Archive for category Mirror

[Abstract] Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation

Abstract:

The paper suggests a therapeutic device for hemiparesis that combines robot-assisted rehabilitation and mirror therapy. The robot, which consists of a motor, a position sensor, and a torque sensor, is provided not only to the paralyzed wrist, but also to the unaffected wrist to induce a symmetric movement between the joints. As a user rotates his healthy wrist to the direction of either flexion or extension, the motor on the damaged side rotates and reflects the motion of the normal side to the symmetric angular position. To verify performance of the device, five stroke patients joined a clinical experiment to practice a 10-minute mirroring exercise. Subjects on Brunnstrom stage 3 had shown relatively high repulsive torques due to severe spasticity toward their neutral wrist positions with a maximum magnitude of 0.300kgfm, which was reduced to 0.161kgfm after the exercise. Subjects on stage 5 practiced active bilateral exercises using both wrists with a small repulsive torque of 0.052kgfm only at the extreme extensional angle. The range of motion of affected wrist increased as a result of decrease in spasticity. The therapeutic device not only guided a voluntary exercise to loose spasticity and increase ROM of affected wrist, but also helped distinguish patients with different Brunnstrom stages according to the size of repulsive torque and phase difference between the torque and the wrist position.

Source: Robot-assisted mirroring exercise as a physical therapy for hemiparesis rehabilitation – IEEE Conference Publication

Advertisements

, , , , , , , , ,

Leave a comment

[Abstract] EEG-guided robotic mirror therapy system for lower limb rehabilitation – IEEE Conference Publication

Abstract:

Lower extremity function recovery is one of the most important goals in stroke rehabilitation. Many paradigms and technologies have been introduced for the lower limb rehabilitation over the past decades, but their outcomes indicate a need to develop a complementary approach. One attempt to accomplish a better functional recovery is to combine bottom-up and top-down approaches by means of brain-computer interfaces (BCIs). In this study, a BCI-controlled robotic mirror therapy system is proposed for lower limb recovery following stroke. An experimental paradigm including four states is introduced to combine robotic training (bottom-up) and mirror therapy (top-down) approaches. A BCI system is presented to classify the electroencephalography (EEG) evidence. In addition, a probabilistic model is presented to assist patients in transition across the experiment states based on their intent. To demonstrate the feasibility of the system, both offline and online analyses are performed for five healthy subjects. The experiment results show a promising performance for the system, with average accuracy of 94% in offline and 75% in online sessions.

Source: EEG-guided robotic mirror therapy system for lower limb rehabilitation – IEEE Conference Publication

, , , , , , ,

Leave a comment

[Abstract] Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion 

Abstract

Objective

To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain.

Design

Single-blind case series.

Setting

Three outpatient physical therapy clinics.

Participants

Patients with shoulder pain and limited AROM (N=69).

Intervention

Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder.

Main Outcome Measures

We measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy.

Results

There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°.

Conclusions

A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.

Source: Immediate Effects of Mirror Therapy in Patients With Shoulder Pain and Decreased Range of Motion – Archives of Physical Medicine and Rehabilitation

, , , , , , ,

Leave a comment

[Abstract] Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study 

To investigate the effectiveness of mirror therapy combined with neuromuscular electrical stimulation in promoting motor recovery of the lower limbs and walking ability in patients suffering from foot drop after stroke.

Randomized controlled study.

Inpatient rehabilitation center of a teaching hospital.

Sixty-nine patients with foot drop.

Patients were randomly divided into three groups: control, mirror therapy, and mirror therapy + neuromuscular electrical stimulation. All groups received interventions for 0.5 hours/day and five days/week for four weeks.

10-Meter walk test, Brunnstrom stage of motor recovery of the lower limbs, Modified Ashworth Scale score of plantar flexor spasticity, and passive ankle joint dorsiflexion range of motion were assessed before and after the four-week period.

After four weeks of intervention, Brunnstrom stage (P = 0.04), 10-meter walk test (P < 0.05), and passive range of motion (P < 0.05) showed obvious improvements between patients in the mirror therapy and control groups. Patients in the mirror therapy + neuromuscular electrical stimulation group showed better results than those in the mirror therapy group in the 10-meter walk test (P < 0.05). There was no significant difference in spasticity between patients in the two intervention groups. However, compared with patients in the control group, patients in the mirror therapy + neuromuscular electrical stimulation group showed a significant decrease in spasticity (P < 0.001).

