Turkiye Klinikleri Journal of Health Sciences

.: ORIGINAL RESEARCH
The Relationship Between Fear of Movement, Balance and Fear of Falling in Stroke Patients with Shoulder Pain
Omuz Ağrısı Olan İnme Hastalarında Hareket Korkusu, Denge ve Düşme Korkusu Arasındaki İlişki
Cevher SAVCUN DEMİRCİa, Meral SERTELb, Birol ÖNALc, Saniye AYDOĞAN ARSLANb, Eylem TÜTÜN YÜMİNd, Müyesser ARASe
aDepartment of Physiotherapy and Rehabilitation, Balıkesir University Faculty of Health Sciences, Balıkesir, TURKEY
bDepartment of Physiotherapy and Rehabilitation, Kırıkkale University Faculty of Health Sciences, Kırıkkale, TURKEY
cHacettepe University Faculty of Physical Therapy and Rehabilitation, Ankara, TURKEY d
dDepartment of Physiotherapy and Rehabilitation, Bolu Abant İzzet Baysal University Faculty of Health Sciences, Bolu, TURKEY
eDepartment of Physical Medicine and Rehabilitation, Ankara Yıldırım Beyazıt University Faculty of Medicine, Ankara, TURKEY
Turkiye Klinikleri J Health Sci. 2021;6(2):274-80
doi: 10.5336/healthsci.2020-76460
Article Language: EN
Full Text
ABSTRACT
Objective: Shoulder pain is a common problem after stroke and causes functional limitations in patients. Pain leads to keep away from the movement and physical activities. The aim of this study was to evaluate the fear of movement in stroke patients with shoulder pain and to investigate its relationship with balance and fear of falling. Material and Methods: Forty six stroke patients were included in the study and divided into two groups, with and without shoulder pain. Fear of movement was evaluated by the Tampa Scale for Kinesiophobia, functional balance was by the Berg Balance Scale and fear of falling was by the Tinetti's Falls Efficacy Scale. Results: The mean age of patients with and without pain were 65.60±11.37 years and 60.56±14.18 years respectively. In the shoulder painful group, it was determined that there was a negative correlation between balance and the fear of movement (r=-0.417; p=0.048) and that there was a positive correlation between the fear of falling and the fear of movement (r=0.429; p=0.041). In the shoulder painless group, there was no significant correlation (p>0.05). There was a statistically significant difference between the kinesiophobia values of two groups (p˂0.05). Conclusion: When balance problems and falls observed in stroke patients are combined with pain and fear of movement, it becomes important to take into account and evaluate the fear of movement in rehabilitation practices.

Keywords: Hemiplegia; kinesiophobia; balance; falling, pain
ÖZET
Amaç: Omuz ağrısı, inme sonrası yaygın görülen bir problemdir ve hastalarda fonksiyonel kısıtlılıklara neden olur. Ağrı, hareketten ve fiziksel aktivitelerden uzak durmaya yol açar. Bu çalışmanın amacı, omuz ağrısı olan inmeli hastalarda hareket korkusunu değerlendirmek, denge ve düşme korkusu ile ilişkisini araştırmaktır. Gereç ve Yöntemler: Çalışmaya 46 inme hastası dâhil edildi ve omuz ağrısı olanlar ve olmayanlar olarak 2 gruba ayrıldı. Hareket korkusu Tampa Kinezyofobi Ölçeği ile fonksiyonel denge Berg Denge Ölçeği ile ve düşme korkusu Tinetti Düşme Etkinlik Ölçeği ile değerlendirildi. Bulgular: Ağrısı olan ve olmayan hastaların yaş ortalaması sırasıyla 65,60±11,37 yıl ve 60,56±14,18 yıl idi. Omuz ağrılı grupta denge ve hareket korkusu arasında negatif (r=-0,417; p=0,048), düşme korkusu ile hareket korkusu arasında pozitif (r=0,429; p=0,041) korelasyon olduğu belirlendi. Omuz ağrısı olmayan grupta anlamlı korelasyon yoktu (p>0,05). İki grubun hareket korkusu değerleri arasında istatistiksel olarak anlamlı fark vardı (p˂0,05). Sonuç: İnme hastalarında görülen denge problemleri ve düşmeler, ağrı ve hareket korkusu ile birleştiğinde, rehabilitasyon uygulamalarında hareket korkusunun dikkate alınması ve değerlendirilmesi önem kazanmaktadır.

