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İNMELİ HASTALARDA JOHNSTONE BASINÇ SPLİNTİ VE ELEKTRİK STİMÜLASYON UYGULAMASININ DENGE, FONKSİYONEL BAĞIMSIZLIK VE MOBİLİTE ÜZERİNE ETKİSİNİN KARŞILAŞTIRILMASI: RANDOMİZE ÇALIŞMA

Yıl 2025, Cilt: 6 Sayı: 1, 175 - 189, 28.02.2025
https://doi.org/10.70813/ssd.1437036

Öz

Amaç: Alt ekstremiteye uygulanan Johnstone basınç splinti ve Nöromusküler Elektrik Stimülasyonu (NMES) uygulamasının inmeli bireylerde denge, fonksiyonel bağımsızlık ve mobilite üzerine etkisini araştırmak.
Yöntem: Çalışma akut/subakut 33 inmeli hasta ile yapıldı. Hastalara konvansiyonel nörolojik rehabilitasyon eğitimine ek olarak Johnstone basınç splinti ve NMES uygulaması uygulanarak randomize iki gruba ayrıldı. Her iki grup 6 hafta, haftada 5 gün, günde 45-60 dakika eğitim uygulandı. Değerlendirmelerde Fugl Meyer testi, Brunnstrom, Fonksiyonel Bağımsızlık Ölçeği, Motrisite İndeksi, Berg Denge Testi, 10 Metre Yürüme Testi ve Zamanlı Kalk Yürü Testi kullanıldı. Değerlendirmeler tedavi öncesi, 3. hafta ve 6. hafta yapıldı.
Bulgular: Katılımcıların yaş ve VKİ ortalamaları, 63.29±12.63 yıl ve 24.57±4.26 kg/m2 idi. Her iki grupta da tedavi öncesine göre hem 3. hafta hem de 6. hafta sonuçlarında istatistiksel olarak anlamlı gelişmeler saptandı (p<0.05). Altı haftalık uygulama sonrasında gruplar arası karşılaştırılmada Johnstone basınç splinti uygulanan grubun değerlendirilen tüm parametrelerde, NMES uygulanan gruba göre daha fazla anlamlı düzeyde gelişme gösterdiği bulundu (p<0.05).
Sonuç: Konvansiyonel nörolojik rehabilitasyon uygulamasına ek olarak uygulanan Johnstone basınç splintinin inmeli hastaların motor gelişimini, bağımsızlık düzeyini, gövde kontrolünü, dengesini ve yürüme hızını elektrik stimülasyon uygulamasına göre daha fazla geliştirdiği görüldü.