1. Brewer L, Horgan F, Hickey A, Stroke rehabilitation: recent advances and future therapies. QJM 2013; 106: 1125. Google Scholar CrossRef, Medline
2. Bethoux F, Rogers HL, Nolan KJ, The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial. Neurorehabil Neural Repair 2014; 28: 688697. Google Scholar Link
3. O’Dell MW, Dunning K, Kluding P, Response and prediction of improvement in gait speed from functional electrical stimulation in persons with poststroke drop foot. PM R 2014; 6: 587601; quiz 601. Google Scholar CrossRef, Medline
4. Michielsen ME, Selles RW, van der Geest JN, Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair 2011; 25: 223233. Google Scholar Link
5. Samuelkamaleshkumar S, Reethajanetsureka S, Pauljebaraj P, Mirror therapy enhances motor performance in the paretic upper limb after stroke: a pilot randomized controlled trial. Arch Phys Med Rehabil 2014; 95: 20002005. Google Scholar CrossRef, Medline
6. Sousa Nanji L, Torres Cardoso A, Costa J, Analysis of the Cochrane review: interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; 11: CD010820; Acta Med Port 2015; 28: 551553. Google Scholar
7. Thieme H, Mehrholz J, Pohl M, Mirror therapy for improving motor function after stroke. Cochrane Database Syst Rev 2012; 3: CD008449. Google Scholar CrossRef
8. Stein C, Fritsch CG, Robinson C, Effects of electrical stimulation in spastic muscles after stroke: systematic review and meta-analysis of randomized controlled trials. Stroke 2015; 46: 21972205. Google Scholar CrossRef, Medline
9. Knutson JS, Fu MJ, Sheffler LR, Neuromuscular electrical stimulation for motor restoration in hemiplegia. Phys Med Rehabil Clin N Am 2015; 26: 729745. Google Scholar CrossRef, Medline
10. Sabut SK, Sikdar C, Kumar R, Functional electrical stimulation of dorsiflexor muscle: effects on dorsiflexor strength, plantarflexor spasticity, and motor recovery in stroke patients. NeuroRehabilitation 2011; 29: 393400. Google Scholar Medline
11. You G, Liang H, Yan T. Functional electrical stimulation early after stroke improves lower limb motor function and ability in activities of daily living. NeuroRehabilitation 2014; 35: 381389. Google Scholar Medline
12. Kojima K, Ikuno K, Morii Y, Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial. NeuroRehabilitation 2014; 34: 235244. Google Scholar Medline
13. Kim H, Lee G, Song C. Effect of functional electrical stimulation with mirror therapy on upper extremity motor function in poststroke patients. J Stroke Cerebrovasc Dis 2014; 23: 655661. Google Scholar CrossRef, Medline
14. Yun GJ, Chun MH, Park JY, The synergic effects of mirror therapy and neuromuscular electrical stimulation for hand function in stroke patients. Ann Rehabil Med 2011; 35: 316321. Google Scholar CrossRef, Medline
15. Lee D, Lee G, Jeong J. Mirror Therapy with Neuromuscular Electrical Stimulation for improving motor function of stroke survivors: a pilot randomized clinical study. Technol Health Care 2016; 24: 503511. Google Scholar CrossRef, Medline
16. Gregson JM, Leathley M, Moore AP, Reliability of the Tone Assessment Scale and the modified Ashworth scale as clinical tools for assessing poststroke spasticity. Arch Phys Med Rehabil 1999; 80: 10131016. Google Scholar CrossRef, Medline
17. Mehrholz J, Wagner K, Rutte K, Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil 2007; 88: 13141319. Google Scholar CrossRef, Medline
18. Lee HJ, Cho KH, Lee WH. The effects of body weight support treadmill training with power-assisted functional electrical stimulation on functional movement and gait in stroke patients. Am J Phys Med Rehabil 2013; 92: 10511059. Google Scholar CrossRef, Medline
19. Flansbjer UB, Holmback AM, Downham D, Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med 2005; 37: 7582. Google Scholar CrossRef, Medline
20. Sawner KA, LaVigne JM, Brunnstrom S. Brunnstrom’s movement therapy in hemiplegia: a neurophysiological approach. 2nd ed. Philadelphia, PA: Lippincott, 1992. Google Scholar
21. Cho KH, Lee JY, Lee KJ, Factors related to gait function in post-stroke patients. J Phys Ther Sci 2014; 26: 19411944. Google Scholar CrossRef, Medline
22. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67: 206207. Google Scholar CrossRef, Medline
23. Jung IG, Yu IY, Kim SY, Reliability of ankle dorsiflexion passive range of motion measurements obtained using a hand-held goniometer and Biodex dynamometer in stroke patients. J Phys Ther Sci 2015; 27: 18991901. Google Scholar CrossRef, Medline
24. Bakhtiary AH, Fatemy E. Does electrical stimulation reduce spasticity after stroke? A randomized controlled study. Clin Rehabil 2008; 22: 418425. Google Scholar Link
25. Sütbeyaz S, Yavuzer G, Sezer N, Mirror therapy enhances lower-extremity motor recovery and motor functioning after stroke: a randomized controlled trial. Arch Phys Med Rehabil 2007; 88: 555559. Google Scholar CrossRef, Medline
26. Arya KN. Underlying neural mechanisms of mirror therapy: implications for motor rehabilitation in stroke. Neurol India 2016; 64: 3844. Google Scholar CrossRef, Medline
27. Guo F, Xu Q, Abo Salem HM, The neuronal correlates of mirror therapy: a functional magnetic resonance imaging study on mirror-induced visual illusions of ankle movements. Brain Res 2016; 1639: 186193. Google Scholar CrossRef, Medline
28. Gondin J, Brocca L, Bellinzona E, Neuromuscular electrical stimulation training induces atypical adaptations of the human skeletal muscle phenotype: a functional and proteomic analysis. J Appl Physiol 2011; 110: 433450. Google Scholar CrossRef, Medline
29. Jones S, Man WD, Gao W, Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev 2016; 10: CD009419. Google Scholar CrossRef
30. Shin HK, Cho SH, Jeon HS, Cortical effect and functional recovery by the electromyography-triggered neuromuscular stimulation in chronic stroke patients. Neurosci Lett 2008; 442: 174179. Google Scholar CrossRef, Medline
31. Sheffler LR, Chae J. Neuromuscular electrical stimulation in neurorehabilitation. Muscle Nerve 2007; 35: 562590. Google Scholar CrossRef, Medline
32. Weerdesteyn V, de Niet M, van Duijnhoven HJ, Falls in individuals with stroke. J Rehabil Res Dev 2008; 45: 11951213. Google Scholar CrossRef, Medline
33. Yavuzer G, Selles R, Sezer N, Mirror therapy improves hand function in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil 2008; 89: 393398. Google Scholar CrossRef, Medline
34. Alfieri V. Electrical treatment of spasticity. Reflex tonic activity in hemiplegic patients and selected specific electrostimulation. Scand J Rehabil Med 1982; 14: 177182. Google Scholar Medline
35. King TIII. The effect of neuromuscular electrical stimulation in reducing tone. Am J Occup Ther 1996; 50: 6264. Google Scholar CrossRef, Medline
36. Rushton DN. Functional electrical stimulation and rehabilitation—an hypothesis. Med Eng Phys 2003; 25: 7578. Google Scholar CrossRef, Medline
37. Touzalin-Chretien P, Dufour A. Motor cortex activation induced by a mirror: evidence from lateralized readiness potentials. J Neurophysiol 2008; 100: 1923. Google Scholar CrossRef, Medline

