In the early 2000's, Professor Stuart McGill's research on commonly prescribed 'core' exercises led to his proposal that the partial crunch, side plank, and bird dog are ideal for people with low back pain. Sometime after these three little exercises were dubbed "McGill's Big 3". In this article, I will argue that labelling these three little exercises as BIG seems uniquely unfair to them. Most things labelled 'big' are, well, BIG! Like on the morning we are about to get married our best man or women says "Big Day!"; or when Zuckerberg and cronies invented FaceBook they were like, "this is going to be BIG!"; or when the 1st nuclear bomb was about to be dropped they were like, "this ones going to be BIG!" (sadly, they were right). This unfair label places expectations on these three little exercises they just can't (and don't) live up too.

 

 

Before proceeding let us tease out the 'McGill' from the exercises. Professor Stuart McGill is not a small figure in our industry. Nor is he a little man. I've had first hand experience working with Professor McGill and have had the pleasure of hosting him on five or six separate occasions (memory lapsing 😣 getting old) - offering his courses "Low Back Disorders" and "Building the Ultimate Back" to clinicians, coaches and trainers in Victoria, Vancouver (1-2x), Calgary (2x), and Moncton, Canada. McGill had an incredibly productive research career, published three commendable books, and disseminated numerous high quality continuing education courses to coaches, trainers and clinicians. McGill has made big contributions to the health and fitness industry - I believe he was the first to highlight (or, certainly the first to widely disseminate) how internal forces created by our own muscles can impart heavy loads on our spine. He's enhanced our understanding of spine biomechanics, including how commonly prescribed exercises impart loads on the spine.

 

 

In the following critique please keep in mind I am not criticizing the man or his work; I am criticizing the notion that we should refer to these three exercises as the "Big 3". Or any other of the ridiculous adjectives used to describe them, i.e. the ultimate, the best, the key. The notion of course is that these three exercises are disproportionately essential or helpful. To be honest, I imagine that if Stu were to read this article he would likely agree with most if not all of what I will say here. The contents of his work as a whole makes the "Big 3" minuscule in relation to the significance to the rest. In fact, I don't think it is Stu who has blown these exercises out of proportion; he wasn't even the first to popularize them. Yoga, the fitness and rehab industry had been performing these exercises for decades prior. Unfortunately, managing or preventing back pain is not simple, and labelling three little exercises as  "big" or "best" - the panacea for low back pain - is inaccurate, misleading, and potentially harmful. 

 

 

In this article I will discuss:

 

• The origin of McGill's Big 3 and how we can use the same principles in other exercise selections.
• The difference between managing, rehabilitating, and primary prevention of low back pain, and performance based 'core' stabilization exercise.
• The considerations that may give rise to other, high value options.
• McGill's truly big contributions to those rehabilitating or suffering from low back pain.

 

The Origin of McGill's Big 3

 

McGill was a professor and researcher in the field of spine biomechanics. One of his areas of research was to study how commonly prescribed back rehabilitation or 'core' strengthening exercises load our spine. His research highlighted and led to a better understanding of how external (i.e. a heavy box being lifted) and internal forces (i.e. the forces our own muscles exert on our body) contribute to load on our spine. McGill felt that many exercises being prescribed by the fitness industry and practitioners treating back pain patients were potentially harmful. He proposed that a better understanding of the loads placed on the spine during commonly prescribed exercise would help practitioners select more effective and safe exercises for patients with back pain. For example, his research demonstrated that the forward plank and sit up produce incredibly high compressive load on the lumbar intervertebral discs. He proposed that patients suffering from low back pain may have an intolerance to these loads, and by performing them regularly they may cause or perpetuate low back pain. Therefore,

McGill proposed the partial crunch, side plank and bird-dog were good exercises for back pain due to the fact that they:

 

1. Expose the spine - or more specifically the intervertebral discs (IVD) - to minimal compression load. And while doing so,

2. Maximize muscle activity (EMG) of the primary muscles that stabilize the lower back.

The premise is to maximize muscle activity to improve stability with minimum compression load.

 

Many have debated the effectiveness or necessity of these exercises, however, based on McGill's stated priority for patients with low back pain the "Big 3" exercises do indeed active 'the core' muscles while keeping compression load relatively low. For some, this understanding is essential.