Kaynakça

  • Ahmed, I., Mustafaoglu, R., & Erhan, B. (2024). The effects of low-intensity resistance training with blood flow restriction versus traditional resistance exercise on lower extremity muscle strength and motor functionin ischemic stroke survivors: a randomized controlled trial. Topics in Stroke Rehabilitation, 31(4), 418-429. doi:10.1080/10749357.2023.2259170
  • Ambrosini, E., Ferrante, S., Pedrocchi, A., Ferrigno, G., & Molteni, F. (2011). Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke, 42(4), 1068-1073.
  • Armutlu, K., Karabudak, R., & Nurlu, G. (2001). Physiotherapy approaches in the treatment of ataxic multiple sclerosis: a pilot study. Neurorehabilitation and neural repair, 15(3), 203-211.
  • Aytan Akca, N., Özkurt, S., & Köksal, A. (2024). Akut hemiplejili hastalarda yarı sürükleyici sanal gerçeklik uygulamasının mobilite, fonksiyonellik, denge, düşme korkusu üzerine etkisi. [The effects of semi-immersive virtual reality applications on mobility, functionality, balance, fear of falling in patients with acute hemiplegia]. Disiplinlerarası Yenilik Araştırmaları Dergisi, 4(1), 51-63. doi:10.56723/dyad.1309756
  • Buchanan, K., & Hourihan, S. (2016). Physical and postural management of spasticity. 57-82.
  • Carey, L. M., Lamp, G., & Turville, M. (2016). The state-of-the-science on somatosensory function and its impact on daily life in adults and older adults, and following stroke: a scoping review. OTJR: occupation, participation and health, 36(2_suppl), 27S-41S.
  • Feys, H., De Weerdt, W., Verbeke, G., Steck, G. C., Capiau, C., Kiekens, C., Dejaeger, E., Van Hoydonck, G., Vermeersch, G., & Cras, P. (2004). Early and repetitive stimulation of the arm can substantially improve the long-term outcome after stroke: a 5-year follow-up study of a randomized trial. Stroke, 35(4), 924-929.
  • Feys, H. M., De Weerdt, W. J., Selz, B. E., Cox Steck, G. A., Spichiger, R., Vereeck, L. E., Putman, K. D., & Van Hoydonck, G. A. (1998). Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Stroke, 29(4), 785-792.
  • Gökşen, A., & Çekok, F. K. (2024). Yaşlı Bireylerin Kas Tendon Morfolojisinin Fiziksel Performans ve Denge Üzerine Etkisi. [Effect of Muscle Tendon Morphology on Physical Performance and Balance in Elderly Individuals]. Hacettepe University Faculty of Health Sciences Journal, 11(2), 477-490. doi:10.21020/husbfd.1373362
  • Harb, A., & Kishner, S. (2024). Modified Ashworth Scale. In StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Stephen Kishner declares no relevant financial relationships with ineligible companies.: StatPearls Publishing
  • Henry, M., & Baudry, S. (2019). Age-related changes in leg proprioception: implications for postural control. J Neurophysiol, 122(2), 525-538. doi:10.1152/jn.00067.2019
  • Hiengkaew, V., Jitaree, K., & Chaiyawat, P. (2012). Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed “Up & Go” Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees of ankle plantarflexor tone. Archives of physical medicine and rehabilitation, 93(7), 1201-1208.
  • Hong, Z., Sui, M., Zhuang, Z., Liu, H., Zheng, X., Cai, C., & Jin, D. (2018). Effectiveness of neuromuscular electrical stimulation on lower limbs of patients with hemiplegia after chronic stroke: a systematic review. Arch Phys Med Rehabil, 99(5), 1011-1022. e1011.
  • Iosa, M., Bini, F., Marinozzi, F., Fusco, A., Morone, G., Koch, G., Cinnera, A. M., Bonnì, S., & Paolucci, S. (2016). Stability and harmony of gait in patients with subacute stroke. Journal of medical and biological engineering, 36(5), 635-643.
  • Kerem, M., Livanelioglu, A., & Topcu, M. (2001). Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine & Child Neurology, 43(5), 307-313.
  • Kimberley, T. J., Lewis, S. M., Auerbach, E. J., Dorsey, L. L., Lojovich, J. M., & Carey, J. R. (2004). Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Experimental Brain Research, 154(4), 450-460.
