help button home button ClinMed NetPrints
HOME HELP FEEDBACK BROWSE ARTICLES BROWSE BY AUTHOR
Warning: This article has not yet been accepted for publication by a peer reviewed journal. It is presented here mainly for the benefit of fellow researchers. Casual readers should not act on its findings, and journalists should be wary of reporting them.

This Article
Right arrow Abstract Freely available
Services
Right arrow Similar articles in this netprints
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sobol, Y. Ts.
Right arrow Articles by Makeev, B. L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Sobol, Y. Ts.
Right arrow Articles by Makeev, B. L.
Related Collections
Right arrow Cardiovascular Medicine:
Other Cardiovascular Medicine

Right arrow CLINICAL:
Critical Care / Intensive Care

Right arrow Physiotherapy
Right arrow Rehabilitation Medicine
Right arrow Sports Medicine

clinmed/2003020002v1 (February 13, 2003)
Contact author(s) for copyright information

A SPECIAL REHABILITATION PHYSICAL TRAINING EXERCISE PROGRAM FOR HIGH-RISK UNCONSCIOUS SURGICAL PATIENTS

 Sobol Y.T.1 Phys. Therap., Psycol., Sobol C.V.2 Ph.D., Makeev B.L.1 M.D.

 

1) Military Academy, St.-Petersburg, Russia, 2) Sechenov Institute of Evolutionary Physiology & Biochemistry, Russian Academy of Science, Thorez. pr., 44, 194223 St.-Petersburg, Russia.

Running title:

Exercise program for high-risk surgical patients

 

Address for the correspondence:

C.V. Sobol, Ph.D.

Sechenov Institute of Evolutionary Physiology & Biochemistry,

Russian Academy of Science,

Thorez pr. 44, St.-Petersburg, Russia 194223.

Fax: +7 (812) 552-30-12

E-mail: csobol{at}KS2794.spb.edu

 

ABSTRACT

 

Objectives:  This study evaluates short- and long-term effects of a special therapeutic physical exercises (TPE) applied immediately after the operations. Design:  The TPE were designed for high-risk surgical patients without consciousness and/or with severe postoperative complications. 165 patients without consciousness after the operations were divided into three groups: control group (n = 17) to whom no TPE were applied; group 1 (n = 80) who performed the TPE by about 50%; group 2 (n = 68) who performed the TPE completely. Outcome Parameters: Short-term effects were the in-hospital mortality rate, regain of consciousness, and complications after surgical interventions. Long-term effects were the number of reemployed patients and the time of repeated operations. Setting: The TPE program was tested for 24 years (1966-1990) at the Surgical Department, Military Medical Academy, St.-Petersburg, Russia. Results:  The in-hospital mortality rate was 100% in control group, 36% in group 1, and 0% in group 2; regain of consciousness was 38+12 hr in control group and 4.1+1.5 hr in group 2 after the operations. Postoperative complications were the least in group 2. Period of hospitalization was 5 times shorter in patients of group 2 as compared with group 1. The periods between repeated operations were longer in patients of group 2 in comparison to group 1, and the number of reemployed patients of group 2 was 7 times higher. Conclusions: TPE for high-risk surgical patients, has significant short- and long-term benefits. TPE is proposed to be integrated into a basic medical therapy rehabilitation process.

Key words: early physical exercise training, surgical patients, rehabilitation, postoperative complications, quality of life.

 

INTRODUCTION

 

Physical therapy procedures for most patients with cardiovascular diseases, especially for those who underwent cardiac surgery appear to be a part of the basic medical therapy. Their efficacy, short- and long-term effects are widely discussed in literature [1], [2], [3], [4], [5]. Performance of special exercises by surgical patients during postoperative period may have some physiological and psychological effects [3], [6], [7]. These include changes of cardiac activity (rhythm, pulse, and blood pressure) and of respiration as well as improved general well-being [8], [9], [10]. However, no improved survival has been demonstrated [5].

 The main criterion for patients to perform exercises after a surgical intervention is that they should have consciousness and stable hemodynamics, and intensity of application depends on status and physical endurance of patients [8], [9], [4]. However, the exercises of any kind are contraindicated for surgical patients without consciousness and/or with severe postsurgical complications, as performance of rehabilitation exercises may aggravate status of such patients [8], [9].

