ORIGINALARTICLE

PATIENT EXPERIENCES FOLLOWING TOTAL KNEE ARTHROPLASTY IN PESHAWAR,

PAKISTAN: A QUALITATIVE THEMATIC ANALYSIS

Muhammad Waqar¹, Samir Khan Kabir¹, Muhammad Arif ², Wasim Anwar³

How to cite this article

ABSTRACT

OBJECTIVES

Waqar M, Kabir SK, Arif M, Anwar

W. Patient Experiences Following

Total Knee Arthroplasty in Peshawar,

Pakistan: A Qualitative Thematic

Analysis. J Gandhara Med Dent Sci.

2026;13(2):109-115

This study aimed to explore the psychosocial, cultural, and economic factors

that inuence the decision to undergo TKA and the postoperative recovery

process in a resource-limited context.

METHODOLOGY

A qualitative descriptive study was conducted using semi-structured

interviews with 31 patients (16 females, 15 males; aged 48-82 years)

recruited from public and private hospitals between January and May 2025.

Data were analyzed using Braun and Clarke’s reexive thematic analysis

framework. Data saturation was achieved after 31 interviews.

RESULTS

https://doi.org/10.37762/jgmds.13-2.832

Date of Submission: 07-12-2025

Date Revised:

Date Acceptance:

06-03-2026

26-03-2026

²Professor, Department of Orthopaedics

and Spine Surgery, Hayatabad Medical

Complex, Peshawar

Five overarching themes emerged: 1. preoperative suering and fear, 2.

hospital experience amid systemic constraints, 3. inequities in postoperative

rehabilitation, 4. cultural and nancial determinants, and 5. transformative

outcomes post-surgery. Delayed surgical decision-making, reliance on

traditional healing (55%), and signicant nancial burde n (79%

catastrophic expenditure) were prominent ndings.

³Associate Professor, Department of

Orthopaedics and Spine Surgery,

Hayatabad Medical Complex, Peshawar

Correspondence

CONCLUSION

¹Samir Khan Kabir, Assistant Professor,

Department of Orthopaedics and Spine

Surgery, Hayatabad Medical Complex,

Peshawar

TKA in Peshawar involves a complex biopsychosocial journey, shaped by

cultural norms, economic hardship, and limitations in the health system.

Addressing disparities in rehabilitation access and nancial protection is

critical to optimizing outcomes.

+92-345-9060962

wkhan43@gmail.com

KEYWORDS: Total Knee Arthroplasty, Patient Experience, Pakistan,

Qualitative Research, Rehabilitation Access

vital role in pre- and post-operation of TKA.²In their

paper they mention four points which are common

INTRODUCTION

Total Knee Arthroplasty (TKA) is a highly eective

surgical procedure that restores mobility in over 90% of

patients with end-stage knee osteoarthritis globally.¹

This procedure involves replacing a damaged or worn-

out knee joint, often caused by trauma or osteoarthritis,

with an articial implant (prosthesis). The primary

goals of TKA are to reduce pain, increase mobility, and

restore functionality when conservative treatments,

such as medication and physical therapy, have proven

amongst patients in need of TKA, almost every patient

goes through these stages; Putting up and putting o-

Patients endured severe knee pain for years, changing

activity and postponing surgery using alternate

methods, Waiting and worrying - After choosing on

TKR, patients felt anxious and unsure about the

procedure, complications, and recovery, Letting go and

letting in

Patients fought with losing their

independence, but eventually accepted help, support,

and the new knee as part of themselves and Hurting and

hoping - Despite substantial postoperative discomfort,

patients remained hopeful for functional progress and a

higher quality of life.^6,7This series of emotions may be

because of how little people know about the procedure,

and that TKA may seem intimidating in the beginning.

