Efecto del ejercicio físico sobre la condición física en adultos con lesión medular: una revisión sistemática
Palabras clave:
Traumatismos de la médula espinal, ejercicio, fuerza muscular, composición corporal, entrenamiento de resistencia
Resumen
Esta revisión pretende determinar el efecto del ejercicio físico sobre la capacidad física, fuerza-resistencia muscular, composición corporal y rendimiento funcional en adultos con lesión medular. La búsqueda sistemática se realizó en las bases de datos PubMed, Trip Medical Database, Scopus, Web of Science, Registro Cochrane Central de Ensayos Controlados, Scielo y ScienceDirect entre los años 1990-2016. Se identificaron 2906 artículos en las bases de datos consultadas. El 31% de los estudios incluidos fueron realizados en Canadá, 46,1% en Estados Unidos y Australia, 15,3% en Holanda y 7,6% en Brasil, el tiempo post operatorio para intervención con ejercicio físico osciló entre 11,58 meses y los 24 años. El 100% de los estudios reportaron el protocolo de intervención utilizado en términos de longitud, duración, frecuencia e intensidad, el 46% de los estudios reportó niveles de lesión medular. Los resultados de las intervenciones mediadas a través de ejercicio físico sobre los componentes de la salud física en pacientes con lesión medular son alentadores. Los estudios analizados evidencian los beneficios sobre la capacidad física, fuerza y resistencia muscular, composición corporal y rendimiento funcional en pacientes con lesión medular que favorecen la calidad de vida y el bienestar psicológico de dicha población.
Referencias
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5. Froelich-Grobe K, Lee J, Aaronson L, Nary D, Washburn R, Little T. Exercise for Everyone: A Randomized Controlled Trial of Project Workout on Wheels in Promoting Exercise Among Wheelchair Users. Archives of Physical Medicine and Rehabilitation. 2014 Aug; 20(95): 20-28. DOI: https://doi.org/10.1016/j.apmr.2013.07.006
6. Arsom K, Ginis M, Jorgensen S, Stapleton J. Exercise and Sport for Persons Whit Spinal Cord Injury. Physical Medicine and Rehabilitation. 2012 Apr; 27(84): 894-900. DOI: https://doi.org/10.1016/j.pmrj.2012.08.006
7. Harvey LA, Lin CW, Glinsky J, De Wolf A. The Effectiveness of Physical Interventions for People whit Spinal Cord Injuries: A Systematic Review. Spinal Cord. 2009 Jun; 47(71): 184-195. DOI: https://doi.org/10.1038/sc.2008.100
8. Kathleen A, Arbour-Nicitopuolus K, Ginis M, A.E L. Planning leisure-time physical activity and coping self-efficacy in persons whit spinal cord Injury: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2009 Dec; 90(19): 2003-2011. DOI: https://doi.org/10.1016/j.apmr.2009.06.019
9. Hicks AL, Ginins M, Pelletiere C, Ditor D, Foulon B, Wolfe D. The Development of Evidence-Informed Physical Activity Guidelines for Adults whit Spinal Cord Injury: A Systematic Review. Spinal Cord. 2011 Jun; 49(11): 1088-1096. DOI: https://doi.org/10.1038/sc.2011.63
10. Swinnen E, Duerinck S, Baeyens JP, Meeusen R, Kerckhfs E. Effectiveness of robot-assisted gait training in pesons with spinal cord injury: A systematic review. Journal of Rehabilitation Medicine. 2010 Enero; 42(6): 520-526. DOI: https://doi.org/10.2340 /16501977-0538
11. Liberati A, Douglas GA, Jennifer T, Cynthia M, Gotzche P, John PAI, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care Interventions: explanation and elaboration. PLoS Medicine, BMJ, Journal of Clinical Epidemiology, and Open Medicine. 2009 Julio; 62(10): e1-e34. DOI: https://doi.org/10.1016/j.jclinepi.2009.06.006
12. Moher D, Liberati A, Jennifer T, Altman D, Group atP. Reprint preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, BMJ, Journal of Clinical Edidemiology, and Open Medicine. 2009 Septiembre; 89(9): 873-880. DOI: https://doi.org/10.1093/ptj/89.9.873
13. Higgins J, Green S. Cochrane collab. [Online]. 2011 [Update 2016 september 17; cited 2017 Abril 10. Available from: www.handbook.cochrane.org.