This study appears to be the first attempt that showed both the prominent short-term (the in-hospital morbidity and mortality rate, regain of consciousness, and complications after surgical interventions, period of hospitalization) and the long-term beneficial effects (the number of reemployed patients and the time of repeated operations) of application of therapeutic physical exercises (TPE). The TPE were applied immediately after the operations and designed for  high-risk  patients  without  consciousness  after  surgical  interventions. The method has been elaborated by Sobol Y.T. and has been tested for 24 years (1966-1990) at the Surgical Department of the Military Medical Academy, St. Petersburg, Russia.

Some results of this study were presented as a short communication at the 3rd International Congress on Heart Failure (Geneva, Switzerland, May, 1995).

 

 

PATIENTS AND METHODS

Background:

The TPE method has been designed especially for high risk operations, e.g., the heart and lung operations, esophagus transplantation, and for cancer patients. Patients had additional risk factors connected with their preoperative status: sclerosis, contusion, gastric paresis, exhaustion, adiposity, and immunodeficiency (e.g. after irradiation), extensive peritonitis, sepsis, diabetes, high arterial pressure, hepatorenal insufficiency, cardiopulmonary insufficiency, psychoses, etc. There also were the combinations of the risk factors.

The method was approved by the Research Committee of the Military Medical Academy Surgical Department in 1976. The method was designed mainly for military times when the convalescence period is extremely restricted.

Target audience for TPE method:

In this study we are considering only surgical patients.

1. Unconscious surgical patients with stable and unstable haemodynamics.

2. Conscious surgical patients with insufficient activity after surgery and patients with     threatening postoperative complications.

3. Cancer surgical patients to whom nothing was done during the operation.

Operations and postoperative complications for which the TPE method was used:

The total number of the surgical patients who were admitted to the Military Medical Academy in St. Petersburg between 1966 and 1990 and performed completely the therapeutic exercises after the operation were 32,841. Only Sobol Y.T. served the patients; sometimes the relatives of the patients performed the therapeutic exercise program under supervision of Sobol Y.T.

a) The operations were composed of the following groups:

1.   Chest surgical intervention.

1.1. Congenital heart defects - 7,876 patients.

1.2. Acquired heart defects including valvular prosthesis, ischemic heart disease,      electrocardiostimulation transplantation, aneurysm, and others - 6,460 patients.

1.3. Lung operations and other chest operations, e.g. esophagus transplantation, including cancer patients - 5,890 patients.

2.  Other operations including operations for abdominal emergencies, e.g. cholecystitis,      pancreatitis, peritonitis, acute appendicitis. Operations for acute traumatic conditions, e.g. hepatic trauma, splenic trauma, heart trauma, etc. Kidney transplantation, breast operations, and others   - 12,615 patients.

b) Complications after surgery included:

Local: wound infection, wound hematomas, intraabdominal hematomas, etc.

General: acute pulmonary embolus, acute pulmonary edema, postoperative atelectasis, postoperative pancreatitis, tracheostomy, hepatorenal insufficiency, cardiovascular insufficiency, suppuration, acute urinary retention, gastric paresis, etc.

The TPE method for unconscious surgical patients:

The study included 165 patients without consciousness after the operations. The main criterion for the selection of patients is the fulfillment of TPE.  The patients were divided into three groups. Control group included 17 patients to whom no therapeutic exercises were applied. The patients could not perform exercises because of the absence of Sobol Y.T. Group 1 included 80 patients who performed the therapeutic exercises partially, by about 50%, during the postoperative period. The patients in this group did not perform the full complex of the exercises completely by themselves because of an inappropriate control of the hospital stuff. Group 2 included 68 patients who performed completely the therapeutic exercises after the operation. The classification of the patients in the groups according to the diagnosis and the surgical intervention is presented in Table 1. The patients were chosen to have virtually the same operations and postoperative periods for all groups, although 18 patients recognized as hopeless after the conference of expert physicians were included in the group 2; no such severely sick patients were in the control and group 1. Besides, the patients of the group 2 had somewhat more complicated operations than the patients of two other groups.

The therapeutic physical exercises program:

The program included some elements of massage of the chest, head, diaphragm, arms, and legs, and the bending of hands and feet under the controlled breathing and cardiac rhythm. There is a minimal complex of exercises that consists of three types of exercises (elements of massage and movements of minimal groups of muscles). The complex stimulates blood circulation and improves heart work;  at  the same time, the complex does not overload the heart work. This is the main difference from accepted methods of physical training and massage.