McDonald and co researchers write that patients who

had some knowledge about the procedure before the

ineective.^2,3,4

For

many

patients,

knee

pain

signicantly restricts their ability to perform daily

tasks, such as walking, dressing, cooking, cleaning, and

climbing stairs. The potential benets have been

observed that many patients, especially in developing

countries like Pakistan, hesitate to undergo the

procedure, even when experiencing severe pain.⁵

Patients in Khyber Pakhtunkhwa face additional

barriers due to socioeconomic constraints, cultural operation had less anxiety than those of others.⁸Though

norms, and misconceptions about the procedure. These anxiety in itself does not play a role in a patient's

factors contribute to a reluctance to seek TKA, even physical recovery, it can boost condence, which in

when knee pain signicantly impacts quality of life. turn helps the patient with the steps required for

Jacobson and co believe that race, sex, ethnicity, recovery, such as the rst walk after surgery. In the

socioeconomic status, and educational material play a paper, they write that psychological well-being aects

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J Gandhara Med Dent Sci

109

Patient Experiences Following Total Knee Arthroplasty

the functional outcomes of the surgery. Moreover, they

Age, gender, kind of surgery, and hospital setting all

showed signicant disparities. While older patients

placed greater priority on mobility and pain

management, younger patients were more concerned

with joint longevity and returning to leisure activities.

While men were more concerned with lifting big

objects, women were more interested in most

categories, particularly with self-care and therapy.

While knee patients concentrated on stair climbing, hip

patients were more concerned with sexual function and

dislocation.¹¹It is interesting to note that tertiary centre

patients were more nervous about their interactions

with the surgeon and their expectations for recovery,

and they also thought of themselves as less healthy.

Many patients continued to worry about infections

linked to transfusions despite safety improvements. All

things considered, these results highlight the necessity

of customised preoperative counselling that blends a

core set of knowledge with patient-specic instruction.

They may also serve as a roadmap for creating

improved educational and communication resources.¹¹

In another study by Ballantyne and co, four main

themes surfaced: earlier experiences with healthcare

shaped attitudes; arthritis changed personal identity;

social interactions inuenced decisions; and arthritis

was frequently evaluated in the context of other

comorbidities. Some people dreaded surgery because of

bad experiences in the past or a lack of support from

their doctors, while others downplayed arthritis by

considering it to be age-related or less serious than

other illnesses. Family support frequently decreased the

perceived need for surgery. To defend against

avoidance, participants tended to rely on prior

experiences rather than on expectations for the future.

Social norms and physician communication also

contributed. The study emphasises the intricacy of

decision-making and the necessity of customised

communication, patient-centered education, and more

research contrasting willing and unwilling patients.³

While much of the medical literature has focused on the

clinical outcomes of TKA and the roles of surgeons and

medical procedures, there is limited research on the

patient perspective, particularly in resource-constrained

settings such as Pakistan.¹This study aims to address

this gap by exploring the psychosocial and cultural

factors inuencing patients' experiences with TKA,

focusing specically on patients in Peshawar, Pakistan.

The study seeks to understand why patients are often

reluctant to undergo TKA, even though the procedure

oers signicant potential for pain relief and improved

quality of life. Through semi-structured interviews and

note that patients who were well informed pre-

operatively had their hospital stay cut short by an

average of 2 days.⁸Indicating how eective it can be to

be well educated on the procedure beforehand.

Marcinkowski, Wang, and Dignam write in their paper

that Total Knee Joint Arthroscopy (TKJA) is not just a

surgical procedure but also an emotional journey.⁹They

write that patients need to undergo severe physical and

mental changes to have a new lifestyle, adapting to their

new physiological needs. In the paper they summarize

the journey into three stages; Enduring - Patients

demonstrate determination and stoicism during the

lengthy wait for surgery and the arduous recuperation,

Thinking Twice - They reevaluate their expectations,

adjust to new realities, and learn to accept assistance,

balancing independence and social support, Keeping

Faith - Recovery is fuelled by a strong mindset, self-

belief, and hope, even when outcomes or timelines

deviate from expectations.⁹TKR for patients is a very

personal and emotional journey rather than a medical

event. It entails enduring extended periods of hardship,

reconsidering independence and coping techniques, and

believing in a brighter future. Recovery success

depends on both physical and psychological resilience,

social support, and realistic preparedness for the

challenges

ahead.⁹

Although

there

are

some

commonalities in the recovery patterns of individuals,

Macario and colleagues note that this does not always

mean that all patients will recover in the same way.