  • Kitis, A., & Kayihan, H. (2010). Comparison of EMC biofeedback and Johnstone pressure splints in children with hemiplegic cerebral palsy/Hemiplejik serebral paralizili cocuklarda Johnstone basinc splintleri ile EMG biofeedback uygulamasinin karsilastirilmasi. Turkish Journal of Physical Medicine and Rehabilitation, 56(3), 116-124.
  • Knutson, J. S., Fu, M. J., Sheffler, L. R., & Chae, J. (2015). Neuromuscular electrical stimulation for motor restoration in hemiplegia. Physical medicine and rehabilitation clinics of North America, 26(4), 729.
  • Kopack, J. K. (2024). Exercise Considerations for Persons With Neurologic Diagnoses. In Principles of Therapeutic Exercise for the Physical Therapist Assistant (pp. 563-594): Routledge.
  • Mahmoudi, Z., Mohammadi, R., Sadeghi, T., & Kalbasi, G. (2021). The effects of electrical stimulation of lower extremity muscles on balance in stroke patients: a systematic review of literatures. Journal of Stroke and Cerebrovascular Diseases, 30(8), 105793.
  • Mustafaoglu, R., Erhan, B., Yeldan, I., Gunduz, B., & Tarakci, E. (2020). Does robot-assisted gait training improve mobility, activities of daily living and quality of life in stroke? A single-blinded, randomized controlled trial. Acta Neurologica Belgica, 120. doi:10.1007/s13760-020-01276-8
  • Nozoe, M., Kanai, M., Kubo, H., Takeuchi, Y., Kobayashi, M., Yamamoto, M., Furuichi, A., Yamazaki, M., Shimada, S., & Mase, K. (2017). Efficacy of neuromuscular electrical stimulation for preventing quadriceps muscle wasting in patients with moderate or severe acute stroke: A pilot study. NeuroRehabilitation, 41(1), 143-149.
  • Nozoe, M., Miyata, K., Kubo, H., Ishida, M., & Yamamoto, K. (2024). Establishing minimal clinically important differences and cut-off values for the lower limb motricity index and trunk control test in older patients with acute stroke: a prospective cohort study. Topics in Stroke Rehabilitation, 1-10.
  • Poole, J. L., Whitney, S. L., Hangeland, N., & Baker, C. (1990). The effectiveness of inflatable pressure splints on motor function in stroke patients. The Occupational Therapy Journal of Research, 10(6), 360-366.
  • Santos, G. F., Jakubowitz, E., Pronost, N., Bonis, T., & Hurschler, C. (2021). Predictive simulation of post-stroke gait with functional electrical stimulation. Scientific reports, 11(1), 21351.
  • Sheffler, L. R., & Chae, J. (2007). Neuromuscular electrical stimulation in neurorehabilitation. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 35(5), 562-590.
  • Skirven, T. M., Osterman, A. L., Fedorczyk, J., Amadio, P. C., Felder, S., & Shin, E. K. (2020). Rehabilitation of the hand and upper extremity: Elsevier Health Sciences.
  • Stein, C., Fritsch, C. G., Robinson, C., Sbruzzi, G., & Plentz, R. D. (2015). Effects of Electrical Stimulation in Spastic Muscles After Stroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Stroke, 46(8), 2197-2205. doi:10.1161/strokeaha.115.009633
  • Taşvuran Horata, E., Özdemir, H., Kundakcı, Y., & Eker, İ. (2024). Comparison of single and dual-task gait parameters of children with cancer and typically developing children. Journal of Exercise Therapy and Rehabilitation, 11, 114-122. doi:10.15437/jetr.1203252
  • Varas-Diaz, G., & Bhatt, T. (2021). Application of neuromuscular electrical stimulation on the support limb during reactive balance control in persons with stroke: a pilot study. Experimental Brain Research, 239(12), 3635-3647.
  • Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., & Kwakkel, G. (2014). What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one, 9(2), e87987.
  • Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., Deruyter, F., Eng, J. J., Fisher, B., & Harvey, R. L. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-e169.
  • Yıldız, A., Mustafaoğlu, R., & Kesiktaş, F. N. (2023). Spinal Kord Yaralanması Olan Hastalarda Fiziksel Engelliler İçin Fiziksel Aktivite Ölçeği’nin (FEFA) Geçerlik ve Güvenilirliği. [Validity and Reliability of the Physical Activity Scale for the Physical Disabilities in patients with Spinal Cord Injury]. Sakarya Üniversitesi Holistik Sağlık Dergisi, 6(3), 450-463. doi:10.54803/sauhsd.1322366