The arterial and venous blood pressure, pCO2 and pO2, respiration, temperature, electrocardiogram, quality and quantity of urine, chest X-ray film are to be taken into account at the performance of the minimal TPE complex. These are valuable indexes of the correct application of the complex of exercises. The performance of the exercises also depends on the cardiac rhythm (tachycardia, arrhythmia, etc.). The details are not described here.

The minimal complex of exercises is performed once or several times, usually 5, 8 or 12 times, immediately after the operation or after the complications to determine the response of the patient to the physical methods of treatment.  It is also performed to remove the fatigue after the full complex of exercises and therapeutic procedures.

After a relative stabilization of haemodynamics, the exercises involving a large group of muscles were added. It is a full complex. The full complex was also repeated several times up to the restoration of independent and conscious activity of patients. The patients continued to perform the therapeutic exercise program by themselves.

At the first step of the TPE application the hospital stuff, relatives or physical therapists are performing the TPE, until the patients regain consciousness. At this moment the cardiopulmonary resuscitation unit, injection systems, and drainage lines may be used. The second step starts when the patient regains consciousness and is able to understand the situation; he begins performing the TPE by himself and regulates the TPE intensity, depending on his feeling and the morbidity rate; all basic medical therapeutic procedures are performed according to prescriptions. The patients are preoperatively prepared physically and psychologically for the TPE performance. For the unconscious  patients,  Sobol Y.T. performed the TPE program permanently. In some cases the relatives of patients performed the TPE program under the supervision of Sobol Y.T.

The contraindications for the application of TPE:

The therapeutic exercise program was not applied in the cases of the following complications: massive hemorrhage, an attack of paroxysmal tachycardia, unconsciousness after hypertonic crisis or renal colic, diabetic coma, progressing pathological reflexes (clonic convulsions).

The main outcome parameters:

The study end points were the in-hospital mortality rate, regain of consciousness after the operation, complications after surgical interventions.

Statistics:

Numerical data were usually expressed as the mean + SEM, and the statistical significance of differences was estimated using Student's t-test. The p<0.01 was considered to be statistically significant.

 

RESULTS

 

At the time of the study, patients from all areas of the former USSR were admitted to the Military Medical Academy. Owing to the exercise therapy, the postoperative period was very easy, and the rate of mortality was lower than 1%, although surgical interventions were very complicated, as it can be seen from the case study below. It was true only for patients who performed the TPE.

The in-hospital mortality rate and complications after surgery interventions are presented in Table 2. As seen from Table 2, the in-hospital mortality rate in group 2 was minimal  (0%),  and  all  patients  regained  consciousness,  on average, in 4.1+1.5 hr after the operations.  In contrast, only 7 patients of control group regained consciousness, on average, in 38+12 hr after the operations (p<0.001); the recovery of consciousness being only partial, i.e. the patients awoke incompletely. Later, all these patients died during the postoperative period due to severe complications (Table 2). Ten patients of control group did not regain consciousness at all.

Compared to control group and group 1, the patients of group 2 had fewer complications after the surgery (Table 2). The duration of hospitalization was 4 times shorter (Table 2), and the periods between repeated comissurotomies were longer, which means that the efficacy of surgical interventions was increased. The patients of group 2 had the second operation, mitral commissurotomy, after 13.6+0.9 years (n=3), whereas patients of group 1, after 2.4+0.3 years (n=9, p<0.001). Only 3 patients out of 44 (acquired heart defects) of group 2 needed valvular prosthetics during the second operation, on average, in 8.2+0.6 years, while 6 out of 41 (acquired heart defects, group 1) needed valvular prosthetics during the second operation in 1.8+0.5 years (p<0.001).

The application of the TPE program also helped the patients to survive after unsuccessful operations. In case of ineffective commissurotomies with the necessity of valvular prosthetics, the in-hospital mortality rate in the patients of group 2 amounted to 0%, while in the patients of group 1, 89% (8 out of 9 patients died).

Finally, 79% (n=54) of patients of group 2 were reemployed permanently or periodically, 1.5 year after the operations, whereas, in contrast, only 11% (n=7) of patients of group 1 were reemployed.

