dysarthria) or swallowing (dysphagia)
- Pins and needles in the face or mouth
- Nausea
- Tinnitus
- Previous diagnosis of vertebrobasilar insufficiency
- Symptoms that worsen with manipulation
Lists differ between sources: the cervical chapter lists anticoagulants as absolute, the lumbar chapter as relative. Many “relative” items (dizziness, vision change, speech or swallowing trouble) also appear among the signs of artery problems above, so explain them before any neck thrust.
StatPearls · HVLA cervical 2022 · IFOMPT Cervical Framework · 20206 · Informed consent
- Informed consent is a voluntary decision made knowing the benefits and risks.Ahpra shared Code of conduct · 2022
- Explain in plain words: what HVLA is, the expected benefit, the material risks, and other options (mobilisation, exercise, no treatment).Ahpra shared Code of conduct · 2022 · IFOMPT Cervical Framework · 2020
- Give time for questions and check they understood.Ahpra shared Code of conduct · 2022 · IFOMPT Cervical Framework · 2020
- Get express consent, spoken or written, before you start. Don’t ask halfway through a technique.IFOMPT Cervical Framework · 2020
- Consider written consent for higher-risk procedures. Record what you discussed and their consent, every time.Ahpra shared Code of conduct · 2022 · IFOMPT Cervical Framework · 2020
- New technique or new diagnosis: do the full consent again. Same treatment next visit: re-check it verbally.IFOMPT Cervical Framework · 2020
- They can withdraw at any time, and a no is respected. Avoid a one-size-fits-all form: tailor the risks to the person.IFOMPT Cervical Framework · 2020 · Ahpra shared Code of conduct · 2022
Numbers you can share
61%
of 465 patients reported at least one reaction after spinal manipulation: mostly headache, stiffness or local soreness. Most started within 4 hours and settled within 24 hours. Upper neck manipulation raised the odds (OR 3.2).
Cagnie et al. · Man Ther 200422–41%
had short-lived minor or moderate reactions after manual therapy (22% in trials, 41% in cohort studies). Major events: about 0.13%.
Carnes et al. · Man Ther 20100
serious adverse events in 50,276 neck manipulations in a UK survey. Worst-case estimate: about 6 per 100,000 manipulations. Within 7 days, headache in up to about 4 per 100 visits.
Thiel et al. · Spine 2007= control
In trials, neck HVLA caused no more mild or moderate side effects than control treatments. But trials are too small to catch rare serious events, and only 61% of 154 trials reported harms at all.
Pankrath et al. · Pain Physician 2024 · Gorrell et al. · BMJ Open 20230.4–5
per 100,000 patients: best estimate of vertebral artery dissection linked to manual therapy. General population rate: 0.75–2.9 per 100,000.
IFOMPT Cervical Framework · 2020Benign reactions are common and serious events are rare. Tell patients both as part of consent.
Swait & Finch · Chiropr Man Therap 20177 · Doing the thrust safely
- Use the least force you can: low amplitude, short lever.
- Stay in mid-range. Take care at end range, especially extension and rotation. For rotation thrusts, use coupled side-bending and slight compression to find the level in mid-range.
- Keep the patient comfortable. Supine with the head on a pillow is encouraged: you can watch their face and eyes and keep talking.
- Hold the pre-thrust position first and check for comfort or any unusual response.
- Watch the response to every neck movement, not just the thrust.
- Be honest about your skill. If you can’t do it safely, don’t; refer to a colleague trained in the technique.
Alternative
Consider the thoracic spine instead: thoracic manipulation improved neck pain, disability and range in the short term (18 trials, 914 patients), with no serious side effects reported.
Yang et al. · Technol Health Care 2024 · IFOMPT Cervical Framework · 2020Artery stretch
In cadavers, vertebral artery stretch during neck HVLA is smaller than during normal range-of-motion testing and far below the point where it tears (up to 3.8% vs up to 12.5%). These were healthy arteries; the main worry is one that is already damaged.
Herzog et al. · J Electromyogr Kinesiol 2012 · Fagundes, Duarte & Herzog · Clin Biomech 2025 · IFOMPT Cervical Framework · 20208 · After the thrust, and if something goes wrong
Expected: soreness, stiffness, headache or tiredness, usually within hours and gone in about a day.Cagnie et al. · Man Ther 2004
Warning signs. Warning signs of a serious event: a sharp rise in headache or neck pain, nausea or vomiting, dizziness, or changed sensation, during treatment or within 48 hours, often before clear neurological signs. If in doubt, keep monitoring for up to 48 hours.
Leung et al. · J Bodyw Mov Ther 2025Emergency. Signs of stroke, or the patient becomes unresponsive: start your emergency plan (CPR if needed) and call an ambulance (000 in Australia). Have the plan ready and keep CPR training current.
IFOMPT Cervical Framework · 2020Serious events were also reported after gentle mobilisation, exercise, acupuncture and massage, not only manipulation.Leung et al. · J Bodyw Mov Ther 2025
Afterwards: document it, explain openly to the patient what happened, and report it as required.Ahpra shared Code of conduct · 2022
9 · Does neck manipulation cause artery dissection? The evidence
- People with neck pain or headache from an early dissection often see a practitioner before their stroke. Chiropractic and GP visits were linked to later stroke to a similar degree in under-45s.Cassidy et al. · Spine 2008 · Cassidy et al. · J Stroke Cerebrovasc Dis 2017
- Meta-analysis: a small association (OR 1.74) on very low-quality evidence, most likely explained by neck pain being an early symptom of dissection.Church et al. · Cureus 2016
- AHA/ASA statement: an association exists, but it is unclear whether manipulation causes dissection or the dissection was already there.Biller et al. (AHA/ASA) · Stroke 2014
- US claims data: over-65s had no higher risk after neck manipulation than after a GP visit. In younger insured adults the overall risk was very low, with mixed results across comparisons.Whedon et al. · BMC Geriatr 2022 · Whedon et al. · Eur Spine J 2023
- Newest (2026): in 431,492 matched patients with new neck pain or headache, dissection was less common after chiropractic manipulation than after an ibuprofen prescription; vertebral artery dissection did not differ.Trager et al. · Chiropr Man Therap 2026
- Case reports: 44.8% of 134 serious events were judged preventable with proper screening; 10.4% were not preventable. No clear patient profile was found, though women may be at higher risk of dissection.Puentedura et al. · J Man Manip Ther 2012 · Kranenburg et al. · Musculoskelet Sci Pract 2017
Risk is very low but not zero. Screening can’t catch every case. Its main job is to spot a dissection that is already happening.
Sources
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PubMed citations built and checked on 23 Oct 2026. One German meta-analysis (Lange 2025) is not in PubMed; it was checked against its DOI record on 25 Oct 2026.