According to their research, there was a great deal of

variation in the information demands of each patient

having a complete hip or knee replacement, even

though the majority of them had similar major

concerns, such as the need for physical therapy, their

capacity to take care of themselves, and their

anticipated mobility following surgery. Standardised

teaching might not be enough, as some patients

indicated by adding their own queries. This variation

implies that patient education should include

foundational set of pertinent data, supplemented by

material specic to each patient's problems. Given that

more patients have access to the internet, web-based

platforms could be a useful means of disseminating

evidence-based information that is both generic and

individualised. However, even when there is no data,

doctors must agree on concise, understandable

responses to commonly asked questions for this to be

successful.¹⁰Trousdale and his co-authors write that,

apart from education, other factors also play a role in

anxieties.¹¹While most patients undergoing total hip or

knee arthroplasty were not very worried, this study

examined their concerns and found that postoperative

pain, recovery time, walking ability, and return to

activities were consistently ranked as the top concerns.

qualitative analysis, this research will capture the

diverse

psychosocial

dynamics

and

structural

challenges that inuence patients’ decisions before,

during, and after surgery. By focusing on these patient

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110

Patient Experiences Following Total Knee Arthroplasty

experiences, the study will provide valuable insights were also held to evaluate the analytical process and

into how cultural and economic factors shape thematic structure critically. Ethical approval for the

healthcare decisions in this context.

study was obtained from the relevant institutional

review board, and all procedures adhered to principles

of condentiality, voluntary participation, and cultural

sensitivity. Ethical approval was obtained from the

METHODOLOGY

This study employed a qualitative descriptive design to Hayatabad Medical Complex Ethics Committee (App

gain an in-depth understanding of patient experiences No. 2551-2, Dated: 24-12-2024). All participants were

following total knee arthroplasty within a real-world, assured of their condentiality, and interviews were

resource-constrained

context.

Participants

were conducted in accordance with cultural norms and

purposively recruited from both a public tertiary care gender sensitivities. Audio recordings and data les

hospital and a private healthcare facility in Peshawar to were securely stored and accessible only to the research

capture variation in socioeconomic status and team.

healthcare access. A total of 31 patients who had

undergone unilateral TKA within the previous 6 months

were included, ensuring that participants had sucient

RESULTS

recall of their surgical journey while still engaged in From the analysis of the semi-structured interviews,

recovery. Eligibility criteria included being over 40 five themes emerged. These themes reect the diverse

years of age, mentally competent to participate in an and complex experiences of patients undergoing Total

interview, and uent in either Urdu or Pashto, allowing Knee Arthroplasty (TKA) and highlight the profound

participants to express their experiences in their inuence of psychological, cultural, social, and

preferred language. Data were collected through in- financial factors. The following results were derived

depth semi-structured interviews conducted by trained from the thematic analysis of the data collected.

bilingual researchers. Interviews ranged from 45 to 120 Theme 1: Preoperative Experiences - “ A Prison of

minutes and were guided by an interview protocol that Pain and Fear”

explored preoperative experiences of pain and decision- Participants described their preoperative lives as being

making, perceptions of hospital care, challenges during trapped in a relentless cycle of physical dysfunction and

postoperative recovery, and the inuence of cultural emotional distress. Many experienced profound

and nancial factors. All interviews were audio- functional impairment, making even basic activities,

recorded with participant consent and transcribed such as prayer and hygiene, monumental tasks.

verbatim. For illiterate participants, informed consent Sub-theme: Physical Pain and Dependency

procedures were adapted by reading the consent form Nasreen, a 52-year-old patient from a public hospital,

aloud, and verbal consent was documented in the recalled:

presence of a witness, ensuring ethical inclusivity. Data "I crawled to the bathroom for 3 years. Prayer?

analysis was conducted using Braun and Clarke‘s Impossible - bending felt like walking on broken glass."

reexive thematic analysis approach, which emphasizes This sense of loss and dependency was a recurring

iterative engagement with the data and the active role of theme in the interviews, where the emotional toll

the researcher in meaning-making⁶. Transcripts were compounded the physical limitations.

repeatedly reviewed to achieve immersion, followed by Sub-theme: Fear and Psychological Suering

inductive coding to identify patterns and recurring The psychological suering was often tied to the fear of

concepts. Codes were then organized into broader surgery, with many patients experiencing heightened

themes that captured the underlying structure of anxiety as they imagined potential complications. Wali,

participants‘ experiences. NVivo software was utilized a 71-year-old patient, spoke of the constant dread he

to facilitate data management and organization; lived with:

however, the analytical process remained interpretive "I dreamt of paralysis and my sons selling land for my

rather than mechanistic. Reexivity was maintained treatment - I would rather die than burden them."

throughout the analysis, with researchers documenting Many participants delayed surgery for 5.3±2.1 years on

their assumptions and perspectives to minimize bias average, often seeking non-medical alternatives such as

and enhance transparency. To ensure rigor, several consultations with traditional healers (hakeems) (55%

of participants). This preference for indigenous healing

methods reects the region's cultural importance of

traditional practices. The delay exacerbated both

physical deterioration and psychological distress.