Two examples of practical effects of TPE application

CASE 1.  Female, aged 42 years. Diagnosis: combined valvular disease with predominant stenosis. On December 20, 1975, operation on emergency commissurotomy was performed. Aggravating factors were: 1) pulmonary edema, 2) repeated intubations (5 times) and wrong position of the lung tube, 3) one-lung general anesthesia with total atelectasis of the left lung with a displacement of the mediastinum, 4) thoracotomy on the background of pulmonary edema, 5) mitral commissurotomy during cardiac arrest, 6) absence of urinary excretion during the operation.

The resuscitation unit with lung ventilation was used. The patient was unconscious, and reflexes could not be provoked. Immediately after the operation the TPE was performed permanently for 3.5 hr, until the patient regained consciousness. The hemodynamics after the operation and at the moment of recovery of clear consciousness are presented in Table 3. As a result of application of TPE, 500 ml of urine were obtained 1 hr after the operation, without administration of diuretics. Additional 500 ml of urine were obtained in 5.5 hours after the operation.

The following medical services were used: 1) in 0.5 hr after the operation, the subclavian vein was punctured, and 5 mg of benzohexonium were injected; 2) in 1 hr  after the operation, additional 12.5 mg of benzohexonium were injected; 3) in 1.5 hr  after the operation, intravenous injections were made of aminasinum - 25 mg,  diprasinum - 50 mg, and euphyllinum - 240 mg; 4) in 2.5 hr after the operation, a spinal  puncture was made, and sodium carbonate was injected.

When the patient regained consciousness, she performed the exercise therapy method by herself. The patient was discharged from the hospital in 15 days after the operation.

CASE 2.  Male, aged 24 years. Diagnosis: complicated heart disease with predominant insufficiency, circulatory insufficiency 4/2. Two months before the operation, the patient had an acute infarction with pneumonia. On December 10, 1975, an operation of mitral valve prosthetics was performed.  Aggravating factors were: 1) cardiac arrest during the operation; 2) in addition to the initial 15 mg, the second injection of 25 mg of benzohexonium at the end of the operation, 3) absence of urine during the operation.

The resuscitation unit with lung ventilation was used. There was no reaction to light, the patient was unconscious. Immediately after the operation, the TPE were performed permanently for 5 hr 45 min, until the patient regained consciousness. The hemodynamics after the operation and at the moment of recovery of clear consciousness are presented in Table 3. As a result of application of the exercise therapy method, 400 ml of urine were obtained 2 hr after the operation, without administration of diuretics. After that, 500 ml of blood were injected. No additional basic medical services were used.

When the patient regained consciousness, he performed the exercise therapy method by himself. The patient was discharged from the hospital in 15 days after the operation.

   

DISCUSSION

 

This study demonstrates pronounced short- and long-term therapeutic effects of postoperative application of the TPE. For recent years, the postoperative management focused on an early mobilization that resulted in a short length of hospital stay [11]. It is commonly accepted that the earliest rehabilitation in patients is possible following a less invasive heart surgery and may start 1-2 weeks postoperatively [8], [9], [5]. We are recommending application of the TPE immediately after the operation to shorten considerably the period of hospitalization. The proposed TPE were designed for unconscious surgical patients with both the stable and unstable haemodynamics and differed significantly in the type of physical exercises among accepted physical therapy procedures. We are to emphasize that the intensity, time of application, and type of physical exercises are quite different for the surgical and therapeutic, e.g. myocardial infarction, patients. In this study we are considering only surgical patients without consciousness, when the TPE were applied immediately after the operations and more intensively than for therapeutic patients. The TPE are much more effective for conscious patients after the operation and also may be successfully applied to therapeutic patients, but this is out of the scope of this study.

Unfortunately, at present there are no exercises of any kind for unconscious surgical patients, as application of well-known methods of physical therapy or massage might aggravate the state of such patients. Thus, application of massage for such patients with heart problems can lead to the cardiac arrest. Moreover, our TPE were designed for the patients with a very high risk for the postoperative morbidity and mortality rate, when for such cases the medical community considers a nonsurgical therapy [11].

