Turkiye Klinikleri Journal of Pediatrics

.: REVIEW
Exercise Testing in Children with Cystic Fibrosis
Kistik Fibrozisli Çocuklarda Egzersiz Testleri
Azime ACAR HİSARKAYAa, Alkım BEYHANb, Selma CİVAR YAVUZa
aDepartment of Sports and Health Sciences, Akdeniz University Faculty of Sport Sciences,
bDepartment of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, TURKEY
Turkiye Klinikleri J Pediatr. 2019;28(2):77-86
doi: 10.5336/pediatr.2018-63938
Article Language: EN
Full Text
ABSTRACT
 Cystic fibrosis is a genetic disease in children. The respiratory system is affected due to thickening of secretions. Therefore, pulmonary functions are deteriorated and dyspnea may occur during exercise. Children with cystic fibrosis may not tolerate exercise. Exercise testing is important to determine exercise-related complications and to plan exercise. Exercise tests are necessary applications for all individuals engaged in exercise. Exercise tests are used to determine the prognosis of the disease, exercise tolerance, mortality, efficacy of the treatment and exercise prescription. In this review, the studies using exercise test with children with cystic fibrosis aged between 4 and 18 years were examined. The subjects related to exercise and exercise test are briefly mentioned. The studies have been published between 1986 and 2018 years. The purpose of this review is to emphasize the importance of exercise tests in children with cystic fibrosis and to examine the various exercise tests used in previous studies. In this study, laboratory and field tests were used. Laboratory tests were performed using bicycle ergometers and treadmill. Wingate, Godfrey, CPETSRT and Bruce protocol were used in laboratory tests. In the field tests, generally 6 minutes walk test, 2 minutes walk test, 3 minutes step test, Munich fitness test and shuttle test were used. These protocols were selected according to the age, height and weight of the child. These tests were modified for children.

Keywords: Children; cystic fibrosis; exercise test
ÖZET
 Kistik fibrozis çocuklarda görülen genetik bir hastalıktır. Sekresyonların kalınlaşmasından dolayı solunum sistemi etkilenir. Bu nedenle, pulmoner fonksiyonlar bozulur ve egzersiz sırasında dispne meydana gelebilir. Kistik fibrozisli çocuklar egzersizi tolere edemeyebilir. Egzersize bağlı komplikasyonları belirlemek ve egzersiz planlaması yapabilmek için egzersiz testi önemlidir. Egzersiz testleri egzersiz yapan tüm bireyler için gerekli bir uygulamadır. Egzersiz testleri hastalığın prognozunu, egzersiz toleransını, mortaliteyi, tedavinin etkinliğini ve egzersiz reçetesini belirlemede kullanılır. Bu derleme çalışmasında, 4-18 yaş arası kistik fibrozisli çocuklarla yapılan egzersiz testi kullanılan çalışmalar incelenmiştir. Egzersiz ve egzersiz testi ile ilgili konulara kısaca değinilmiştir. İncelenen çalışmalar 1986 ile 2018 yılları arasında yayınlanmıştır. Derlemenin amacı kistik fibrozisli çocuklarda egzersiz testinin önemini vurgulamak ve daha önceki çalışmalarda kullanılan çeşitli egzersiz testlerini incelemektir. Bu çalışmada laboratuvar ve alan testleri kullanılmıştır. Laboratuvar testleri bisiklet ergometresi ve koşu bandı kullanılarak uygulanmıştır. Laboratuvar testlerinde Wingate, Godfrey, CPET-SRT ve Bruce protokolü kullanılmıştır. Alan testlerinde ise genellikle 6 dakika yürüme testi, 2 dakika yürüme testi, 3 dakika step testi, Münih fitnes testi ve mekik testi kullanılmıştır. Bu protokoller çocuğun yaşına, boyuna ve kilosuna göre seçilmiştir. Testler çocuklar için modifiye edilmiştir.