Source: Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled studyClinical Rehabilitation – Qun Xu, Feng Guo, Hassan M Abo Salem, Hong Chen, Xiaolin Huang, 2017

, , , , , ,

Leave a comment

[ARTICLE] Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke – Full Text PDF

Abstract.

[Purpose] The purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

[Subjects and Methods] The subjects of this study were 14 patients with stroke (6 females and 8 males). The subjects were assessed by measuring the alpha and beta waves of the EEG (QEEG-32 system CANS 3000). The mirror therapy intervention was delivered over the course of four weeks (a total of 20 sessions).

[Results] Relative alpha power showed statistically significant differences in the F3, F4, O1, and O2 channels in the situation comparison and higher for hand observation than for mirror observation. Relative beta power showed statistically significant differences in the F3, F4, C3, and C4 channels.

[Conclusion] This study analyzed activity of the brain in each area when patients with stroke observed movements reflected in a mirror, and future research on diverse tasks and stimuli to heighten activity of the brain should be carried out.

INTRODUCTION

Dysfunction from upper extremity hemiparesis impairs performance of many activities of daily living (ADL)1) . Individuals affected by stroke will learn or relearn competencies necessary to perform ADL. Traditionally, the practice of skills provided in neurologic rehabilitation has focused on reducing motor impairment and minimizing physical disability2, 3) . Since 2000, various studies of upper extremity function recovery using interventions such as constraint-induced movement therapy, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training have been carried out4) . Such interventions were effective in increasing upper extremity functions in patients with stroke and are continually utilized in the clinical field5–7) .

