Turkiye Klinikleri Journal of Health Sciences

.: ORIGINAL RESEARCH
Farklı Fizyoterapi Uygulamalarının Spastisite Üzerine Kısa Dönem Etkilerinin Karşılaştırılması: Randomize Çapraz Çalışma
A Comparison of Immediate Effects of Different Physiotherapy Applications on Spasticity: Randomized Cross-Over Study
Güngör ÇOŞKUNa, Serkan TAŞb
aÜsküdar Üniversitesi Sağlık Bilimleri Enstitüsü, Fizyoterapi ve Rehabilitasyon ABD, İstanbul, Türkiye
bAlanya Alaaddin Keykubat Üniversitesi Sağlık Bilimleri Fakültesi, Fizyoterapi ve Rehabilitasyon Bölümü, Antalya, Türkiye
Turkiye Klinikleri J Health Sci. 2022;7(2):436-44
doi: 10.5336/healthsci.2021-84421
Article Language: TR
Full Text
ÖZET
Amaç: Bu çalışmanın amacı, spastisite regülasyonunda kullanılan transkütanöz elektriksel sinir stimülasyonu [transcutaneous electrical nerve stimulation (TENS)], nöromusküler elektrik stimülasyonu (NMES) ve lokal vibrasyon uygulamalarının, kronik inmeli hastalarda spastisite üzerine anlık etkilerini incelemek ve uygulamaların etkilerini birbirleriyle karşılaştırmaktır. Gereç ve Yöntemler: Çapraz kontrollü olarak tasarlanan bu çalışma, 15 kronik inme hastasının katılımı ile gerçekleşti. Rastgele olarak 1 hafta arayla hastaların gastroknemius kasına TENS ve NMES, tibialis anterior kasına lokal vibrasyon uygulaması yapıldı. Uygulamalardan önce ve sonra hastaların gastroknemius kas tonusu Modifiye Ashworth Skalası (MAS); yürüyüş hızları Zamanlı Kalk ve Yürü Testi (ZKYT); dengeleri Berg Denge Ölçeği (BDÖ) ve ayak bileği eklem hareket açıklığı gonyometre ile değerlendirildi. Bulgular: TENS, NMES ve vibrasyon sonrası hastaların MAS skorları benzerdi (p>0,05). Tüm uygulamalardan sonra ZKYT skorlarının azaldığı bulundu (p<0,05); ancak uygulamalar arasında fark yoktu (p=0,655). TENS, NMES ve vibrasyon sonrası BDÖ skoru artsa (p<0,05) da fark, tüm gruplarda benzerdi (p=0,335). TENS sonrası hastaların aktif plantar fleksiyon, pasif dorsi fleksiyon ve aktif dorsi fleksiyon derecesinde; vibrasyon sonrası pasif plantar fleksiyon, aktif plantar fleksiyon ve pasif dorsi fleksiyon derecesinde artış vardı (p<0,05). Sonuç: Kronik inmeli hastalara uygulanan tek seanslık TENS, NMES ve vibrasyon uygulamalarının, hastaların kas tonusu üzerine etkisi olmazken; denge, yürüme hızı ve eklem hareket açıklığı üzerine istatistiksel olarak etkili olduğu bulundu. Bununla birlikte parametrelerin uygulama öncesi ve sonrası değerleri arasındaki farklar çok azdı. Tüm uygulamaların, incelenen parametreler üzerine etkileri benzerdi.

Anahtar Kelimeler: İnme; kas spastisitesi; elektriksel uyarı tedavisi; fizik tedavi modaliteleri
ABSTRACT
Objective: To examine the immediate effects of transcutaneous electrical nerve stimulation (TENS), neuromuscular electrical stimulation (NMES), and local vibration applications used in spasticity regulation in patients with chronic stroke and to compare the effects of the applications with each other. Material and Methods: This cross-over and controlled study was conducted with the participation of 15 chronic stroke patients. Applications of TENS and NMES to the gastrocnemius muscle and local vibration to the tibialis anterior muscle of the patients were made randomly 1 week apart. Before and after each application, the gastrocnemius muscle tone of the patients via Modified Ashworth Scale (MAS), gait speed via Timed Up and Go Test (TUG), balance via Berg Balance Scale (BBS), and ankle range of motion via goniometer were evaluated. Results: MAS scores of patients were similar after TENS, NMES, and vibration (p>0.05). TUG scores decreased after all applications (p<0.05), but there was no difference between applications (p=0.655). The BBS score increased after TENS, NMES, and vibration (p<0.05), but the difference was similar in all groups (p=0.335). Patients' active plantar flexion, passive dorsi flexion, and active dorsi flexion increased after TENS, and their passive plantar flexion, active plantar flexion, and passive dorsi flexion increased after vibration (p<0.05). Conclusion: The single session TENS, NMES, and vibration applications in chronic stroke patients had no effect on muscle tone; however, these applications were statistically effective on balance, walking speed, and range of motion. The differences between parameters before and after the application were very small. The effects of all applications on the investigated parameters were similar.