Anahtar Kelimeler: Çocuk; kistik fibrozis; egzersiz testi
REFERENCES:
  1. Hasanoğlu E, Düşünsel N. Bideci A. Temel Pediatri. Baskı. Ankara: Güneş Tıp Kitabevi; 2010. p.616.
  2. Mathias H, Ralph B. Cystic fibrosis. In: LeMura LM, Von Duvillard SP, eds. Clinical Exercise Physiology: Application and Physiological Principles. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p.169.
  3. Konstan MW. Therapies aimed at airway inflammation in cystic fibrosis. Clin Chest Med. 1998;19(3): 505-13. [Crossref ]
  4. Stevens D, Oades PJ, Armstrong N, Williams CA. A survey of exercise testing and training in UK cystic fibrosis clinics. J Cyst Fibros. 2010;9(5):302-6. [Crossref] [PubMed]
  5. Urguhart DS. Exercise testing in cystic fibrosis: why (and how)? J R Soc Med. 2011;104 Suppl 1:S6-14. [Crossref] [PubMed] [PMC]
  6. Cooper CB, Storer TW. Exercise Testing and Interpretation. A Practical Approach. Chapter 4. 1st ed. New York: Cambridge University Press; 2001. p.93-148. [Crossref ]
  7. Almajed A, Lands LC. The evolution of exercise capacity and its limiting factors in cystic fibrosis. Paediatr Respir Rev. 2012;13(4):195-9. [Crossref] [PubMed]
  8. Nixon PA, Orenstein DM, Kelsey SF, Doershuk CF. The prognostic value of exercise testing in patients with cystic fibrosis. N Engl J Med. 1992;327(25): 1785-8. [Crossref ] [PubMed]
  9. Pianosi P, LeBlanc J, Almudevar A. Relationship between FEV1 and peak oxygen uptake in children with cystic fibrosis. Pediatr Pulmonol. 2005;40(4):324-9. [Crossref] [PubMed]
  10. Moore GA, Durstine L, Marsh P. ACSM?S Exercise Management for Persons with Chronic Diseases and Disabilities. Chapter 2:5. 2nd ed. Champaign, III: Human Kinetics; 2002. p.374.
  11. Berman N, Bailey R, Barstow TJ, Cooper DM. Spectral and bout detection analysis of physical activity patterns in healthy, prepubertal boys and girls. Am J Human Biol. 1998;10(3):289-97. [Crossref]
  12. Kamar A. Sporda Yetenek Beceri ve Performans Testleri. 1. Baskı. Nobel Publication, Ankara: Nobel Yayıncılık; 2003. p.149-79.
  13. Arikan H, Yatar İ, Calik-Kutukcu E, Aribas Z, Saglam M, Vardar-Yagli N, et al. A comparison of respiratory and peripheral muscle strength, functional exercise capacity, activities of daily living and physical fitness in patients with cystic fibrosis and healthy subjects. Res Dev Disabil. 2015;45-46:147-56. [Crossref] [PubMed]
  14. Nixon Patricia A. Cystic fibrosis. ACSM?S Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign, III: Human Kinetics, 2002. p.111.
  15. Ergün P, Yıldız Ö. Pulmoner Rehabilitasyon Cep Kitabı. Ankara: Türk Toraks Derneği; 2013. p.23.
  16. Selvadurai HC, McKay KO, Blimkie CJ, Cooper PJ, Mllis CM, Van Asperen PP. The relationship between genotype and exercise tolerance in children with cystic fibrosis. Am J Respir Crit Care Med. 2002;165(6):762-5. [Crossref ] [PubMed]
  17. Klijn PH, Oudshoorn A, van der Ent CK, van der Net J, Kimpen JL, Helders PJ. Effects of anaerobic training in children with cystic fibrosis: a randomized controlled study. Chest. 2004;125(4):1299-305. [Crossref] [PubMed]
  18. Hebestreit H, Arets HG, Aurora P, Boas S, Cerny F, Hulzebos EH, et al. Statement on exercise testing in cystic fibrosis. Respiration. 2015;90(4):332-51. [Crossref] [PubMed]
  19. Weir E, Burns DP, Devenny A, Young D, Paton JY. Cardiopulmonary exercise testing in children with cystic fibrosis: one centre?s experience. Arch Dis Child. 2017;102(5): 440-4. [Crossref ] [ PubMed]
  20. Kent L, O?Neill B, Davison G, Nevill A, Murray J, Reid A, et al. Cycle ergometer tests in cystic fibrosis. Pediatr Pulmonol. 2012;47(12): 1226-34. [Crossref] [PubMed]