However, most of the treatment protocols for the paretic upper extremity are labor intensive and require one on one manual interaction with therapists for several weeks, which makes the provision of intensive treatment for all patients difficult8) . Hence, alternative strategies and therapies are needed to reduce the long-term disability and functional impairment from upper extremity hemiparesis9) .

Mirror therapy may be a suitable alternative because it is simple; inexpensive; and, most importantly, patient-directed treatment that may improve upper extremity function8, 10) . Emerging methods in mirror therapy aim to restore motor control through a change in brain function, i.e. motor relearning11, 12) . Voluntary movements of the paretic upper extremity and hand by referring to a mirror activate the bilateral cortex and cause reorganization for other areas around the damaged brain to replace its function, thereby affecting recovery in motor function13) .

Although such methods are promising, they have failed to restore functional motor control for many patients who have experienced stroke. It is important to explore new methods that may facilitate the recovery of brain function and the restoration of more normal motor control14) . Many studies have addressed the neurophysiological effects of mirror therapy. The EEG study gave diverse stimulations to the thumb with or without a mirror to examine which area of the cortex was activated. They observed common activation areas in the primary motor cortex (M1), cingulate, and prefrontal cortex15) . And the study with healthy adults used mirror therapy with functional MRI (fMRI) and showed no difference between the dominant and non-dominant hand. Excitability of M1 ipsilateral to a unilateral hand movement was facilitated by viewing a mirror reflection of the moving hand16) . This finding provides neurophysiological evidence supporting the application of mirror therapy in stroke rehabilitation. Even though, previous studies concerned healthy subjects and had no interventions, a diversity of studies have shown upper extremity functional improvement through mirror therapy8) .

Thus, the purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

Full Text PDF

 

, , , , , , , ,

Leave a comment

[WEB PAGE] How to Regain Movement in a Paralyzed Hand with MusicGlove – Flint Rehabilitation Devices

 

“Can I use MusicGlove if I have no hand movement?”

We hear this question a lot, and we’re obligated to answer with, “Unfortunately MusicGlove requires that you can touch your thumb to at least one of your finger tips and release this grip by a quarter of an inch or more.”

It’s a stiff, clinical response, but it’s the truth about 80% of the time.

Recently we had one woman challenge this notion – and it made us soooo happy!

Margaret, a post rehabilitation exercise specialist, purchased a MusicGlove for her husband, a stroke survivor who had absolutely no movement in his affected hand. He could not lift a single finger.

He was in stage 1 of the Brunnstrom stages of recovery: Flaccidity.

Flaccidity’s Common Misconception

Some stroke survivors are told that there’s no hope for flaccidity, and limiting statements like this should be taken with a grain of salt.

Case in point: Margaret’s husband’s therapist said that he wouldn’t regain any hand movement, and that he would eventually lose all movement and die… What?!?!

We can’t even believe words like that are spoken in the clinic! Obviously this isn’t the norm, but it was still shocking to hear.

Needless to say, Margaret dismissed what the therapist said and started researching her options.

Because the truth is that if you have no movement in your affected hand, it’s still possible to regain movement. You can do whatever you put your mind to, as long as you put in the time and hard work.

And it helps to have a little ingenuity.

A Different Way to Use MusicGlove

Margaret refused to accept that her husband couldn’t regain hand movement, so she took matters into her own hands.

She purchased MusicGlove and used it in combination with mirror therapywith a twist. A huge twist.

Typically, mirror therapy involves using a tabletop mirror to reflect your ‘good’ hand in place of your affected hand. (See this image.)

When performing hand therapy exercises in this manner, it ‘tricks’ your brain into thinking that you’re actually moving your affected hand and helps rewire your brain.

It’s a highly effective method for regaining hand function after stroke. So Margaret used this principle, but ditched the mirror.

She placed the MusicGlove on her husband’s ‘good hand’ and had him use it that way. While he was doing this, she would assist his affected hand to mirror his movements.

She wouldn’t move his hand to the game; she moved his hand to exactly match what his other hand was doing. So if he missed a note, she missed a note.

This bilateral synchronicity helped rewire her husband’s brain, and he went from being completely flaccid to having twitches!

Gratitude for the Little Things

While twitches might not seem like a big deal to you, they were a big deal to this couple – especially when his therapist said it wasn’t possible.

Can you imagine the satisfaction and happiness they felt?

And twitches are just the beginning.

If he continues to use the device passively, then he can continue to improve until he can use the device independently. Then in due time and effort, he might progress into stage 7 of stroke recovery: full muscle control.