14. Robinson K, Dickersin K. Development of a higlhy sensitive search strategy for the retrieval of reports of controlled trials using PubMed. International Journal of Epidemiology. 2002 Octubre; 31(1): 150-156. DOI: https://doi.org/10.1093/ije/31.1.150
15. McNeely M, Campbell K, Rowe B, Klassen T, Mackey J, Courneya K. Effects of exercise on breast cancer patients and survivors: a systematic review and metaanalysis. Clinical Medicine Archives Journal. 2006 Julio; 175(1): 34-41. DOI: https://doi.org/10.1503/cmaj.051073
16. Association AP. PEDro Physiotherapy evidence database. [Online]; 2017 [Update january 19 ; cited 2017 Septiembre 24. Available from: https://www.pedro.org.au/.
17. Verhagen A, de Vet H, de Bie R, Kessels A, Boers M, Bouter L, et al. The delphi list: A criteria List for quality assessment of randomized clinical trials for conducting systematic reviews developed by delphi consensus. Journal Clinical of Epidemiology. 1998 Febrero; 51(12): 1235-1241. DOI: https://doi.org/10.1016/S0895-4356(98)00131-0
18. Moseley A, Herbert R, Sherrington C, Mher C. Evidence for physiotherapy practice: A survey of the physiotherapy evidence database (PEDro). Australian Journal of Physiotherapy. 2002 Abril; 48(1): 43-49. DOI: https://doi.org/10.1016/S0004-9514(14)60281-6
19. Harvey L, Fornusek C, Bowden J, Pontifex N, Glinsky J, Middleton J, et al. Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: A randomized controlled trial. Spinal Cord. 2010 Enero; 48(7): 570-575. DOI: https://doi.org/10.1038/sc.2009.191
20. Lavado E, Cardoso J, Silva L, Dela Bela L, Atallah A. Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: a randomized controlled trial. Clinical Rehabilitation. 2013 Enero; 27(2): 142-149. DOI: https://doi.org/10.1177/0269215512450522
21. Ralston K, Harvey L, Batty J, Lee B, Ben M, Cusmiani R, et al. Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: a randomised cross-over trial. Journal of Physiotherapy. 2013 junio; 59(4): 237-243. DOI: https://doi.org/10.1016/S1836-9553(13)70200-5
22. Nooijen C, Stam H, Bergem M, Bongers-Janssen H, Valent L, van Lageveld S, et al. A behaivioural intervention increase physical activity in people with subacute spinal cord injjury: a randomised trial. Journal of Physiotherapy. 2016 Enero; 62(1): 35-41. DOI: https://doi.org/10.1016/j.jphys.2015.11.003
23. Mulroy S, Thompson L, Kemp B, Hatchett P, Newsan C, Gutierrezz Lupold D, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: A randomized controlled trial. Physical Therapy Clinical Research Network. 2011 Marzo; 91(3): 305-324. DOI: https://doi.org/10.2522/ptj.20100182
24. Giangregorio L, Craven C, Richards K, Kapadia N, Hitzig S, Masani K, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on body composition. Jouranl of Sppinal Cord Medicine. 2012 october; 35(5): 351-360. DOI: https://doi.org/10.1179/2045772312Y.0000000041
25. Hitzig S, Craven C, Panjwani A, Kapadia N, Giangregorio L, Richards K, et al. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Spinal Cord Injury Rehabilitation. 2013 march; 19(4): 245-258. DOI: https://doi.org/10.1310/sci1904-245
26. Kapadia N, Masani K, Craven C, Giangregorio L, Hitzig S, Richards K, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency. Journal of Spinal Cord Medicine. 2014 april; 37(5): 511-524. DOI: https://doi.org/10.1179/2045772314Y.0000000263
27. Bakkum A, Paulson T, Bishop N, Goosey-Tolfrey V, Stolwijk-Swuste J, van Kuppelvelt D, et al. Effects of hybrid cycle and handcycle excercise on cardiovascular disease risk factor in people with spinal cord injury: A randomized controlled trial. Journal of Rehabilitation Medicine. 2015 may; 47(6): 523-530. DOI: https://doi.org/10.2340/16501977-1946
28. Gorgey A, Mather K, Cupp H, Gater D. Effects of resistance training on adiposity and metabolism after spinal cord injury. Journal of the American College of Sports Medicine. 2012 august; 44(1): 165-174. DOI: https://doi.org/10.1249/mss.0b013e31822672aa
29. Hicks A, Martin K, Ditor D, Latimer A, Craven C, Bugaresti J, et al. Long-term exercise training in persons with spinal cord injury: efects on strength, arm ergometry performance and psychological well-being. Spinal Cord. 2003 may; 41(1): 34-43. DOI: https://doi.org/10.1038/sj.sc.3101389
30. Gorgey A, Khalil R. Neuromuscular electrical stimulation training increases intermuscular fascial length but not tendon cross-sectional area after spinal cord injury. Spinal Cord Injury Rehabilitation. 2015 june; 21(1): 87-92. DOI: https://doi.org/10.1310/sci2101-87
31. Nash M. S, van de Ven I, van Elk N, Johnson B. M. Resistance training program of the upper extremity in manual wheelchair users. Archives of Physical Medicine and Rehabilitation. 2007 january; 88(1): 70-75. DOI: https://doi.org/10.1016/j.apmr.2006.10.003
32. Ditor D, Latimer A, Martin Ginins K, Arbour K, McCartney N, Hicks A. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress, and pain. Spinal Cord. 2003 november; 41(8): 446-450. DOI: https://doi.org/10.1038/sj.sc.3101487
33. Bakkum A, de Groot S, van der Woude L, Janssen T. The effects of hybrid cycle training in inactive people with long-term spinal cord injury: design of a multicenter randomized controlled trial. Disability and Rehabilitation. 2012 june; 35(13): 1127-1132. DOI: https://doi.org/10.3109/09638288.2012.715719
34. Wirz M, Zemon D, Rupp R, Schell A, Colomo G, Dietz V. Effectiveness of automated locomotor trainning in patients with chronic incomplete spinal cord injury: a multicenter trial. Archives of Physiscal Medicine and Rehabilitation. 2005 august; 86(4): 672-680. DOI: https://doi.org/10.1016/j.apmr.2004.08.004
35. Wessels M, Cees L, Inge E, de Groot S. Body-weight-supported gait training for restoration of walking in people with an incomplete spinal cord injury: A systematic review. Journal of Rehabilitation Medicine. 2010 january; 42(6): 513-519. DOI: https://doi.org/10.2340/16501977-0525
36. Jiménez B, Martín J, Abadía O, Herrero JA. Resistance Training Program of the Upper Extremity in Manual Wheelchairs Users. Archives of Physiscal Medicine and Rehabilitation. 2007 september; 7(27): 152-159. DOI: https://doi.org/10.1016/j.apmr.2006.10.003
37. Harvey L, Herbert R, Glinsky J, Moseley A, J B. Effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury: a randomized controlled trial. Spinal Cord. 2009 june; 47(1): 62-66. DOI: https://doi.org/10.1038/sc.2008.71
38. Hicks A. L, Ginis K. M, Pelletier C. A, Ditor D. S, Foulon B, Wolfe D. L. The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review. Spinal Cord. 2011 june; 49(11): 1103–1127. DOI: https://doi.org/10.1038/sc.2011.62
39. Cobos-Carbó A. Ensayos Clínicos Aleatorizados. Medicina Clínica. 2005; 125, 21-27. DOI: https://doi.org/10.1016/S0025-7753(05)72205-3
2. Wyndaele C, Wyndaele J. Incident, prevalence, and epidemiology of spinal cord injury: What learns a worldwide literature survery? Spinal Cord. 2006 Feb; 23(10): 523-529. DOI: https://doi.org/10.1038/sj.sc.3101893
3. Sisto A, Evans S, Nick. Activity and fitness in spinal cord injury: review and update. Curriculum Physical Medical Rehabilitation. 2014 Jun; 3(3): 147-157. DOI: https://doi.org/10.1007/s40141-014-0057-y
4. OMS. World Health Organization. [Online]; 2013 [Update 2016 august 26; cited 2014 Abril 10]. Available from: http://www.who.int/mediacentre/factsheetd/fs384/es/.
5. Froelich-Grobe K, Lee J, Aaronson L, Nary D, Washburn R, Little T. Exercise for Everyone: A Randomized Controlled Trial of Project Workout on Wheels in Promoting Exercise Among Wheelchair Users. Archives of Physical Medicine and Rehabilitation. 2014 Aug; 20(95): 20-28. DOI: https://doi.org/10.1016/j.apmr.2013.07.006
6. Arsom K, Ginis M, Jorgensen S, Stapleton J. Exercise and Sport for Persons Whit Spinal Cord Injury. Physical Medicine and Rehabilitation. 2012 Apr; 27(84): 894-900. DOI: https://doi.org/10.1016/j.pmrj.2012.08.006
7. Harvey LA, Lin CW, Glinsky J, De Wolf A. The Effectiveness of Physical Interventions for People whit Spinal Cord Injuries: A Systematic Review. Spinal Cord. 2009 Jun; 47(71): 184-195. DOI: https://doi.org/10.1038/sc.2008.100
8. Kathleen A, Arbour-Nicitopuolus K, Ginis M, A.E L. Planning leisure-time physical activity and coping self-efficacy in persons whit spinal cord Injury: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2009 Dec; 90(19): 2003-2011. DOI: https://doi.org/10.1016/j.apmr.2009.06.019
9. Hicks AL, Ginins M, Pelletiere C, Ditor D, Foulon B, Wolfe D. The Development of Evidence-Informed Physical Activity Guidelines for Adults whit Spinal Cord Injury: A Systematic Review. Spinal Cord. 2011 Jun; 49(11): 1088-1096. DOI: https://doi.org/10.1038/sc.2011.63
10. Swinnen E, Duerinck S, Baeyens JP, Meeusen R, Kerckhfs E. Effectiveness of robot-assisted gait training in pesons with spinal cord injury: A systematic review. Journal of Rehabilitation Medicine. 2010 Enero; 42(6): 520-526. DOI: https://doi.org/10.2340 /16501977-0538
11. Liberati A, Douglas GA, Jennifer T, Cynthia M, Gotzche P, John PAI, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care Interventions: explanation and elaboration. PLoS Medicine, BMJ, Journal of Clinical Epidemiology, and Open Medicine. 2009 Julio; 62(10): e1-e34. DOI: https://doi.org/10.1016/j.jclinepi.2009.06.006
12. Moher D, Liberati A, Jennifer T, Altman D, Group atP. Reprint preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, BMJ, Journal of Clinical Edidemiology, and Open Medicine. 2009 Septiembre; 89(9): 873-880. DOI: https://doi.org/10.1093/ptj/89.9.873
13. Higgins J, Green S. Cochrane collab. [Online]. 2011 [Update 2016 september 17; cited 2017 Abril 10. Available from: www.handbook.cochrane.org.
14. Robinson K, Dickersin K. Development of a higlhy sensitive search strategy for the retrieval of reports of controlled trials using PubMed. International Journal of Epidemiology. 2002 Octubre; 31(1): 150-156. DOI: https://doi.org/10.1093/ije/31.1.150
15. McNeely M, Campbell K, Rowe B, Klassen T, Mackey J, Courneya K. Effects of exercise on breast cancer patients and survivors: a systematic review and metaanalysis. Clinical Medicine Archives Journal. 2006 Julio; 175(1): 34-41. DOI: https://doi.org/10.1503/cmaj.051073
16. Association AP. PEDro Physiotherapy evidence database. [Online]; 2017 [Update january 19 ; cited 2017 Septiembre 24. Available from: https://www.pedro.org.au/.
17. Verhagen A, de Vet H, de Bie R, Kessels A, Boers M, Bouter L, et al. The delphi list: A criteria List for quality assessment of randomized clinical trials for conducting systematic reviews developed by delphi consensus. Journal Clinical of Epidemiology. 1998 Febrero; 51(12): 1235-1241. DOI: https://doi.org/10.1016/S0895-4356(98)00131-0
18. Moseley A, Herbert R, Sherrington C, Mher C. Evidence for physiotherapy practice: A survey of the physiotherapy evidence database (PEDro). Australian Journal of Physiotherapy. 2002 Abril; 48(1): 43-49. DOI: https://doi.org/10.1016/S0004-9514(14)60281-6
19. Harvey L, Fornusek C, Bowden J, Pontifex N, Glinsky J, Middleton J, et al. Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: A randomized controlled trial. Spinal Cord. 2010 Enero; 48(7): 570-575. DOI: https://doi.org/10.1038/sc.2009.191
20. Lavado E, Cardoso J, Silva L, Dela Bela L, Atallah A. Effectiveness of aerobic physical training for treatment of chronic asymptomatic bacteriuria in subjects with spinal cord injury: a randomized controlled trial. Clinical Rehabilitation. 2013 Enero; 27(2): 142-149. DOI: https://doi.org/10.1177/0269215512450522
21. Ralston K, Harvey L, Batty J, Lee B, Ben M, Cusmiani R, et al. Functional electrical stimulation cycling has no clear effect on urine output, lower limb swelling, and spasticity in people with spinal cord injury: a randomised cross-over trial. Journal of Physiotherapy. 2013 junio; 59(4): 237-243. DOI: https://doi.org/10.1016/S1836-9553(13)70200-5
22. Nooijen C, Stam H, Bergem M, Bongers-Janssen H, Valent L, van Lageveld S, et al. A behaivioural intervention increase physical activity in people with subacute spinal cord injjury: a randomised trial. Journal of Physiotherapy. 2016 Enero; 62(1): 35-41. DOI: https://doi.org/10.1016/j.jphys.2015.11.003
23. Mulroy S, Thompson L, Kemp B, Hatchett P, Newsan C, Gutierrezz Lupold D, et al. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: A randomized controlled trial. Physical Therapy Clinical Research Network. 2011 Marzo; 91(3): 305-324. DOI: https://doi.org/10.2522/ptj.20100182
24. Giangregorio L, Craven C, Richards K, Kapadia N, Hitzig S, Masani K, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on body composition. Jouranl of Sppinal Cord Medicine. 2012 october; 35(5): 351-360. DOI: https://doi.org/10.1179/2045772312Y.0000000041
25. Hitzig S, Craven C, Panjwani A, Kapadia N, Giangregorio L, Richards K, et al. Randomized trial of functional electrical stimulation therapy for walking in incomplete spinal cord injury: effects on quality of life and community participation. Spinal Cord Injury Rehabilitation. 2013 march; 19(4): 245-258. DOI: https://doi.org/10.1310/sci1904-245
26. Kapadia N, Masani K, Craven C, Giangregorio L, Hitzig S, Richards K, et al. A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency. Journal of Spinal Cord Medicine. 2014 april; 37(5): 511-524. DOI: https://doi.org/10.1179/2045772314Y.0000000263
27. Bakkum A, Paulson T, Bishop N, Goosey-Tolfrey V, Stolwijk-Swuste J, van Kuppelvelt D, et al. Effects of hybrid cycle and handcycle excercise on cardiovascular disease risk factor in people with spinal cord injury: A randomized controlled trial. Journal of Rehabilitation Medicine. 2015 may; 47(6): 523-530. DOI: https://doi.org/10.2340/16501977-1946