Physiological and psychological background for the application of TPE immediately after the operation

Anesthesia and surgical intervention cause a physiological instability of pathological processes (reflexes) in the organism. Application of the TPE designed for unconscious surgical patients immediately after the operation promotes recovery of normal physiological relationships between organs and systems of organs. The minimal complex of exercises does not cause the cardiovascular system overloading, as it follows from monitoring of cardiac activity. Persistent repetition of a minimal complex of exercises yields a therapeutic effect. The effect is seen as an improvement of the cardiac rhythm and work of the renal system and gastrointestinal tract. The phlegm did not accumulate in the lungs, and temperature did not increase. No edema of surgical stitches was present. There were observed a painkilling effect and normalization of interactions between organs and systems, which were altered as a result of disease. The next step is an appropriate preparation of the patients to the therapeutic rising, mainly during the first day after the operation. The rising leads to further mobilization of reserves of the patients, as the organs and systems of organs are in the normal position.

Immobilization of surgical patients is one of the reasons for the physical and nervous exhaustion of severely sick patients, which thereby increases complications after the operation. On the other hand, the wrong early mobilization is also dangerous for high-risk patients, if someone attempts to raise such severe surgical patient without performing a minimal complex of exercises, which might lead to cardiac arrest, loss of consciousness or even death.

The hospital stuff should perform the exercise therapy method immediately after the surgical intervention. It stimulates circulation (data not shown) and promotes elimination of products of drug metabolism. The patient regains consciousness very quickly and can perform the TPE by himself.

Benefits of TPE application

The comparison of groups 1 and 2 is not quite correct, as all the patients performed TPE, although the patients of group 1 did it incompletely. Nevertheless, the comparison was done to evaluate both short- and long-term effects.

Short-term effects:

1. The application of TPE leads to a considerable reduction of the in-hospital mortality rate. All patients in group 2 survived and were discharged home, whereas nobody of control group survived.

2. The patients regained consciousness after the operation very quickly, approximately 10 times faster that the patients of control group, and were able to perform TPE by themselves. A quick mobilization of patients resulted in a shortening the time of the use of resuscitation unit and drainage lines. This, in turn, leads to items 3 and 4.

3. There were very few complications after surgery interventions, when the TPE were applied. On the whole, the exercise therapy in a complex treatment produced a manifold effect on the treatment process of severely sick patients. The patients, to whom the TPE were applied, used less patient-controlled analgesia and oral narcotic pain-killers, the number of intravenous infusions, and therapeutic procedures. The postoperative pain and morbidity were reduced considerably, and in most cases completely. Thus, the whole rehabilitation process was changing in the direction of simplification.

4. Rehabilitation programs based on the proposed exercise therapy method shortened the convalescence period and time of return to work. The hospitalization period was reduced by 5 times, as it follows from comparison of groups 1 and 2. Taking into account that some cardiac patients can be discharged quickly [12], the proposed TPE would help such patients to recover at home without reducing the efficacy of operations. Moreover, the TPE can be used as the basis for home-based rehabilitation programs [13] both for surgical and therapeutic patients.

Long-term effects:

1. Efficacy of operations increased after the complete TPE application, as the periods between repeated operations, both mitral commisurotomies and valvular prosthetics, were longer 5.4 and by 4.6 times, respectively, in the patients of group 2 as compared to group 1. Moreover, the in-hospital mortality rate after ineffective commissurotomies was very high in group 1.

2. The number of reemployed patients of group 2 was 7 times higher than of group 1.

Conclusion:

This appears to be the first study that showed that a special TPE program for clinically complicated cases, surgical patients without consciousness and/or with severe postoperative complications, had pronounced short- and long-term benefits including in-hospital mortality, morbidity rates, and "quality of life". We propose integrating the TPE program into the basic medical therapy rehabilitation process.

 

                                                         REFERENCES

[1]. Longmuir PE, Turner JA, Rowe RD, Olley PM. Postoperative exercise rehabilitation benefits children with congenital heart disease. Clin Invest Med 1985;8:232-238.

[2]. Newton M, Mutrie N, McArthur JD. The effects of exercise in a coronary rehabilitation programme. Scott Med J 1991;36:38-41.

[3]. Saner H, Saner B, Staubli R. Initial results with a comprehensive ambulatory rehabilitation program for heart patients. Schweiz Med Wochenschr 1994 Nov 19;124:2075-2082.

[4]. Robichaud-Ekstrand S, Loyer J. Exercises that should be prescribed for heart patients. Can Nurse 1996;92:39-46.