  21. Cerny FJ, Cropp GJ, Bye MR. Hospital therapy improves exercise tolerance and lung function in cystic fibrosis. Am J Dis Child. 1984;138(3):261-5. [Crossref] [PubMed]
  22. Klijn PH, van der Net J, Kimpen JL, Helders PJ, Van der Ent CK. Longitudinal determinants of peak aerobic performance in children with cystic fibrosis. Chest. 2003;124(6):2215-9. [Crossref ] [PubMed]
  23. Werkman MS, Hulzebos EHJ, Helders PJM, AretS BGM, Takken T. Estimating peak oxygen uptake in adolescents with cystic fibrosis. Arch Dis Child. 2013;1-5. [Crossref ] [PubMed]
  24. Saynor ZL, Barker AR, Oades PJ, Williams CA. A protokol to determine valid VO2 max in young cystic fibrosis patients. J Sci Med Sport. 2013;16(6):539-44. [Crossref ] [PubMed]
  25. Keochkerion D, Chief M, Delanaud S, Gauthier R, Maingourd Y, Ahmaidi S. Timing and driving components of the breathing strategy in children with cystic fibrosis during exercise. Pediatr Pulmonol. 2005;40(5):449-56. [Crossref ] [ PubMed]
  26. Boungers BC, Werkman MS, Arets HG, Takken T, Hulzebos HJ. A possible alternative exercise test for youths with cystic fibrosis. Med Sci Sports Exerc. 2015;47(3):485-92. [Crossref ] [PubMed]
  27. Edlund LD, French RW, Herbst JJ, Ruttenburg HD, Ruhling RO, Adams TD. Effects of a swimming program on children with cystic fibrosis. Am J Dis Child. 1986;140(1):80-3. [Crossref ] [PubMed]
  28. Lima CA, Andrade Ade F, Campos SL, Brandão DC, Fregonezi G, Mourato IP, et al. Effects of noninvasive ventilation on treadmill 6-min walk distance and regional chest wall volumes in cystic fibrosis: randomized controlled trial. Respir Med. 2014;108(10):1460-8. [Crossref ] [ PubMed]
  29. Cox NS, Follett J, McKay OK. Modified shuttle test performance in hospitalized children and adolescents with cystic fibrosis. J Cyst Fibros. 2006;5(3):165-70. [Crossref] [PubMed]
  30. Upton CJ, Tyrrell JC, Hiller EJ. Two minute walking distance in cystic fibrosis. Arch Dis Child. 1998;63(12):1444-8. [Crossref ] [PubMed] [PMC]
  31. Butland RJ, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed). 1982;284(6429):1607-8. [Crossref] [PubMed] [PMC]
  32. Narang I, Pike S, Rosenthal M, Balfour-Lynn IM, Bush A. Three-minute step test to assess exercise capacity in children with cystic fibrosis with mild lung disease. Pediatr Pulmonol. 2003;35(2):108-13. [Crossref] [PubMed]
  33. Cunha MT, Rozov T, de Oliveira RC, Jardim JR. Six-minute walk test in children and adolescents with cystic fibrosis. Pediatr Pulmonol. 2006;41(4):618-22. [Crossref ] [PubMed]
  34. Gulmans VA, van Veldhoven NH, de Meer K, Helders PJ. The six-minute walking test in children with cystic fibrosis: reliability and validity. Pediatr Pulmonol. 1996;22(2): 85-9. [Crossref]
  35. Jorquera Guillén MA, Salcedo Posadas A, Villa Asensi JR, Girón Moreno RM, Neira Rodríguez MA, Sequeiros González A. Reproducibility of the walking test in patients with cystic fibrosis. An Esp Pediatr. 1999;51(5):475-8.
  36. Radtke T, Stevens D, Benden C, Williams CA. Clinical exercise testing in children and adolescents with cystic fibrosis. Pediatr Phys Ther. 2009;21(3):27581. [Crossref ] [PubMed]
  37. Tuncay F. [Evaluation of the cardiopulmonary rehabilitation patient]. J PMR Sci. 2010;13 Suppl:17-26.
  38. Urguhart DS, Vendruscolo FM. Clinical interpretation of cardiopulmonary exercise testing in cystic fibrosis and implications for exercise counselling. Paediatr Respir Rev. 2017;24:72-8. [Crossref ] [ PubMed]
  39. Rogers D, Prasad SA, Doull I. Exercise testing in children with cystic fibrosis. J R Soc Med. 2003;96 Suppl 43:23-9.

.: Up To Date

Login

 Forgot your password?

 New Registration  

Contact

Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com