Theme 2: Hospital Stay - “Human Kindness in

Scarcity”

strategies were employed. Member checking was

conducted with a subset of participants to validate the

accuracy of interpretations, leading to renement of

certain

themes,

particularly

those

postoperative recovery and family support. Peer

debrieng sessions with qualitative research experts

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Patient Experiences Following Total Knee Arthroplasty

Theme 4: Cultural and Financial Inuences - “Chains

Despite resource constraints in public hospitals, many

participants shared stories of profound compassion

from healthcare workers that helped them cope during

their hospital stay.

of Duty and Debt”

Cultural expectations and nancial constraints were

signicant factors shaping both the decision to undergo

surgery and the recovery process.

Sub-theme: Compassion Amid Scarcity

Sub-theme: Gendered Cultural Expectations

Female participants reported intense pressure to resume

Gul, a 63-year-old patient, recalled a moment of

vulnerability and kindness:

"Sister Aisha, despite being petite herself, used all of their domestic duties as soon as possible, often despite

her

force

support

when

fell." medical advice to rest. Zarqa,

48-year-old

recalled:

This sense of solidarity and human connection stood homemaker,

"By day 12, I was cooking for my family of 15. My

mother-in-law said, ‘A woman's worth is in her work.’"

Sub-theme: Financial Strain of Surgery

out as a signicant emotional support for patients

during an otherwise dicult time.

Sub-theme: Systemic Challenges and Resilience

While

participants

public

hospitals

aids,

noted Many participants also highlighted the nancial burden

and of surgery, with 79% reporting that the cost of the

overcrowding,

insucient

mobility

surgery, rehabilitation, and time o work consumed

understang, many reframed these challenges in light

of the support they received from healthcare sta. This over 40% of their total household income. Sher, a 76-

theme encapsulates the balance between institutional year-old patient, poignantly shared:

scarcity and individual compassion that shaped the "We sold our only cow. Now my grandchildren drink

hospital experience in Peshawar.

tea without milk."

Financial strain, particularly in lower-income families,

was a persistent theme that added stress during both the

preoperative and postoperative phases.

Table 1: Hospital Resource Comparison

Resource

Public

1:18

Private

Nurse-patient ratio

1:4

1.1±0.4

68%

Sub-theme: Financial Obligations of Men

Days to physiotherapy

Pain control adequate

5.2±2.3

37%

Men in the region, particularly in rural areas, felt a

heightened sense of responsibility to return to work

quickly to support their families, even at the expense of

Theme 3: Postoperative Recovery - “Abandoned

After Surgery”

their

health.

One

farmer

stated:

While the surgery itself was seen as successful by most "Men are expected to keep working even at an old age.

participants, many reported feeling abandoned during I cannot let them (the whole family) down." The

the postoperative recovery phase, primarily due to a financial strain of the procedure further exacerbated this

lack of standardized physiotherapy.

pressure to regain mobility quickly.

Sub-theme: Disparity in Rehabilitation Access

Yousuf, a 70-year-old public hospital patient, shared his

frustration:

Table 2: Qualitative Synthesis

Preoperative

Postoperative

"Will I die under anesthesia?"

"Can homeopathic medicine

avoid surgery?"

"When can I kneel in prayer?"

"Can I use a squatting toilet?"

"No therapist visited. My son had to request many times

before someone actually showed up."

This disparity in access to rehabilitation created a

divide between those who received structured follow-up Theme 5: Reflections - “Pain Was Hell, But I would

and those who had to manage their recovery Do It Again.”

independently, often relying on family members for Despite the profound challenges they faced - ranging

from years of preoperative suering to dicult

postoperative recovery - many participants expressed a

support.

Sub-theme: Family Support and Self-reliance

Due to gaps in institutional support, 87% of participants deep sense of gratitude and transformation following

reported relying solely on family members for their TKA.

assistance with postoperative exercises. While family Sub-theme: Transformation and Relief

support was invaluable, it could not replace Parveen, a 61-year-old patient, shared:

"I could walk pain-free after 10 years, it almost felt

surreal."

professional rehabilitation, leaving patients feeling

abandoned during this critical phase of recovery.