It’s a big, hairy goal – one that only a confident post-rehab specialist would think of – but it’s possible.

“The body achieves what the mind believes.”

Power in Believing

If this couple took their therapists’ word as law, they wouldn’t have experienced this progress. They wouldn’t have witnessed his potential.

Whatever you believe becomes your reality. Make the choice to believe in a higher recovery.

Learn to question your therapists and get curious about your potential.

Movement or Not, Is MusicGlove for You?

If you have no hand movement, then you can use MusicGlove – it just requires time, patience, and assistance.

You can use the device passively by using your unaffected hand to move your affected hand, which still helps your brain rewire itself. You can do this until you regain enough hand function to use the device actively without assistance.

There’s no guarantee about what will happen because every recovery is different.

The choice is yours to make.

But no matter what you choose, always believe in a higher recovery.

Challenge the status quo, and believe in progress even when no one else does.

Click here to learn more about MusicGlove. You’ll find our clinical trial results, more information about the device, a few video testimonials, and our contact number in case you’d like to discuss your questions with us.

Source: How to Regain Movement in a Paralyzed Hand with MusicGlove – Flint Rehabilitation Devices

, , , , , , ,

Leave a comment

[Abstract] Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors

Abstract

Background/aim

Stroke is a leading cause of disability in developed countries. One of the most widespread techniques in clinical practice is mirror therapy (MT). To determine the effectiveness of MT over other methods of intervention in the recovery of upper limb function in people who have had a stroke.

Methods

A systematic review was conducted. The search string was established based on the last systematic review about MT that dated from 2009: “upper extremity” OR “upper limb “AND “mirror therapy” AND stroke. For this search Pubmed, Scopus and SciELO databases were used.

Results

Fifteen studies were included in the systematic review. Recovery of the upper limb, upper limb function and gross manual dexterity were frequently measured in these studies.

Conclusions

In the primary variables in promoting recovery, MT alone showed better results in acute and chronic stroke patients in upper limb functioning than either conventional rehabilitation (CR) or CR plus MT.

 

Source: Systematic review of mirror therapy compared with conventional rehabilitation in upper extremity function in stroke survivors – Pérez-Cruzado – 2016 – Australian Occupational Therapy Journal – Wiley Online Library

, , , , , , ,

Leave a comment

[VIDEO] Mirror Therapy

Your brain can be tricked! 🙂

He thought the rubber hand was his own hand, after getting his real and rubber hand stroked simultaneously.
He pulled his own hand away, when the rubber hand gets hit by a fork! 🙂
Amazing, right?

, , , , , ,

Leave a comment

[Abstract] Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. – PubMed

Abstract

BACKGROUND:

Mirror therapy (MT) has been proposed to improve the motor function of chronic individuals with stroke with mild to moderate impairment. With regards to severe upper limb paresis, MT has shown to provide limited motor improvement in the acute or sub-acute phase. However, no previous research has described the effects of MT in chronic individuals with stroke with severely impaired upper limb function.

AIM:

The aim of this study was to determine the effectiveness of MT on chronic stroke survivors with severe upper-limb impairment in comparison with passive mobilization.

DESIGN:

A randomized controlled trial.

SETTING:

Rehabilitative outpatient unit.

POPULATION:

A total of 31 chronic subjects poststroke with severely impaired upper limb function were randomly assigned to either an experimental group (N.=15), or a control group (N.=16).

METHODS:

Twenty-four intervention sessions were performed for both groups. Each session included 45-minute period of MT (experimental group) or passive mobilization (control group), administered three days a week. Participants were assessed before and after the intervention with the Wolf Motor Function Test, the Fugl-Meyer Assessment, and the Nottingham Sensory Assessment.

RESULTS:

Improvement in motor function was observed in both groups on the time (P=0.002) and ability (P=0.001) subscales of the Wolf Motor Function Test. No differences were detected in kinesthesis or stereognosis. However, the experimental group showed a significant improvement in tactile sensation that was mainly observed as an increased sensitivity to light touches.

CONCLUSIONS:

In comparison with passive mobilization, MT in chronic stroke survivors with severely impaired upper-limb function may provide a limited but positive effect on light touch sensitivity while providing similar motor improvement.

CLINICAL REHABILITATION IMPACT:

MT is a therapeutic approach that can be used in the rehabilitation of severely impaired upper limb in chronic stroke survivors, specifically to address light touch sensitivity deficits.

Source: Mirror therapy in chronic stroke survivors with severely impaired upper limb function: a randomized controlled trial. – PubMed – NCBI

, , , , , ,

Leave a comment

%d bloggers like this: