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Article ; Online: Prevalence of spasticity in humans with spinal cord injury with different injury severity.

Sangari, Sina / Perez, Monica A

2022 Volume 128, Issue 3, Page(s) 470–479

Abstract: Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and ... ...

Abstract	Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute,
MeSH term(s)	Humans ; Muscle Spasticity/epidemiology ; Muscle Spasticity/etiology ; Prevalence ; Quadriceps Muscle ; Spinal Cord Injuries/complications ; Spinal Cord Injuries/epidemiology ; Spinal Cord Injuries/rehabilitation
Language	English
Publishing date	2022-05-04
Publishing country	United States
Document type	Journal Article ; Research Support, U.S. Gov't, Non-P.H.S. ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
ZDB-ID	80161-6
ISSN	1522-1598 ; 0022-3077
ISSN (online)	1522-1598
ISSN	0022-3077
DOI	10.1152/jn.00126.2022
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Article ; Online: Corticospinal excitability across lower limb muscles in humans.

Eisner-Janowicz, Ines / Chen, Bing / Sangari, Sina / Perez, Monica A

Journal of neurophysiology

2023 Volume 130, Issue 3, Page(s) 788–797

Abstract: Electrophysiological studies in nonhuman primates reported the existence of strong corticospinal output from the primary motor cortex to distal compared with proximal hindlimb muscles. The extent to which corticospinal output differs across muscles in ... ...

Abstract	Electrophysiological studies in nonhuman primates reported the existence of strong corticospinal output from the primary motor cortex to distal compared with proximal hindlimb muscles. The extent to which corticospinal output differs across muscles in the leg in humans remains poorly understood. Using transcranial magnetic stimulation over the leg representation of the primary motor cortex, we constructed motor evoked potential (MEP) recruitment curves to measure the resting motor threshold (RMT), maximum MEP amplitude (MEP-max), and slope in the biceps femoris, rectus femoris, tibialis anterior, soleus, and a foot muscle (i.e., abductor hallucis) in intact humans. We found that the RMT was lower and the MEP-max and slope were larger in the abductor hallucis compared with most other muscles tested. In contrast, the RMT was higher and the MEP-max and slope were lower in the biceps femoris compared to all other muscles tested. Corticospinal responses in the rectus femoris, tibialis anterior, and soleus were in between those obtained from other leg muscles, with the soleus having a higher RMT and lower MEP-max and slope than the rectus femoris and tibialis anterior. To examine the origin of increases in corticospinal excitability in the abductor hallucis, we compared short-interval intracortical inhibition (SICI) and
MeSH term(s)	Humans ; Electromyography ; Lower Extremity/physiology ; Muscle, Skeletal/physiology ; Leg/physiology ; Transcranial Magnetic Stimulation/methods ; Evoked Potentials, Motor/physiology ; Pyramidal Tracts/physiology
Language	English
Publishing date	2023-07-12
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	80161-6
ISSN	1522-1598 ; 0022-3077
ISSN (online)	1522-1598
ISSN	0022-3077
DOI	10.1152/jn.00207.2023
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Article ; Online: Distinct Corticospinal and Reticulospinal Contributions to Voluntary Control of Elbow Flexor and Extensor Muscles in Humans with Tetraplegia.

Sangari, Sina / Perez, Monica A

The Journal of neuroscience : the official journal of the Society for Neuroscience

2020 Volume 40, Issue 46, Page(s) 8831–8841

Abstract: Humans with cervical spinal cord injury (SCI) often recover voluntary control of elbow flexors and, to a much lesser extent, elbow extensor muscles. The neural mechanisms underlying this asymmetrical recovery remain unknown. Anatomical and physiological ... ...