 

The origin of McGill's Big 3 exercises for people with low back pain had nothing to do with defining the "best core stability exercises". This is a blanket statement we simply cannot make. For whom are these 'core' exercises the best for? Are they "best" for an elite and highly capable human; an elite weightlifter, rugby or hockey player, for example? Perhaps we can agree that the demands of these exercises are too contextually limited and vastly outmatched by the demands of dynamic athletic endeavours, unless the athlete in question is a highly capable billiards player. Perhaps we can also agree there are a myriad of safe and effective options that would challenge the 'core' in a variety of movement patterns and positions that are more task specific and scalable to the demands and abilities of the athlete. 

 

 

McGill's "Big 3" for Managing and Rehabilitating Back Pain, Primary Prevention, and Performance

 

This section could be a textbook, or three. In fact it is. Thus I will aim to be succinct in this summary.

 

1. Managing and Rehabilitating Back Pain:

 

Our knowledge and understanding of how exercise imparts acute, chronic and cumulative load on the spine is essential, and not intuitive. It is the reason all fitness and rehab professionals should read McGill's books, and the reason why the partial crunch, side plank and bird dog are good starting points for those who don't have extensive knowledge and understanding of low back pain.

 

However, we must ask what we truly get out of these exercises. One answer is: a proportionately small amount of compression load on the spine (specifically, the IVDs of the lumbar spine) with a proportionately high amount of muscle activity of the primary muscles that directly stabilize it. The goal is to achieve a sufficient baseline of stability to control our spine. If a person with back pain is compression intolerant and incapable of creating the tension necessary to stabilize it, the "Big 3" is the proposed solution. I argue however that on the whole, the "Big 3" is the size of an apple - not as small as a peanut but not big like watermelons. 

 

In my opinion, practitioners prescribing these exercises or advocating for them, including my prior self, have made an assumption that it is the specific exercises that are essential. However, anyone who has seen McGill coach these exercises will know that great detail and attention is paid to the quality that the client performs them. He coaches the shit out of these exercises, in the best possible way. He also oozes an essence of confidence - as in 'this is the right thing for you' and 'you can do this'. He brings so much more to the interaction than the exercise. So is it the exercise, the coaching, or other functional factors that are related but not essentially gained from the exercise, that helps the patient?

 

The process of coaching an exercise includes: 

 

1) Careful attention paid to a person, which contains many social, emotional and cognition nuggets that can help (sometimes hinder), and,

2) Careful attention paid to the quality of postural stabilization, movement control, and coordination.

 

If we influence how a person moves; if we change the ability to efficiently control and coordinate movement and the quality of postural stabilization, does exercise selection matter? 

 

Well, I think it does. But not often in the way the "big 3's" benefits have been defined.

 

In the coursework Dynamic Neuromuscular Stabilization's (DNS) coursework, we are fond of saying: 

 

"it's not about the exercise!"

 

Many who judge DNS from afar believe it is about rolling around like babies. It is not. DNS is fundamentally focused on the neurophysiological mechanisms of postural stabilization; defining the quality of human postural stabilization and locomotor function; and using this understanding to derive rehabilitation methods to improve it. The babies bit comes from the fact we reference the healthy developing baby to better understand this; the rolling around like babies bit comes from the fact we can utilize developmental exercise as an implement to build better coordination and control. We believe many of these positions and patterns contain distinct benefits and ideal access points into influencing it. But we also know we can train it in other positions and patterns that do not directly mimic infant development.

 

In the practice of DNS principles, it is common to completely abate a persons pain during movement or exercise "x,y or z" simply by improving their coordination and control over it, raising the question of whether it is the movement or the control over it that matters most. Evaluating a patient to determine their positions and patterns of intolerance, and positions and patterns of preference, is essential. Consideration should be given to the external and internal forces associated with specific exercises. This gives us a best chance of selecting the best starting points for exercise intervention. However, consider the possibility that exercise selection may matter only as much as it exposes a specific challenge to the control and coordination of the body performing it. When control and coordination - the primary postural stabilization mechanisms of the body are restored - the previously painful pattern(s) become pain-free. Importantly for the clinician and patient, this gives incredible flexibility to prescribe and practice an array of exercises the promotes better control, to abate movement-related pain, in a variety of contexts. Limiting our options to the Big 3 limits our ability to see more direct and pertinent paths toward building a better quality to postural stabilization, which can be applied to numerous exercise options, freeing the possibilities for a more resilient, pain free movement system.