Sub-theme: Flexion Contractures

For many, regaining mobility and independence

Eleven patients in public hospitals developed exion restored not only their physical well-being but also their

contractures greater than 15°,

condition that mental and emotional health.

Sub-theme: Endorsement for Early Intervention

significantly delayed their functional recovery. This

was a self-reported nding based on participant

Many participants advocated for early intervention,

accounts, as clinical records were not accessed for advising others not to delay surgery out of fear or

verification.

financial hesitation. These recommendations served as

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Patient Experiences Following Total Knee Arthroplasty

a powerful endorsement of TKA.

patients awaiting joint replacement and can negatively

impact postoperative recovery.¹⁵McDonald et al.

further demonstrated that structured preoperative

education signicantly reduces anxiety and improves

recovery outcomes.⁸Importantly, this study extends

these ndings by situating psychological distress within

a broader socioeconomic context, where fear is

compounded by nancial vulnerability and familial

responsibility, an aspect that is less emphasized in high-

income settings. The hospital experience described by

Table 2: Qualitative Synthesis

Theme

Preoperative

Pain/Fears

Sub-theme

Example Quote

Pain and Anxiety

Before Surgery

"I was in constant

pain, and the thought

of surgery made me

terried."

Hospitalization

Experiences

Staff Support

During Stay

"The nurses were

kind, but the lack of

equipment was

frustrating."

Rehabilitation

Challenges

Difculty

Accessing

Therapy

"I could not get

physiotherapy

participants reects

critical interplay between

systemic constraints and interpersonal care. Despite

limited resources, patients consistently valued empathy

and support from healthcare providers. This nding

aligns with research by Doyle et al., which established

that patient experience is strongly associated with

clinical eectiveness and safety outcomes.¹⁶In low-

resource settings, where infrastructural limitations are

common, the relational dimension of care becomes

even more signicant, often compensating for systemic

deficiencies. One of the most signicant contributions

of this study is the identication of disparities in

regularly, which

delayed my

recovery."

Cultural/Financial

Impacts

Financial Burden

of Surgery

"I had to sell our

livestock to aord

the surgery and

rehab."

Reections on

Surgery

Post-surgery

Transformation

"I could walk pain-

free after 10 years; it

almost felt surreal."

DISCUSSION

postoperative

rehabilitation.