Keywords: Stroke; muscle spasticity; electric stimulation therapy; physical therapy modalities
REFERENCES:
  1. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011;377(9778):1693-702. [Crossref]  [PubMed] 
  2. Thibaut A, Chatelle C, Ziegler E, Bruno MA, Laureys S, Gosseries O. Spasticity after stroke: physiology, assessment and treatment. Brain Inj. 2013;27(10):1093-105. [Crossref]  [PubMed] 
  3. Gupta AD, Chu WH, Howell S, Chakraborty S, Koblar S, Visvanathan R, et al. A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity. Syst Rev. 2018;7(1):1. [Crossref]  [PubMed]  [PMC] 
  4. Ward AB. A summary of spasticity management--a treatment algorithm. Eur J Neurol. 2002;9 Suppl 1:48-52; dicussion 53-61. [Crossref]  [PubMed] 
  5. Karakaya İÇ, Karakaya MG, Yılmaz ÖT. İnme rehabilitasyonunda kullanılan elektrofiziksel ajanlar. Karaduman A, Aksu Yıldırım S, Tunca Yılmaz Ö, editörler. İnme Sonrası Fizyoterapi ve Rehabilitasyon. 2. Baskı. Ankara: Hipokrat Kitabevi; 2016. p.155-72.
  6. Mahmood A, Veluswamy SK, Hombali A, Mullick A, N M, Solomon JM. Effect of transcutaneous electrical nerve stimulation on spasticity in adults with stroke: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2019; 100(4):751-68. [Crossref]  [PubMed] 
  7. Paoloni M, Mangone M, Scettri P, Procaccianti R, Cometa A, Santilli V. Segmental muscle vibration improves walking in chronic stroke patients with foot drop: a randomized controlled trial. Neurorehabil Neural Repair. 2010; 24(3):254-62. [Crossref]  [PubMed] 
  8. Alashram AR, Padua E, Romagnoli C, Annino G. Effectiveness of focal muscle vibration on hemiplegic upper extremity spasticity in individuals with stroke: A systematic review. Neuro Rehabilitation. 2019;45(4):471-81. [Crossref]  [PubMed] 
  9. Motta-Oishi AA, Magalhães FH, Mícolis de Azevedo F. Neuromuscular electrical stimulation for stroke rehabilitation: is spinal plasticity a possible mechanism associated with diminished spasticity? Med Hypotheses. 2013; 81(5):784-8. [Crossref]  [PubMed] 
  10. van der Salm A, Veltink PH, Ijzerman MJ, Groothuis-Oudshoorn KC, Nene AV, Hermens HJ. Comparison of electric stimulation methods for reduction of triceps surae spasticity in spinal cord injury. Arch Phys Med Rehabil. 2006;87(2):222-8. [Crossref]  [PubMed] 
  11. Park J, Seo D, Choi W, Lee S. The effects of exercise with TENS on spasticity, balance, and gait in patients with chronic stroke: a randomized controlled trial. Med Sci Monit. 2014; 20:1890-6. [Crossref]  [PubMed]  [PMC] 
  12. Research Randomizer [İnternet]. Copyright © 1997-2021 by Geoffrey C. Urbaniak and Scott Plous [Erişim tarihi: 12 Kasım 2020]. Erişim linki: [Link] 
  13. Numanoğlu A, Günel MK. Intraobserver reliability of modified Ashworth scale and modified Tardieu scale in the assessment of spasticity in children with cerebral palsy. Acta Orthop Traumatol Turc. 2012;46(3):196-200. [Crossref]  [PubMed] 
  14. Otman S, Köse N. İnmede fizyoterapi ve rehabilitasyon değerlendirmeleri. Karaduman AA, Aksu Yıldırım S, Tunca Yılmaz Ö, editörler. İnme Sonrası Fizyoterapi ve Rehabilitasyon. 2. Baskı. Ankara: Hipokrat Kitabevi; 2016. p.57-112.
  15. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903. [Crossref]  [PubMed] 
  16. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002;82(2): 128-37. [Crossref]  [PubMed] 