Abstract	Humans with cervical spinal cord injury (SCI) often recover voluntary control of elbow flexors and, to a much lesser extent, elbow extensor muscles. The neural mechanisms underlying this asymmetrical recovery remain unknown. Anatomical and physiological evidence in animals and humans indicates that corticospinal and reticulospinal pathways differentially control elbow flexor and extensor motoneurons; therefore, it is possible that reorganization in these pathways contributes to the asymmetrical recovery of elbow muscles after SCI. To test this hypothesis, we examined motor-evoked potentials (MEPs) elicited by transcranial magnetic stimulation over the arm representation of the primary motor cortex, maximal voluntary contractions, the StartReact response (a shortening in reaction time evoked by a startling stimulus), and the effect of an acoustic startle cue on MEPs elicited by cervicomedullary stimulation (CMEPs) on biceps and triceps brachii in males and females with and without chronic cervical incomplete SCI. We found that SCI participants showed similar MEPs and maximal voluntary contractions in biceps but smaller responses in triceps compared with controls, suggesting reduced corticospinal inputs to elbow extensors. The StartReact and CMEP facilitation was larger in biceps but similar to controls in triceps, suggesting enhanced reticulospinal inputs to elbow flexors. These findings support the hypothesis that the recovery of biceps after cervical SCI results, at least in part, from increased reticulospinal inputs and that the lack of these extra inputs combined with the loss of corticospinal drive contribute to the pronounced weakness found in triceps.
MeSH term(s)	Adult ; Aged ; Cues ; Elbow/physiopathology ; Electromyography ; Evoked Potentials, Motor/physiology ; Female ; Humans ; Male ; Middle Aged ; Motor Cortex ; Muscle Contraction/physiology ; Muscle, Skeletal/physiopathology ; Pyramidal Tracts/physiopathology ; Quadriplegia/physiopathology ; Recruitment, Neurophysiological ; Reflex, Startle ; Reticular Formation/physiopathology ; Spinal Cord Injuries/physiopathology ; Transcranial Magnetic Stimulation ; Young Adult
Language	English
Publishing date	2020-09-03
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	604637-x
ISSN	1529-2401 ; 0270-6474
ISSN (online)	1529-2401
ISSN	0270-6474
DOI	10.1523/JNEUROSCI.1107-20.2020
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Article ; Online: Imbalanced Corticospinal and Reticulospinal Contributions to Spasticity in Humans with Spinal Cord Injury.

Sangari, Sina / Perez, Monica A

The Journal of neuroscience : the official journal of the Society for Neuroscience

2019 Volume 39, Issue 40, Page(s) 7872–7881

Abstract: Damage to the corticospinal and reticulospinal tract has been associated with spasticity in humans with upper motor neuron lesions. We hypothesized that these descending motor pathways distinctly contribute to the control of a spastic muscle in humans ... ...

Abstract	Damage to the corticospinal and reticulospinal tract has been associated with spasticity in humans with upper motor neuron lesions. We hypothesized that these descending motor pathways distinctly contribute to the control of a spastic muscle in humans with incomplete spinal cord injury (SCI). To test this hypothesis, we examined motor-evoked potentials (MEPs) elicited by transcranial magnetic stimulation over the leg representation of the primary motor cortex, maximal voluntary contractions (MVCs), and the StartReact response (shortening in reaction time evoked by a startling stimulus) in the quadriceps femoris muscle in male and females with and without incomplete SCI. A total of 66.7% of the SCI participants showed symptoms of spasticity, whereas the other 33.3% showed no or low levels of spasticity. We found that participants with spasticity had smaller MEPs and MVCs and larger StartReact compared with participants with no or low spasticity and control subjects. These results were consistently present in spastic subjects but not in the other populations. Clinical scores of spasticity were negatively correlated with MEP-max and MVC values and positively correlated with shortening in reaction time. These findings provide evidence for lesser corticospinal and larger reticulospinal influences to spastic muscles in humans with SCI and suggest that these imbalanced contributions are important for motor recovery.
MeSH term(s)	Adult ; Aged ; Efferent Pathways ; Evoked Potentials, Motor ; Female ; Humans ; Male ; Middle Aged ; Motor Cortex/physiopathology ; Muscle Contraction/physiology ; Muscle Spasticity/etiology ; Muscle Spasticity/pathology ; Pyramidal Tracts/pathology ; Quadriceps Muscle/physiopathology ; Reaction Time ; Recruitment, Neurophysiological ; Reticular Formation/pathology ; Spinal Cord Injuries/complications ; Spinal Cord Injuries/pathology ; Transcranial Magnetic Stimulation ; Young Adult
Language	English
Publishing date	2019-08-14
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	604637-x
ISSN	1529-2401 ; 0270-6474
ISSN (online)	1529-2401
ISSN	0270-6474
DOI	10.1523/JNEUROSCI.1106-19.2019
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Article ; Online: Reply to "Letter on Spasticity Predicts Motor Recovery in Motor Complete Spinal Cord Injury".

Sangari, Sina / Chen, Bing / Hobbs, Sara / Olson, Amanda / Anschel, Alan / Kim, Ki / Chen, David / Kessler, Allison / Heinemann, Allen W / Oudega, Martin / Kwon, Brian K / Kirshblum, Steven / Guest, James D / Perez, Monica A

Annals of neurology

2024 Volume 95, Issue 5, Page(s) 1011–1012

MeSH term(s)	Humans ; Spinal Cord Injuries/physiopathology ; Spinal Cord Injuries/complications ; Muscle Spasticity/etiology ; Muscle Spasticity/physiopathology ; Recovery of Function/physiology ; Predictive Value of Tests
Language	English
Publishing date	2024-03-19
Publishing country	United States
Document type	Letter ; Comment
ZDB-ID	80362-5
ISSN	1531-8249 ; 0364-5134
ISSN (online)	1531-8249
ISSN	0364-5134
DOI	10.1002/ana.26908
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Article ; Online: Distinct patterns of spasticity and corticospinal connectivity following complete spinal cord injury.

Sangari, Sina / Kirshblum, Steven / Guest, James D / Oudega, Martin / Perez, Monica A

The Journal of physiology

2021 Volume 599, Issue 19, Page(s) 4441–4454

Abstract: Key points: Damage to corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). Here, we examined to what extent residual corticospinal connections and spasticity are present in muscles below the injury ( ... ...

Abstract	Key points: Damage to corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). Here, we examined to what extent residual corticospinal connections and spasticity are present in muscles below the injury (quadriceps femoris and soleus) in humans with motor complete thoracic SCI. We found three distinct subgroups of people: participants with spasticity and corticospinal responses in the quadriceps femoris and soleus; participants with spasticity and corticospinal responses in the quadriceps femoris only; and participants with no spasticity or corticospinal responses in either muscle. Spasticity and corticospinal responses were present in the quadriceps but never only in the soleus muscle, suggesting a proximal to distal gradient of symptoms of hyperreflexia. These results suggest that concomitant patterns of residual corticospinal connectivity and spasticity exist in humans with motor complete SCI and that a clinical examination of spasticity might be a good predictor of residual descending motor pathways in people with severe paralysis. Abstract: The loss of corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). However, the extent to which residual corticospinal connections and spasticity are present across muscles below the injury remains unknown. To address this question, we tested spasticity using the Modified Ashworth Scale and transmission in the corticospinal pathway by examining motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation over the leg motor cortex (cortical MEPs) and by direct activation of corticospinal axons by electrical stimulation over the thoracic spine (thoracic MEPs), in the quadriceps femoris and soleus muscles, in 30 individuals with motor complete thoracic SCI. Cortical MEPs were also conditioned by thoracic electrical stimulation at intervals allowing their summation or collision. We found three distinct subgroups of participants: 47% showed spasticity in the quadriceps femoris and soleus muscles; 30% showed spasticity in the quadriceps femoris muscle only; and 23% showed no spasticity in either muscle. Although cortical MEPs were present only in the quadriceps in participants with spasticity, thoracic MEPs were present in both muscles when spasticity was present. Thoracic electrical stimulation facilitated and suppressed cortical MEPs, showing that both forms of stimulation activated similar corticospinal axons. Cortical and thoracic MEPs correlated with the degree of spasticity in both muscles. These results provide the first evidence that related patterns of residual corticospinal connectivity and spasticity exist in muscles below the injury after motor complete thoracic SCI and highlight that a clinical examination of spasticity can predict residual corticospinal connectivity after severe paralysis.
MeSH term(s)	Evoked Potentials, Motor ; Humans ; Motor Cortex ; Muscle Spasticity/etiology ; Muscle, Skeletal ; Pyramidal Tracts ; Spinal Cord ; Spinal Cord Injuries/complications ; Transcranial Magnetic Stimulation
Language	English
Publishing date	2021-09-16
Publishing country	England
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	3115-x
ISSN	1469-7793 ; 0022-3751
ISSN (online)	1469-7793
ISSN	0022-3751
DOI	10.1113/JP281862
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Article ; Online: Transient increase in recurrent inhibition in amyotrophic lateral sclerosis as a putative protection from neurodegeneration.

Sangari, Sina / Peyre, Iseline / Lackmy-Vallée, Alexandra / Bayen, Eléonore / Pradat, Pierre-François / Marchand-Pauvert, Véronique

Acta physiologica (Oxford, England)

2022 Volume 234, Issue 4, Page(s) e13758

Abstract: Aim: Adaptive mechanisms in spinal circuits are likely involved in homeostatic responses to maintain motor output in amyotrophic lateral sclerosis. Given the role of Renshaw cells in regulating the motoneuron input/output gain, we investigated the ... ...

Abstract	Aim: Adaptive mechanisms in spinal circuits are likely involved in homeostatic responses to maintain motor output in amyotrophic lateral sclerosis. Given the role of Renshaw cells in regulating the motoneuron input/output gain, we investigated the modulation of heteronymous recurrent inhibition. Methods: Electrical stimulations were used to activate recurrent collaterals resulting in the Hoffmann reflex depression. Inhibitions from soleus motor axons to quadriceps motoneurons, and vice versa, were tested in 38 patients and matched group of 42 controls. Results: Compared with controls, the mean depression of quadriceps reflex was larger in patients, while that of soleus was smaller, suggesting that heteronymous recurrent inhibition was enhanced in quadriceps but reduced in soleus. The modulation of recurrent inhibition was linked to the size of maximal direct motor response and lower limb dysfunctions, suggesting a significant relationship with the integrity of the target motoneuron pool and functional abilities. No significant link was found between the integrity of motor axons activating Renshaw cells and the level of inhibition. Enhanced inhibition was particularly observed in patients within the first year after symptom onset and with slow progression of lower limb dysfunctions. Normal or reduced inhibitions were mainly observed in patients with motor weakness first in lower limbs and greater dysfunctions in lower limbs. Conclusion: We provide the first evidence for enhanced recurrent inhibition and speculate that Renshaw cells might have transient protective role on motoneuron by counteracting hyperexcitability at early stages. Several mechanisms likely participate including cortical influence on Renshaw cell and reinnervation by slow motoneurons.
MeSH term(s)	Amyotrophic Lateral Sclerosis ; Humans ; Motor Neurons/physiology ; Neural Inhibition/physiology ; Renshaw Cells ; Spinal Cord/physiology
Language	English
Publishing date	2022-01-23
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2218636-0
ISSN	1748-1716 ; 1748-1708
ISSN (online)	1748-1716
ISSN	1748-1708
DOI	10.1111/apha.13758
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Article ; Online: Residual descending motor pathways influence spasticity after spinal cord injury.

Sangari, Sina / Lundell, Henrik / Kirshblum, Steven / Perez, Monica A

Annals of neurology

2019 Volume 86, Issue 1, Page(s) 28–41

Abstract: Objective: Spasticity is one of the most common symptoms manifested in humans with spinal cord injury (SCI). The neural mechanisms contributing to its development are not yet understood. Using neurophysiological and imaging techniques, we examined the ... ...

Abstract	Objective: Spasticity is one of the most common symptoms manifested in humans with spinal cord injury (SCI). The neural mechanisms contributing to its development are not yet understood. Using neurophysiological and imaging techniques, we examined the influence of residual descending motor pathways on spasticity in humans with SCI. Methods: We measured spasticity in 33 individuals with motor complete SCI (determined by clinical examination) without preservation of voluntary motor output in the quadriceps femoris muscle. To examine residual descending motor pathways, we used magnetic and electrical stimulation over the leg motor cortex to elicit motor evoked potentials (MEPs) in the quadriceps femoris muscle and structural magnetic resonance imaging to measure spinal cord atrophy. Results: We found that 60% of participants showed symptoms of spasticity, whereas the other 40% showed no spasticity, demonstrating the presence of 2 clear subgroups of humans with motor complete SCI. MEPs were only present in individuals who had spasticity, and MEP size correlated with the severity of spasticity. Spinal cord atrophy was greater in nonspastic compared with spastic subjects. Notably, the degree of spared tissue in the lateral regions of the spinal cord was positively correlated with the severity of spasticity, indicating preservation of white matter related to motor tracts when spasticity was present. Interpretation: These results support the hypothesis that preservation of descending motor pathways influences spasticity in humans with motor complete SCI; this knowledge might help the rehabilitation and assessment of people with SCI. ANN NEUROL 2019.
MeSH term(s)	Adult ; Aged ; Efferent Pathways/diagnostic imaging ; Efferent Pathways/physiopathology ; Evoked Potentials, Motor/physiology ; Female ; Humans ; Male ; Middle Aged ; Motor Cortex/diagnostic imaging ; Motor Cortex/physiopathology ; Muscle Spasticity/diagnostic imaging ; Muscle Spasticity/etiology ; Muscle Spasticity/physiopathology ; Spinal Cord Injuries/complications ; Spinal Cord Injuries/diagnostic imaging ; Spinal Cord Injuries/physiopathology ; Young Adult
Language	English
Publishing date	2019-06-08
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	80362-5
ISSN	1531-8249 ; 0364-5134
ISSN (online)	1531-8249
ISSN	0364-5134
DOI	10.1002/ana.25505
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Article ; Online: Bilateral and asymmetrical contributions of passive and active ankle plantar flexors stiffness to spasticity in humans with spinal cord injury.

Chen, Bing / Sangari, Sina / Lorentzen, Jakob / Nielsen, Jens B / Perez, Monica A

Journal of neurophysiology

2020 Volume 124, Issue 3, Page(s) 973–984

Abstract: Spasticity is one of the most common symptoms present in humans with spinal cord injury (SCI); however, its clinical assessment remains underdeveloped. The purpose of the study was to examine the contribution of passive muscle stiffness and active spinal ...

Abstract	Spasticity is one of the most common symptoms present in humans with spinal cord injury (SCI); however, its clinical assessment remains underdeveloped. The purpose of the study was to examine the contribution of passive muscle stiffness and active spinal reflex mechanisms to clinical outcomes of spasticity after SCI. It is important that passive and active contributions to increased muscle stiffness are distinguished to make appropriate decisions about antispastic treatments and to monitor its effectiveness. To address this question, we combined biomechanical and electrophysiological assessments of ankle plantarflexor muscles bilaterally in individuals with and without chronic SCI. Spasticity was assessed using the Modified Ashworth Scale (MAS) and a self-reported questionnaire. We performed slow and fast dorsiflexion stretches of the ankle joint to measure passive muscle stiffness and reflex-induced torque using a dynamometer and the soleus H reflex using electrical stimulation over the posterior tibial nerve. All SCI participants reported the presence of spasticity. While 96% of them reported higher spasticity on one side compared with the other, the MAS detected differences across sides in only 25% of the them. Passive muscle stiffness and the reflex-induced torque were larger in SCI compared with controls more on one side compared with the other. The soleus stretch reflex, but not the H reflex, was larger in SCI compared with controls and showed differences across sides, with a larger reflex in the side showing a higher reflex-induced torque. MAS scores were not correlated with biomechanical and electrophysiological outcomes. These findings provide evidence for bilateral and asymmetric contributions of passive and active ankle plantar flexors stiffness to spasticity in humans with chronic SCI and highlight a poor agreement between a self-reported questionnaire and the MAS for detecting asymmetries in spasticity across sides.
MeSH term(s)	Adult ; Ankle/physiopathology ; Biomechanical Phenomena/physiology ; Electric Stimulation ; Electromyography ; Female ; H-Reflex/physiology ; Humans ; Male ; Middle Aged ; Motor Neurons/physiology ; Muscle Spasticity/diagnosis ; Muscle Spasticity/physiopathology ; Muscle, Skeletal/physiopathology ; Reflex, Stretch/physiology ; Severity of Illness Index ; Spinal Cord Injuries/physiopathology ; Tibial Nerve/physiology
Language	English
Publishing date	2020-05-20
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	80161-6
ISSN	1522-1598 ; 0022-3077
ISSN (online)	1522-1598
ISSN	0022-3077
DOI	10.1152/jn.00044.2020
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Article ; Online: Interrogating interneurone function using threshold tracking of the H reflex in healthy subjects and patients with motor neurone disease.

Howells, James / Sangari, Sina / Matamala, José Manuel / Kiernan, Matthew C / Marchand-Pauvert, Véronique / Burke, David

Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology

2020 Volume 131, Issue 8, Page(s) 1986–1996

Abstract: Objective: The excitability of the lower motoneurone pool is traditionally tested using the H reflex and a constant-stimulus paradigm, which measures changes in the amplitude of the reflex response. This technique has limitations because reflex ... ...

Abstract	Objective: The excitability of the lower motoneurone pool is traditionally tested using the H reflex and a constant-stimulus paradigm, which measures changes in the amplitude of the reflex response. This technique has limitations because reflex responses of different size must involve the recruitment or inhibition of different motoneurones. The threshold-tracking technique ensures that the changes in excitability occur for an identical population of motoneurones. We aimed to assess this technique and then apply it in patients with motor neurone disease (MND). Methods: The threshold-tracking approach was assessed in 17 healthy subjects and 11 patients with MND. The soleus H reflex was conditioned by deep peroneal nerve stimulation producing reciprocal Ia and so-called D1 and D2 inhibitions, which are believed to reflect presynaptic inhibition of soleus Ia afferents. Results: Threshold tracking was quicker than the constant-stimulus technique and reliable, properties that may be advantageous for clinical studies. D1 inhibition was significantly reduced in patients with MND. Conclusions: Threshold tracking is useful and may be preferable under some conditions for studying the excitability of the motoneurone pool. The decreased D1 inhibition in the patients suggests that presynaptic inhibition may be reduced in MND. Significance: Reduced presynaptic inhibition could be evidence of an interneuronopathy in MND. It is possible that the hyperreflexia is a spinal pre-motoneuronal disorder, and not definitive evidence of corticospinal involvement in MND.
MeSH term(s)	Adult ; Aged ; Electromyography/methods ; Female ; H-Reflex ; Humans ; Interneurons/physiology ; Male ; Middle Aged ; Motor Neuron Disease/diagnosis ; Motor Neuron Disease/physiopathology ; Motor Neurons/physiology ; Muscle, Skeletal/physiopathology ; Neural Inhibition ; Peroneal Nerve/physiopathology ; Synaptic Potentials
Language	English
Publishing date	2020-04-13
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1463630-x
ISSN	1872-8952 ; 0921-884X ; 1388-2457
ISSN (online)	1872-8952
ISSN	0921-884X ; 1388-2457
DOI	10.1016/j.clinph.2020.03.028
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In stock of ZB MED Cologne/Königswinter

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Full text online

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Kategorien

In stock of ZB MED Cologne/Königswinter

Order via subito