 

If we boil the "Big 3" down to its basic, movement-based attributes we have:

 

Bird-Dog:

• Contralateral 'support' (anti-gravity) function of the upper and lower extremities.
• Control of the lumbo-pelvic-hip complex during a stepping forward and backward movement of the lower extremity. The same being true for the shoulder complex in relation to the thorax and lumbar spine. When the lower extremity extends backward, for example, the stabilization mechanism of the trunk and support function of the opposite extremities maintains control of the lumbar spine and pelvis such that 'functional' hip extension be achieved. Ideally, sufficient stability can be achieved to allow full hip hip extension with minimal deviation of the lumbar spine and pelvis. Ideally, this occurs in a highly efficient pattern that requires minimal muscle activity that is proportionate for the required task.
• It is worth noting in typical human movement the stepping forward function in a contralateral pattern is in-phase; meaning the opposite lower and upper extremity step forward in phasic function at the same time. Whereas the bird-dog has the extremities moving in the opposite direction. It is also atypical to have the toes forward on the supporting extremity; a baby crawling will engage the entire lower extremity from knee through dorsal tibia and foot. 
• The expressed goal is to train the multifidus and erector spinae.
• I would argue the primary benefit is training the integration of sagittal stabilization with contralateral support and associated activity of the oblique chains, while resisted the moment of extension created by the activation of the multifidus and erector spinae.

 

Side Plank:

• Primarily ipsilateral 'support' (anti-gravity) function of the upper and lower extremities. In parenthesis because again this is not typical support function. I say primarily because in the side plank both lower extremities engage support function, with one hip working to maintain hip abduction and the other hip working to maintain hip adduction, in a predominantly linear pattern (i.e. pure hip abduction without extension and external rotation; pure hip adduction without hip flexion and internal rotation)
• The expressed goal is to train the oblique muscles, transverse abdominis, and quadratus lumborum (add gluteus medius if you will).
• I would argue the primary benefit is activating, creating stiffness and stability of the lateral trunk, hip and shoulder, while coordinating this with sagittal stabilization to regulate and control position of the head, thorax and pelvis, relative to each other. 

 

Partial Crunch:

• In good coordination, lifting the head, shoulders and thorax from the supporting surface (in the sagittal plane) challenges the integrated function of intra-abdominal pressure and co-activation of the abdominal wall. 
• In good coordination the pelvis remains still; fixed to the floor as the vector of pull from the abdominal wall pulls the upper body towards the pelvis.
• The expressed goal is to train the rectus abdominis and obliques; to facilitate an abdominal brace.
• I would argue the benefit relates to the ability to co-activate and create sufficient IAP to maintain a fixed point in the area around thoracolumbar junction and pelvis, to train the ability to pull the upper body toward the lower, without collapsing into an 'hourglass' strategy, causing excessive flexion of the lumbar spine; or without paradoxically extending the thoracolumbar junction and losing the connection between rib cage and pelvis (open scissors strategy).

*note: this is not an exhaustive list.

 

It is important to note that according to DNS principles, training optimal stabilization function means training for minimum muscle activity for the required task. In other words, the above exercises should be trained to build efficiency and coordination of the muscles that control movement and postural function. Locking shit down and training stiffness as the strategy is not optimal for the same reasons McGill defined - it increases the internally generated loads imparted on our spine. Granted, some patients require training to increase stiffness when they lack the ability to create any; in this circumstance 'hard coaching' and exercise to facilitate more tension, more activity, and more stiffness is ideal to reach the standard of sufficient, not excessive.

 

The point I want to bring forward by highlighting these basic attributes of these exercises is that the exercise is a tool to access traits. One should access if there are alternative and effective exercises - positions or movements - that we can train that build the same; perhaps even better. Or perhaps not better but the same, in which case having more options is better than less, so we can match the incredible diversity of our patient or clients.

 

 

A weak spot of the core stabilization benefits of the 'Big 3':

 

None of these exercises are ideal to promote or challenge the optimal coordination and control of intra-abdominal pressure and the lower abdominal wall / pelvic floor; known mechanisms that underpind trunk stabilization. The supine 3-month position, popularized by Dynamic Neuromuscular Stabilization, is the best-fit exercise for training these qualities. Emphasis, however, is on quality. 