  17. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2): 142-8. [Crossref]  [PubMed] 
  18. Berg K, Wood-Dauphinee S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995;27(1):27-36. [PubMed] 
  19. Sag S, Buyukavci R, Sahin F, Sag MS, Dogu B, Kuran B. Assessing the validity and reliability of the Turkish version of the Trunk Impairment Scale in stroke patients. North Clin Istanb. 2018;6(2):156-65. [PubMed]  [PMC] 
  20. Stein C, Fritsch CG, Robinson C, Sbruzzi G, Plentz RD. Effects of electrical stimulation in spastic muscles after stroke: systematic review and meta-analysis of randomized controlled trials. Stroke. 2015;46(8):2197-205. [Crossref]  [PubMed] 
  21. Chen SC, Chen YL, Chen CJ, Lai CH, Chiang WH, Chen WL. Effects of surface electrical stimulation on the muscle-tendon junction of spastic gastrocnemius in stroke patients. Disabil Rehabil. 2005;27(3):105-10. [Crossref]  [PubMed] 
  22. Cho HY, In TS, Cho KH, Song CH. A single trial of transcutaneous electrical nerve stimulation (TENS) improves spasticity and balance in patients with chronic stroke. Tohoku J Exp Med. 2013;229(3):187-93. [Crossref]  [PubMed] 
  23. Mesci N, Ozdemir F, Kabayel DD, Tokuc B. The effects of neuromuscular electrical stimulation on clinical improvement in hemiplegic lower extremity rehabilitation in chronic stroke: a single-blind, randomised, controlled trial. Disabil Rehabil. 2009;31(24):2047-54. [Crossref]  [PubMed] 
  24. Costantino C, Galuppo L, Romiti D. Short-term effect of local muscle vibration treatment versus sham therapy on upper limb in chronic post-stroke patients: a randomized controlled trial. Eur J Phys Rehabil Med. 2017;53(1):32-40. [Crossref]  [PubMed] 
  25. Ayvat F, Özçakar L, Ayvat E, Aksu Yıldırım S, Kılınç M. Effects of low vs. high frequency local vibration on mild-moderate muscle spasticity: Ultrasonographical and functional evaluation in patients with multiple sclerosis. Mult Scler Relat Disord. 2021;51:102930. [Crossref]  [PubMed] 
  26. Conradsson M, Lundin-Olsson L, Lindelöf N, Littbrand H, Malmqvist L, Gustafson Y, et al. Berg balance scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities. Phys Ther. 2007;87(9):1155-63. [Crossref]  [PubMed] 
  27. Khalifeloo M, Naghdi S, Ansari NN, Akbari M, Jalaie S, Jannat D, et al. A study on the immediate effects of plantar vibration on balance dysfunction in patients with stroke. J Exerc Rehabil. 2018;14(2):259-66. [Crossref]  [PubMed]  [PMC] 
  28. Lee D, Lee G, Jeong J. Mirror therapy with neuromuscular electrical stimulation for improving motor function of stroke survivors: A pilot randomized clinical study. Technol Health Care. 2016;24(4):503-11. [Crossref]  [PubMed] 
  29. Martin RL, McPoil TG. Reliability of ankle goniometric measurements: a literature review. J Am Podiatr Med Assoc. 2005;95(6):564-72. [Crossref]  [PubMed] 
  30. Laddha D, Ganesh GS, Pattnaik M, Mohanty P, Mishra C. Effect of transcutaneous electrical nerve stimulation on plantar flexor muscle spasticity and walking speed in stroke patients. Physiother Res Int. 2016;21(4):247-56. [Crossref]  [PubMed] 
  31. Sahin N, Ugurlu H, Albayrak I. The efficacy of electrical stimulation in reducing the post-stroke spasticity: a randomized controlled study. Disabil Rehabil. 2012;34(2):151-6. [Crossref]  [PubMed] 

.: Up To Date

.: Process List

Login



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