Delayed

absent

The present study provides

comprehensive

physiotherapy in public sector settings resulted in

increased dependency on family members and

suboptimal recovery outcomes. These ndings are

consistent with those of Artz et al., who emphasized the

importance of structured physiotherapy in improving

functional outcomes following TKA.¹⁷Similarly,

Minns Lowe et al. demonstrated that early and

exploration of patient experiences following total knee

arthroplasty (TKA) in a resource-constrained, culturally

embedded context, highlighting that surgical outcomes

are shaped not only by clinical factors but also by

psychological,

sociocultural,

and

structural

determinants. The ndings demonstrate that prolonged

preoperative suering, inequities in postoperative care,

and culturally mediated expectations collectively dene

the patient journey, reinforcing and extending existing

literature. A key nding of this study is the signicant

delay in surgical decision-making, with patients

enduring severe pain for prolonged periods prior to

undergoing TKA. This observation aligns with the

conceptual framework proposed by Jacobson et al., who

supervised

rehabilitation

signicantly

enhances

mobility and reduces complications.¹⁸The present

study adds to this body of evidence by highlighting how

inequitable access to rehabilitation services creates a

form of ―rehabilitation disparity,ǁ particularly in low-

resource healthcare systems. Cultural and gender

dynamics played a crucial role in shaping patient

experiences. Female participants reported early

resumption of domestic responsibilities, often at the

expense of recovery, while male participants faced

pressure to return to work. These ndings are consistent

with broader literature on gender disparities in

healthcare, where social roles inuence both access to

care and recovery trajectories.^12,14Ibrahim et al. also

reported signicant racial and gender disparities in

TKA utilization, emphasizing that sociocultural factors

are critical determinants of surgical outcomes.¹⁴The

described

phase of prolonged tolerance and

postponement of surgery.²Similar patterns have been

reported by Hawker et al. and Ackerman et al., who

identified that willingness to undergo joint replacement

is strongly inuenced by perceived need, expectations,

and social context.^12,13The reliance on traditional

healers observed in this study further supports the

findings of Ibrahim et al., who demonstrated that

cultural beliefs and misconceptions signicantly delay

surgical uptake across diverse populations.¹⁴ From a

behavioral perspective, these ndings are consistent

with the Health Belief Model, wherein perceived

barriers, particularly fear and nancial cost, outweigh

perceived benets. Psychological distress was another

dominant theme, with patients reporting fear of

paralysis, dependency, and nancial burden. These

findings are consistent with prior evidence indicating

that anxiety and emotional distress are prevalent among

present

study

extends

this

understanding

demonstrating how these norms directly interfere with

adherence to postoperative rehabilitation protocols. The

financial burden emerged as a pervasive theme, with

the majority of participants experiencing catastrophic

health expenditures. This nding is consistent with

global evidence on out-of-pocket healthcare spending in

low- and middle-income countries.⁵Xu et al.

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Patient Experiences Following Total Knee Arthroplasty

CONCLUSIONS

highlighted that catastrophic health expenditure can

push households into poverty, particularly in the

absence of nancial protection mechanisms.¹⁹In the

context of TKA, this nancial strain inuences not only

Total knee arthroplasty in Peshawar is not merely a

clinical intervention but

deeply contextualized

experience shaped by sociocultural expectations,

economic realities, and health system constraints. While

the procedure oers substantial benets, these are

mediated by disparities in access to care and

rehabilitation. Addressing these challenges requires a

access to surgery but also postoperative recovery, as

patients may forgo rehabilitation due to cost constraints.

This underscores the concept of “nancial toxicity,”

which is increasingly recognized as

critical

determinant of health outcomes in surgical care.

Despite these challenges, patients reported profound

improvements in mobility and quality of life following

TKA. These ndings are consistent with large-scale

studies demonstrating high satisfaction rates and

comprehensive,

integrates clinical excellence with cultural sensitivity

and systemic reform.

patient-centered

approach

that

functional

gains

after

TKA.^1,12

Importantly,

participants‘ retrospective endorsement of surgery

suggests a shift in risk perception following successful

outcomes, a phenomenon also described by Hawker et

al.¹²This highlights the importance of patient education

and expectation management in bridging the gap

between preoperative fear and postoperative reality.

Collectively, these ndings support a biopsychosocial

and health systems perspective on TKA, emphasizing

that surgical success depends on addressing not only

clinical factors but also structural inequities and

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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LIMITATIONS

2020;21:1-9.

https://doi.org/10.1186/s12891-020-03455-3

PMID: 32646444.

While this study provides valuable insights into patient

experiences following TKR in Peshawar, certain

limitations must be acknowledged. First, the research

was conned to a single city, which may limit the

generalizability of ndings to other regions of Pakistan

with dierent healthcare infrastructures or cultural

dynamics. Moreover, the sample was restricted to

Pashto- and Urdu-speaking patients. The perspectives

of orthopedic surgeons and rehabilitation professionals

were not captured. Including these voices could have

enriched the analysis by oering a multidimensional

perspective on the challenges and strategies along the

surgical care pathway. Future studies should aim to

incorporate a broader geographic scope and a more

diverse set of stakeholders.

7. Cregar WM, Khazi ZM, Lu Y, Forsythe B, Gerlinger TL.

Arthrobrosis after TKA and risk of revision surgery.

Arthroplasty. 2021;36(1):339-344.

https://doi.org/10.1016/j.arth.2020.07.018 PMID: 32861715.

8. McDonald S, Page MJ, Beringer K, et al. Preoperative

education for hip or knee replacement. Cochrane Database Syst

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AUTHORS CONTRIBUTION

Muhammad Waqar - Concept & Design; Data Acquisition;

Drafting Manuscript; Final Approval

16. Doyle C, Lennox L, Bell D. A systematic review of evidence on

the links between patient experience and clinical outcomes.

BMJ Open. 2013;3:e001570. https://doi.org/10.1136/bmjopen-

2012-001570 PMID: 23293244 PMCID: PMC3549241.

Samir Khan Kabir - Concept & Design; Data Acquisition;

Drafting Manuscript; Final Approval

Muhammad Arif - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

Wasim Anwar - Concept & Design; Data Acquisition; Drafting

Manuscript; Supervision; Final Approval

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

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COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.

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