 

 

Once we gain control in this position we often branch into sitting, standing, squats, hinges, lunges, split stance rows, turning, oblique sit, bear, standing high knee marching, single-leg RDLs, all of which can commonly be performed without pain or provocation, have high carry over into daily activities, are readily modified - regressed, progressed and scaled to a patients present capacity and tolerance.

 

Your next question should be "where's the research"?

 

Hundreds of studies have demonstrated that a variety of exercise based programs can be helpful for patients with back pain. This includes walking programs, general exercise, specific stabilization exercise, and yes, McGill's Big 3. I would argue that before calling these three little exercises "big" we should have a large amount of research to support the same. To date, no research has established the three exercises being essential for patients with low back pain, in comparison to other stabilization based exercise programs.

 

 

How about treating sciatica? 

 

There are some rumblings on the internet that these exercises are good for sciatica. In patients with nerve-root compression and sciatica, the position and load on the spine and lower extremity can be incredibly important due to the mechanics of the foramen and nerve root. Understanding these mechanisms along with a thorough evaluation is what guides the prescribed treatment and exercise. In acute sciatica, however, low back stability - or stabilization based exercise - is not our first priority. Addressing and relieving nerve root compression is.

 

In acute low back pain with sciatica:

• a person with an upward sliding dysfunction of a lumbar nerve root will be provoked by the partial crunch.
• a patient with poor extension control, an extension intolerance or sciatica - nerve root compression with closing dysfunction at the foramen - may not tolerate the bird-dog well. 
• The side plank is often performed with the lumbar spine in neutral toward extension; in a patient who has lumbo-pelvic hip control can excessively side bend their trunk as they raise their hips from the floor and provoke their low back pain. Other options can at times be a better starting point. The most common cause of sciatic is nerve root compression at the foramen. Some patients don't tolerate one side of the side plank due to a closing mechanism at the foramen. 

 

This should be clearly stated - It is inappropriate for fitness professionals to independently manage a patient with radiating symptoms into the lower extremity.  Sadly, I have seen many patients with troubling symptoms who were previously and poorly advised by a personal trainer, kinesiologist or coach who felt it was in their scope and expertise to do so.  One memorable patient had symptoms suggestive of cauda equina syndrome - a condition that can result in loss of bowel and bladder function, numbness, tingling and weakness to the lower extremities. This patient saw a certified McGill practitioner, virtually no less, who proceeded to advise them on how to rehabilitate their back pain and sciatica. She was prescribed "bracing" strategies to prevent spine flexion. Unfortunately this patients symptoms were provoked by extension. It is essential that patients with neurological signs or symptoms be evaluated by a practitioner with the knowledge and skills to perform a neurological exam, render a differential diagnosis, apply treatment or refer accordingly. 

 

 

2. Primary Prevention: 

 

This is a tough one, because no research has established any specific exercise or group of exercises as preventative for low back pain, including the "big 3". Here's what we do know:

 

In the realm of prevention - general health parameters and habits matter most.

 

Humans are designed to move, regularly, every day. When humans move regularly, humans are healthy. General health crosses over to back health. Therefore, health habits matter. A myriad of research has now demonstrated correlations between general health, obesity, and systemic inflammation, and the prevalence and severity of degenerative changes in joints, tendons, intervertebral discs, the brain and cardiovascular system.

 

Specific to exercise habits and activity levels:

• In a systematic review and meta-analysis, Shiri et al (7) demonstrated that "Exercise alone reduced the risk of LBP by 33% (risk ratio = 0.67, 95% confidence interval: 0.53, 0.85; I² = 23%, 8 RCTs, n = 1,634), and exercise combined with education reduced it by 27% (risk ratio = 0.73, 95% confidence interval: 0.59, 0.91; I² = 6%, 6 trials, n = 1,381). The severity of LBP and disability from LBP were also lower in exercise groups than in control groups. 
  
  
• Galmés-Panadés et al (2) demonstrated in a group of school aged children a reduced risk for LBP in those who participate in cardiovascular exercise regularly, and who have a higher V02max.
  
  
• In their systematic review, Alzahrani et al (3) provided "evidence there is an inverse association between physical activity and LBP. Medium activity level was associated with lower prevalence of LBP. These findings may have implications for including moderate doses of physical activity in the management and prevention of LBP in clinical practice."
  