28. Gorgey A, Mather K, Cupp H, Gater D. Effects of resistance training on adiposity and metabolism after spinal cord injury. Journal of the American College of Sports Medicine. 2012 august; 44(1): 165-174. DOI: https://doi.org/10.1249/mss.0b013e31822672aa
29. Hicks A, Martin K, Ditor D, Latimer A, Craven C, Bugaresti J, et al. Long-term exercise training in persons with spinal cord injury: efects on strength, arm ergometry performance and psychological well-being. Spinal Cord. 2003 may; 41(1): 34-43. DOI: https://doi.org/10.1038/sj.sc.3101389
30. Gorgey A, Khalil R. Neuromuscular electrical stimulation training increases intermuscular fascial length but not tendon cross-sectional area after spinal cord injury. Spinal Cord Injury Rehabilitation. 2015 june; 21(1): 87-92. DOI: https://doi.org/10.1310/sci2101-87
31. Nash M. S, van de Ven I, van Elk N, Johnson B. M. Resistance training program of the upper extremity in manual wheelchair users. Archives of Physical Medicine and Rehabilitation. 2007 january; 88(1): 70-75. DOI: https://doi.org/10.1016/j.apmr.2006.10.003
32. Ditor D, Latimer A, Martin Ginins K, Arbour K, McCartney N, Hicks A. Maintenance of exercise participation in individuals with spinal cord injury: effects on quality of life, stress, and pain. Spinal Cord. 2003 november; 41(8): 446-450. DOI: https://doi.org/10.1038/sj.sc.3101487
33. Bakkum A, de Groot S, van der Woude L, Janssen T. The effects of hybrid cycle training in inactive people with long-term spinal cord injury: design of a multicenter randomized controlled trial. Disability and Rehabilitation. 2012 june; 35(13): 1127-1132. DOI: https://doi.org/10.3109/09638288.2012.715719
34. Wirz M, Zemon D, Rupp R, Schell A, Colomo G, Dietz V. Effectiveness of automated locomotor trainning in patients with chronic incomplete spinal cord injury: a multicenter trial. Archives of Physiscal Medicine and Rehabilitation. 2005 august; 86(4): 672-680. DOI: https://doi.org/10.1016/j.apmr.2004.08.004
35. Wessels M, Cees L, Inge E, de Groot S. Body-weight-supported gait training for restoration of walking in people with an incomplete spinal cord injury: A systematic review. Journal of Rehabilitation Medicine. 2010 january; 42(6): 513-519. DOI: https://doi.org/10.2340/16501977-0525
36. Jiménez B, Martín J, Abadía O, Herrero JA. Resistance Training Program of the Upper Extremity in Manual Wheelchairs Users. Archives of Physiscal Medicine and Rehabilitation. 2007 september; 7(27): 152-159. DOI: https://doi.org/10.1016/j.apmr.2006.10.003
37. Harvey L, Herbert R, Glinsky J, Moseley A, J B. Effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury: a randomized controlled trial. Spinal Cord. 2009 june; 47(1): 62-66. DOI: https://doi.org/10.1038/sc.2008.71
38. Hicks A. L, Ginis K. M, Pelletier C. A, Ditor D. S, Foulon B, Wolfe D. L. The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review. Spinal Cord. 2011 june; 49(11): 1103–1127. DOI: https://doi.org/10.1038/sc.2011.62
39. Cobos-Carbó A. Ensayos Clínicos Aleatorizados. Medicina Clínica. 2005; 125, 21-27. DOI: https://doi.org/10.1016/S0025-7753(05)72205-3
Publicado
2021-02-18
Cómo citar
García-González, D., & Sandoval-Cuellar, C. (2021). Efecto del ejercicio físico sobre la condición física en adultos con lesión medular: una revisión sistemática. Ustasalud, 20, 31-42. https://doi.org/https://doi.org/10.15332/us.v20i0.2524
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