Comparison of the Effects of Johnstone Pressure Splint and Electrical Stimulation Applications on Balance, Functional Independence, and Mobility in Patients with Stroke: A Randomized Study

Yıl 2025, Cilt: 6 Sayı: 1, 175 - 189, 28.02.2025
https://doi.org/10.70813/ssd.1437036

Öz

Purpose: To investigate the effects of Johnstone pressure splint and Neuromuscular Electrical Stimulation (NMES) applied to the lower extremity on balance, functional independence and mobility in individuals with stroke.
Method: The study was conducted with 33 acute/subacute stroke patients. The patients were randomly divided into two groups by applying Johnstone pressure splint and NMES in addition to conventional neurological rehabilitation training. Both groups were trained for 6 weeks, 5 days a week, 45-60 minutes a day. Fugl Meyer test, Brunnstrom, Functional Independence Scale, Motricity Index, Berg Balance Test, 10 Meter Walk Test and Timed Get Up and Go Test were used in the evaluations. Evaluations were made before treatment, at 3 weeks and 6 weeks.
Results: The mean age and BMI of the participants were 63.29±12.63 years and 24.57±4.26 kg/m2. Statistically significant improvements were found in both the 3rd week and 6th week results compared to the pre-treatment period in both groups (p<0.05). In the comparison between the groups after 6 weeks of application, it was found that the Johnstone pressure splint group showed statistically more improvement in all the evaluated parameters compared to the NMES applied group (p<0.05).
Conclusion: It was observed that the Johnstone pressure splint, which was applied in addition to the conventional neurological rehabilitation application, improved the motor development, level of independence, trunk control, balance and walking speed of the stroke patients more than the electrical stimulation application.