  
• Päivi et al (8) demonstrated a high: BMI, blood pressure, triglycerides, cholesterol and smoking demonstrated a graded association with low back pain. They concluded "this study adds to the evidence for the atherosclerosis-LBP hypothesis, particular in men".
  
  
• Research suggests "that obesity is related to and a causal agent of a multitude of metabolic, cardiovascular, visceral, oncological, and osteoarticular diseases. There is solid epidemiological evidence that links obesity and degenerative spinal disease with chronic lumbar pain." and "high BMI has causal associations with risks of various dorsopathies. Weight control is a good measure to prevent the development of dorsopathies, especially in the obese population."

 

The only data we have on exercise type suggests improved intervertebral disc health with walking and endurance running. Not much can be said about other forms of exercise; my guess is it will fall in line with what we know from the epidemiological data on activity and health status in general, i.e. moderation is likely best in the realm of strength training; cardiovascular exercise and health are likely essential with best evidence for walking and running regularly. 

 

Several studies have reported the impact of occupational work load and the risk for low back pain. Heneweer's systematic review (1) reports: heavy workload, the accumulation of loads, and the frequency of lifts were moderate to strong risk factors for low back pain. Awkward work postures also demonstrated strong correlations to low back pain.

 

Sleep quality has also shown correlation to low back pain; good sleep quality appears protective and compromised sleep is associated with adverse outcomes in chronic low back pain patients (4). 

 

Last but not least on the topic of prevention - one should not underestimate the effects of mental, social and emotional health.

• Silva et al (8) found that the "association between cardiorespiratory fitness and low back pain is anxiety-dependent". They report "participants with self-reported anxiety and low cardiorespiratory fitness had 3.7 times more risk for having low back pain when compared with participants with self-report anxiety and high cardiorespiratory fitness. Among participants with self-reported anxiety, moderate CRF was associated with an 70% greater risk of having low back pain than those with high CR. For participants without self-reported anxiety, no association was found between the risk of having low back pain and CRF. According to the results identified in the present study, participants with self-reported anxiety who had low and moderate CRF had higher risks of low back pain than those with high CRF.
  
  
• The award winning study by Klyne et al (5) demonstrated higher acute phase inflammation was a GOOD thing for recovery from an episode of acute low back pain, whereas signs of chronic inflammation and depression increased the risk for more persistent and chronic symptoms. Numerous studies have demonstrated a relationship between depression and chronic low back pain, the mechanisms that underpin this relationship have not been well established, the possibilities include mental/social health effects on sleep quality, chronic and systemic inflammation, and general health habits that relate to the same. 

 

To summarize, there is no evidence to suggest McGill's Big 3" is "best" for the health and prevention of low back pain. The available evidence strongly suggests that general health habits are primary, which includes a mix of cardiovascular, strengthening and stretching exercise, and the myriad of options available. 

 

Performance:

 

This is pretty simple - an individuals capacity to create the necessary stiffness and stability should match or exceed the demands imposed on them. Perhaps the "big 3" could take a small portion of a program to establish the basic foundations of control it requires. Simply consider the time investment and the return on that investment, in contrast to other options, and program accordingly.

 

McGill's Real Gift to the World

 

#1 - McGill's careful attention to provocative positions and patterns: 

 

McGill has emphasized the first step in treating a patient with back pain is to understand and alleviate provoking factors - the movements, positions or loads that worsen their back pain. Watching McGill interview patients and seeing the level of detail he aspires to understanding what is provoking their pain was inspiring. Beyond the patient interview McGill would commonly have patients demonstrate their daily and work-related tasks and activities that provoke their pain so that he would have a keen understanding of how they move during those activities, developing a best possible understanding of the loads being placed on their back and symptomatology.

 

McGill understood the best treatment and exercise can't beat shitty movement patterns or postures that repeatedly provoke a patients pain through the day. He also understand the need to understand and maximize the activities a person can perform without pain, or that improve pain. In this regard, having a keen understanding of spine biomechanics is incredibly helpful and sometimes essential - arguably no one has spread education on this topic broader than McGill and few have contributed as much to our understanding of spine biomechanics and exercise.