[5]. Carrel T, Mohacsi P. Optimal timing of rehabilitation after cardiac surgery: the surgen's view. Eur Heart J 1998;19 Suppl O:O38-O41.

[6]. Lomama E, Helft G, Persoz A, Dufour JC, Laudy C, Monnet De Lorbeau B, Vacheron A. Factors determining the improvement of effort capacity in aged patients with coronary disease during the 1st month following coronary surgery. Ann Cardiol Angeiol (Paris) 1997;46:579-583.

[7]. Dafoe W, Huston P. Current trends in cardiac rehabilitation. CMAJ 1997 Feb 15;156:527-532.

[8]. Moshkov VN. Exercise therapy in hospital. Moscow, Russia: Medicine, 1977:156.

[9]. Cuzin MI, Shkrob OS, Capemovich RL, Jankelevich EI. Exercise therapy in chest surgery. Moscow, Russia: Medicine, 1984:175.

[10]. Graves JE, Pollock ML. Exercise testing in cardiac rehabilitation. Role in prescribing exercise. Cardiol Clin 1993;11:253-266.

 

[11]. Reilly JJ Jr. Preoperative and postoperative care of standard and high risk surgical patients. Hematol Oncol Clin North Am 1997;11:449-59

 

[12]. Pashkow FJ. Cardiac rehabilitation: not just exercise anymore. Cleve Clin J Med 1996;63:116-123.

 

[13]. Jairath N, Salerno T, Chapman J, Dornan J, Weisel R. The effect of moderate exercise training on oxygen uptake post-aortic/mitral valve surgery. J Cardiopulm Rehabil 1995;15:424-430.

 

 

 

Table 1.  Distribution of the patients according to disease and surgical intervention.

 

Group No

No of patients

 Acquired Heart defects

Congenital Defects

Other operations

Control

    17

    9 (all of them valvular prosthesis)

    8 (3 of them tetrology of Fallot)

       0

     1

    80

    41

    24

     15

     2

    68

    44 (22 of them valvular prosthesis)

    17  (9 of them tetrology of Fallot)

       7

 

Table 2. Survival and postoperative complications for 3 groups of patients in the postoperative period *

Group No

 Control

         1

            2

Total No of patients

   17

     80

    68

No  of survivals

    0

     51 (64%)

    68 (100%)

Regain of consciousness

    7 (40%)

     64 (80%)        

    68 (100%)

Time of hospitalization, days

      -

     65+6

    13+2

Complications:

Tracheostomy

Thromboembolism

Pulmonary complications

Hepatorenal insufficiency

Cardiovascular insufficiency

Suppuration

 

  6 (35%)

  4 (24%)

  6 (35%)

  5 (29%)

  5 (29%)

  4 (24%)

 

       10 (13%)

         6 (8%)

         7 (9%)

         6 (8%)

         6 (8%)

         8 (10%)

 

      0

      2 (3%)

      0

      3 (4%)

      3 (4%)

      2 (3%)

 

* - in brackets the percentages from the total number of patients in each group are given.

 

Table 3. Haemodynamic data of cases 1 and 2 *

  Case

Pulse rate

Arterial pressure

     (mm Hg)

Venous pressure

       (mm Hg)

Temperature

(in Celsius)

     1

      96

    (100)

       145/90

      (115/80)

         30-40

        (40-50)

      36

     (36.6)

     2

120, arrhythmic

     (84)

         80/-

       (110/70)

            60

          (110)

      35.8

     (36.6)

 

     * - without brackets the data of haemodynamic immediately  after the operation are indicated; in brackets -  at the moment of recovery of consciousness after the application of TPE.

 

 





This Article
Right arrow Abstract Freely available
Services
Right arrow Similar articles in this netprints
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Sobol, Y. Ts.
Right arrow Articles by Makeev, B. L.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Sobol, Y. Ts.
Right arrow Articles by Makeev, B. L.
Related Collections
Right arrow Cardiovascular Medicine:
Other Cardiovascular Medicine

Right arrow CLINICAL:
Critical Care / Intensive Care

Right arrow Physiotherapy
Right arrow Rehabilitation Medicine
Right arrow Sports Medicine


HOME HELP FEEDBACK BROWSE ARTICLES BROWSE BY AUTHOR