Kaynakça

  • Ahmed, I., Mustafaoglu, R., & Erhan, B. (2024). The effects of low-intensity resistance training with blood flow restriction versus traditional resistance exercise on lower extremity muscle strength and motor functionin ischemic stroke survivors: a randomized controlled trial. Topics in Stroke Rehabilitation, 31(4), 418-429. doi:10.1080/10749357.2023.2259170
  • Ambrosini, E., Ferrante, S., Pedrocchi, A., Ferrigno, G., & Molteni, F. (2011). Cycling induced by electrical stimulation improves motor recovery in postacute hemiparetic patients: a randomized controlled trial. Stroke, 42(4), 1068-1073.
  • Armutlu, K., Karabudak, R., & Nurlu, G. (2001). Physiotherapy approaches in the treatment of ataxic multiple sclerosis: a pilot study. Neurorehabilitation and neural repair, 15(3), 203-211.
  • Aytan Akca, N., Özkurt, S., & Köksal, A. (2024). Akut hemiplejili hastalarda yarı sürükleyici sanal gerçeklik uygulamasının mobilite, fonksiyonellik, denge, düşme korkusu üzerine etkisi. [The effects of semi-immersive virtual reality applications on mobility, functionality, balance, fear of falling in patients with acute hemiplegia]. Disiplinlerarası Yenilik Araştırmaları Dergisi, 4(1), 51-63. doi:10.56723/dyad.1309756
  • Buchanan, K., & Hourihan, S. (2016). Physical and postural management of spasticity. 57-82.
  • Carey, L. M., Lamp, G., & Turville, M. (2016). The state-of-the-science on somatosensory function and its impact on daily life in adults and older adults, and following stroke: a scoping review. OTJR: occupation, participation and health, 36(2_suppl), 27S-41S.
  • Feys, H., De Weerdt, W., Verbeke, G., Steck, G. C., Capiau, C., Kiekens, C., Dejaeger, E., Van Hoydonck, G., Vermeersch, G., & Cras, P. (2004). Early and repetitive stimulation of the arm can substantially improve the long-term outcome after stroke: a 5-year follow-up study of a randomized trial. Stroke, 35(4), 924-929.
  • Feys, H. M., De Weerdt, W. J., Selz, B. E., Cox Steck, G. A., Spichiger, R., Vereeck, L. E., Putman, K. D., & Van Hoydonck, G. A. (1998). Effect of a therapeutic intervention for the hemiplegic upper limb in the acute phase after stroke: a single-blind, randomized, controlled multicenter trial. Stroke, 29(4), 785-792.
  • Gökşen, A., & Çekok, F. K. (2024). Yaşlı Bireylerin Kas Tendon Morfolojisinin Fiziksel Performans ve Denge Üzerine Etkisi. [Effect of Muscle Tendon Morphology on Physical Performance and Balance in Elderly Individuals]. Hacettepe University Faculty of Health Sciences Journal, 11(2), 477-490. doi:10.21020/husbfd.1373362
  • Harb, A., & Kishner, S. (2024). Modified Ashworth Scale. In StatPearls. Treasure Island (FL) ineligible companies. Disclosure: Stephen Kishner declares no relevant financial relationships with ineligible companies.: StatPearls Publishing
  • Henry, M., & Baudry, S. (2019). Age-related changes in leg proprioception: implications for postural control. J Neurophysiol, 122(2), 525-538. doi:10.1152/jn.00067.2019
  • Hiengkaew, V., Jitaree, K., & Chaiyawat, P. (2012). Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed “Up & Go” Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees of ankle plantarflexor tone. Archives of physical medicine and rehabilitation, 93(7), 1201-1208.
  • Hong, Z., Sui, M., Zhuang, Z., Liu, H., Zheng, X., Cai, C., & Jin, D. (2018). Effectiveness of neuromuscular electrical stimulation on lower limbs of patients with hemiplegia after chronic stroke: a systematic review. Arch Phys Med Rehabil, 99(5), 1011-1022. e1011.
  • Iosa, M., Bini, F., Marinozzi, F., Fusco, A., Morone, G., Koch, G., Cinnera, A. M., Bonnì, S., & Paolucci, S. (2016). Stability and harmony of gait in patients with subacute stroke. Journal of medical and biological engineering, 36(5), 635-643.
  • Kerem, M., Livanelioglu, A., & Topcu, M. (2001). Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine & Child Neurology, 43(5), 307-313.
  • Kimberley, T. J., Lewis, S. M., Auerbach, E. J., Dorsey, L. L., Lojovich, J. M., & Carey, J. R. (2004). Electrical stimulation driving functional improvements and cortical changes in subjects with stroke. Experimental Brain Research, 154(4), 450-460.
  • Kitis, A., & Kayihan, H. (2010). Comparison of EMC biofeedback and Johnstone pressure splints in children with hemiplegic cerebral palsy/Hemiplejik serebral paralizili cocuklarda Johnstone basinc splintleri ile EMG biofeedback uygulamasinin karsilastirilmasi. Turkish Journal of Physical Medicine and Rehabilitation, 56(3), 116-124.