 

It is worth noting here, that there is a dark side to focusing so greatly on things that provoke a patients pain. Fear. Many people with low back pain may become hyper-vigilant about their posture and create stiffness to a degree that is unhealthy. In these people, the excessive protection to avoid "harmful" postures or movements create excessive stiffness and tension that is highly unnatural, limits movement variability, and is known to increase compression loading on the spine.  These characteristics have known correlations to persons suffering from chronic low back pain. Abating fear, promoting natural movement, teaching and learning that movement and load are safe is essential for optimal long term outcomes. It is important to understand and assess a patients positions and patterns of provocation; left unchecked this can perpetuate a patients low back pain. There can be a period whereby we mindfully avoid or limit certain movements or postures as a short term measure, with the ultimate goal to better control movement, build resilience, and the freedom to move through all positions and patterns of movement, without pain or the fear of it.

 

 

#2 - "There is no such thing as Non-Specific Low Back Pain"

McGill's stubbornly, perhaps tad bit arrogantly insists that he (and therefore we) can identify the cause of all patients mechanical low back pain. This attitude and character traits leads to McGill to an incredibly comprehensive assessment. McGill believes, and I agree, that there is no such thing as "Non-Specific Low Back Pain". Rather there are only some patients in which a cause of their low back pain remains unidentified or ill defined. It is thus a practitioners job to identify within each individual patient the primary drivers perpetuating their low back pain (keeping in mind nociplastic pain mechanisms may be at play). This attitude and these traits are the foundation for why McGill has become famous for his 3 hour appointments. Although arguably unnecessary and sub-optimal for reasons I will leave aside for now, we must admire the pursuit. The message I receive here is "pursue a diagnosis that makes sense and makes a difference, and leave no rock unturned until you do".

 

In Summary:

 

 

These three little exercises were promoted for their application to patients with low back pain. There is no evidence to demonstrate they are superior to other specific exercises. We should aim to understand the mechanisms that provoke and relieve a patients pain; we should seek better stability, stamina, strength, control, coordination, and load tolerance. To do this, we should explore a variety of meaningful movements that challenge and develop the same. The 'big 3' remain reasonable options that should be at the disposal for healthcare providers and sufferers of low back pain. In most circumstances, the mechanisms of their benefit are not likely specific to the exercise.

 

 

 

1. Heneweer H, Staes F, Aufdemkampe G, van Rijn M, Vanhees L. Physical activity and low back pain: a systematic review of recent literature. Eur Spine J. 2011 Jun;20(6):826-45. doi: 10.1007/s00586-010-1680-7. Epub 2011 Jan 9. PMID: 21221663; PMCID: PMC3099170.
2. Galmés-Panadés AM, Vidal-Conti J. Association between Physical Fitness and Low Back Pain: The Pepe Cross-Sectional Study. Children (Basel). 2022 Sep 4;9(9):1350. doi: 10.3390/children9091350. PMID: 36138660; PMCID: PMC9498200.
3. Alzahrani, H., Mackey, M., Stamatakis, E. et al. The association between physical activity and low back pain: a systematic review and meta-analysis of observational studies. Sci Rep 9, 8244 (2019). https://doi.org/10.1038/s41598-019-44664-8
4. Kelly GA, Blake C, Power CK, O'keeffe D, Fullen BM. The association between chronic low back pain and sleep: a systematic review. Clin J Pain. 2011 Feb;27(2):169-81. doi: 10.1097/AJP.0b013e3181f3bdd5. PMID: 20842008.
5. Klyne DM, Barbe MF, van den Hoorn W, Hodges PW. ISSLS PRIZE IN CLINICAL SCIENCE 2018: longitudinal analysis of inflammatory, psychological, and sleep-related factors following an acute low back pain episode-the good, the bad, and the ugly. Eur Spine J. 2018 Apr;27(4):763-777. doi: 10.1007/s00586-018-5490-7. Epub 2018 Feb 19. PMID: 29460011.
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   Pages 93-102, ISSN 2529-8496, https://doi.org/10.1016/j.neucie.2017.12.003.
   (https://www.sciencedirect.com/science/article/pii/S2529849617300539)
7. Rahman Shiri, David Coggon, Kobra Falah-Hassani, Exercise for the Prevention of Low Back Pain: Systematic Review and Meta-Analysis of Controlled Trials, American Journal of Epidemiology, Volume 187, Issue 5, May 2018, Pages 1093–1101, https://doi.org/10.1093/aje/kwx337
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