  • Knutson, J. S., Fu, M. J., Sheffler, L. R., & Chae, J. (2015). Neuromuscular electrical stimulation for motor restoration in hemiplegia. Physical medicine and rehabilitation clinics of North America, 26(4), 729.
  • Kopack, J. K. (2024). Exercise Considerations for Persons With Neurologic Diagnoses. In Principles of Therapeutic Exercise for the Physical Therapist Assistant (pp. 563-594): Routledge.
  • Mahmoudi, Z., Mohammadi, R., Sadeghi, T., & Kalbasi, G. (2021). The effects of electrical stimulation of lower extremity muscles on balance in stroke patients: a systematic review of literatures. Journal of Stroke and Cerebrovascular Diseases, 30(8), 105793.
  • Mustafaoglu, R., Erhan, B., Yeldan, I., Gunduz, B., & Tarakci, E. (2020). Does robot-assisted gait training improve mobility, activities of daily living and quality of life in stroke? A single-blinded, randomized controlled trial. Acta Neurologica Belgica, 120. doi:10.1007/s13760-020-01276-8
  • Nozoe, M., Kanai, M., Kubo, H., Takeuchi, Y., Kobayashi, M., Yamamoto, M., Furuichi, A., Yamazaki, M., Shimada, S., & Mase, K. (2017). Efficacy of neuromuscular electrical stimulation for preventing quadriceps muscle wasting in patients with moderate or severe acute stroke: A pilot study. NeuroRehabilitation, 41(1), 143-149.
  • Nozoe, M., Miyata, K., Kubo, H., Ishida, M., & Yamamoto, K. (2024). Establishing minimal clinically important differences and cut-off values for the lower limb motricity index and trunk control test in older patients with acute stroke: a prospective cohort study. Topics in Stroke Rehabilitation, 1-10.
  • Poole, J. L., Whitney, S. L., Hangeland, N., & Baker, C. (1990). The effectiveness of inflatable pressure splints on motor function in stroke patients. The Occupational Therapy Journal of Research, 10(6), 360-366.
  • Santos, G. F., Jakubowitz, E., Pronost, N., Bonis, T., & Hurschler, C. (2021). Predictive simulation of post-stroke gait with functional electrical stimulation. Scientific reports, 11(1), 21351.
  • Sheffler, L. R., & Chae, J. (2007). Neuromuscular electrical stimulation in neurorehabilitation. Muscle & Nerve: Official Journal of the American Association of Electrodiagnostic Medicine, 35(5), 562-590.
  • Skirven, T. M., Osterman, A. L., Fedorczyk, J., Amadio, P. C., Felder, S., & Shin, E. K. (2020). Rehabilitation of the hand and upper extremity: Elsevier Health Sciences.
  • Stein, C., Fritsch, C. G., Robinson, C., Sbruzzi, G., & Plentz, R. D. (2015). Effects of Electrical Stimulation in Spastic Muscles After Stroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Stroke, 46(8), 2197-2205. doi:10.1161/strokeaha.115.009633
  • Taşvuran Horata, E., Özdemir, H., Kundakcı, Y., & Eker, İ. (2024). Comparison of single and dual-task gait parameters of children with cancer and typically developing children. Journal of Exercise Therapy and Rehabilitation, 11, 114-122. doi:10.15437/jetr.1203252
  • Varas-Diaz, G., & Bhatt, T. (2021). Application of neuromuscular electrical stimulation on the support limb during reactive balance control in persons with stroke: a pilot study. Experimental Brain Research, 239(12), 3635-3647.
  • Veerbeek, J. M., van Wegen, E., van Peppen, R., van der Wees, P. J., Hendriks, E., Rietberg, M., & Kwakkel, G. (2014). What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PloS one, 9(2), e87987.
  • Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., Deruyter, F., Eng, J. J., Fisher, B., & Harvey, R. L. (2016). Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47(6), e98-e169.
  • Yıldız, A., Mustafaoğlu, R., & Kesiktaş, F. N. (2023). Spinal Kord Yaralanması Olan Hastalarda Fiziksel Engelliler İçin Fiziksel Aktivite Ölçeği’nin (FEFA) Geçerlik ve Güvenilirliği. [Validity and Reliability of the Physical Activity Scale for the Physical Disabilities in patients with Spinal Cord Injury]. Sakarya Üniversitesi Holistik Sağlık Dergisi, 6(3), 450-463. doi:10.54803/sauhsd.1322366
Toplam 33 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Klinik Tıp Bilimleri (Diğer)
Bölüm Araştırma Makaleleri
Yazarlar

Ümit Erkut 0000-0002-5889-4495

Abdurrahim Yıldız 0000-0002-6049-0705

Esra Atılgan 0000-0002-6381-5982

Yayımlanma Tarihi 28 Şubat 2025
Gönderilme Tarihi 14 Şubat 2024
Kabul Tarihi 24 Aralık 2024
Yayımlandığı Sayı Yıl 2025 Cilt: 6 Sayı: 1

Kaynak Göster

APA Erkut, Ü., Yıldız, A., & Atılgan, E. (2025). İNMELİ HASTALARDA JOHNSTONE BASINÇ SPLİNTİ VE ELEKTRİK STİMÜLASYON UYGULAMASININ DENGE, FONKSİYONEL BAĞIMSIZLIK VE MOBİLİTE ÜZERİNE ETKİSİNİN KARŞILAŞTIRILMASI: RANDOMİZE ÇALIŞMA. Selçuk Sağlık Dergisi, 6(1), 175-189. https://doi.org/10.70813/ssd.1437036