Anahtar Kelimeler: Hemipleji; kinezyofobi; denge; düşme, ağrı
REFERENCES:
  1. Harrison RA, Field TS. Post stroke pain: identification, assessment, and therapy. Cerebrovasc Dis. 2015;39(3-4):190-201. [Crossref] [PubMed] 
  2. Karaahmet OZ, Eksioglu E, Gurcay E, Karsli PB, Tamkan U, Bal A, et al. Hemiplegic shoulder pain: associated factors and rehabilitation outcomes of hemiplegic patients with and without shoulder pain. Top Stroke Rehabil. 2014;21(3):237-45. [Crossref] [PubMed] 
  3. Holmes RJ, McManus KJ, Koulouglioti C, Hale B. Risk Factors for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis. 2020;29(6):104787. [Crossref] [PubMed] 
  4. Gamble GE, Barberan E, Laasch HU, Bowsher D, Tyrrell PJ, Jones AK, et al. Poststroke shoulder pain: a prospective study of the association and risk factors in 152 patients from a consecutive cohort of 205 patients presenting with stroke. Eur J Pain. 2002;6(6):467-74. [Crossref] [PubMed] 
  5. Myers JB, Wassinger CA, Lephart SM. Sensorimotor contribution to shoulder stability: effect of injury and rehabilitation. Man Ther. 2006;11(3):197-201. [Crossref] [PubMed] 
  6. Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med. 2006;36(3):189-98. [Crossref] [PubMed] 
  7. Baierle T, Kromer T, Petermann C, Magosch P, Luomajoki H. Balance ability and postural stability among patients with painful shoulder disorders and healthy controls. BMC Musculoskelet Disord. 2013;14:282. [Crossref] [PubMed] [PMC] 
  8. Philips HC. Avoidance behaviour and its role in sustaining chronic pain. Behav Res Ther. 1987;25(4):273-9. [Crossref] [PubMed] 
  9. Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62(3):363-72. [Crossref] [PubMed] 
  10. Hapidou EG, O'Brien MA, Pierrynowski MR, de Las Heras E, Patel M, Patla T, et al. Fear and Avoidance of Movement in People with Chronic Pain: Psychometric Properties of the 11-Item Tampa Scale for Kinesiophobia (TSK-11). Physiother Can. 2012;64(3):235-41. [Crossref] [PubMed] [PMC] 
  11. Castro-Costa E, Fuzikawa C, Uchoa E, Firmo JO, Lima-Costa MF. Norms for the mini-mental state examination: adjustment of the cut-off point in population-based studies (evidences from the Bambuí health aging study). Arq Neuropsiquiatr. 2008;66(3A):524-8. Erratum in: Arq Neuropsiquiatr. 2009;66(4):932-3. [Crossref] [PubMed] 
  12. Boonstra AM, Schiphorst Preuper HR, Balk GA, Stewart RE. Cut-off points for mild, moderate, and severe pain on the visual analogue scale for pain in patients with chronic musculoskeletal pain. Pain. 2014;155(12):2545-50. [Crossref] [PubMed] 
  13. Folstein MF, Robins LN, Helzer JE. The Mini-Mental State Examination. Arch Gen Psychiatry. 1983;40(7):812. [Crossref] [PubMed] 
  14. Yılmaz ÖT, Yakut Y, Uygur F, Uluğ N. [Turkish version of the Tampa Scale for Kinesiophobia and its test-retest reliability]. Fiz Rehabil. 2011;22(1):44-9. [Link] 
  15. Şahin F, Büyükavci R, Sağ S, Dogu B, Kuran B. Reliability and validity of the Turkish version of the Berg Balance Scale in patients with stroke. Turk J Phys Med Rehabil. 2013;59(3):170-5. [Link] 
  16. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45(6):P239-43. [Crossref] [PubMed] 
  17. Nickel R, Lange M, Stoffel DP, Navarro EJ, Zetola VF. Upper limb function and functional independence in patients with shoulder pain after stroke. Arq Neuropsiquiatr. 2017;75(2):103-6. [Crossref] [PubMed] 
  18. Rosén E, Sunnerhagen KS, Kreuter M. Fear of falling, balance, and gait velocity in patients with stroke. Physiother Theory Pract. 2005;21(2):113-20. [Crossref] [PubMed] 
  19. Dromerick AW, Edwards DF, Kumar A. Hemiplegic shoulder pain syndrome: frequency and characteristics during inpatient stroke rehabilitation. Arch Phys Med Rehabil. 2008;89(8):1589-93. [Crossref] [PubMed] 
  20. Adey-Wakeling Z, Liu E, Crotty M, Leyden J, Kleinig T, Anderson CS, et al. Hemiplegic Shoulder Pain Reduces Quality of Life After Acute Stroke: A Prospective Population-Based Study. Am J Phys Med Rehabil. 2016;95(10):758-63. [Crossref] [PubMed] 
  21. Weerdesteyn V, de Niet M, van Duijnhoven HJ, Geurts AC. Falls in individuals with stroke. J Rehabil Res Dev. 2008;45(8):1195-213. [Crossref] [PubMed] 
  22. Taub NA, Wolfe CD, Richardson E, Burney PG. Predicting the disability of first-time stroke sufferers at 1 year. 12-month follow-up of a population-based cohort in southeast England. Stroke. 1994;25(2):352-7. [Crossref] [PubMed] 
  23. Schmid AA, Rittman M. Fear of falling: an emerging issue after stroke. Top Stroke Rehabil. 2007;14(5):46-55. [Crossref] [PubMed] 
  24. Goh HT, Nadarajah M, Hamzah NB, Varadan P, Tan MP. Falls and Fear of Falling After Stroke: A Case-Control Study. PM R. 2016;8(12):1173-80. [Crossref] [PubMed] 
  25. Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci. 2000;55(5):M299-305. [Crossref] [PubMed] 
  26. Tinetti ME, Williams CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 1998;53(2):M112-9. [Crossref] [PubMed] 
  27. Belgen B, Beninato M, Sullivan PE, Narielwalla K. The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke. Arch Phys Med Rehabil. 2006;87(4):554-61. [Crossref] [PubMed] 
  28. Kim O, Kim JH. Falls and Use of Assistive Devices in Stroke Patients with Hemiparesis: Association with Balance Ability and Fall Efficacy. Rehabil Nurs. 2015;40(4):267-74. [Crossref] [PubMed] 
  29. Thomas JS, France CR. Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain. Spine (Phila Pa 1976). 2007;32(16):E460-6. [Crossref] [PubMed] 
  30. Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993;342(8878):1012-6. [Crossref] [PubMed] 
  31. Sethy D, Sahoo S, Bajpai P, Kujur ES, Biswas A, Mohakud K. Effect of cognitive behaviour therapy on kinesiophobia after CRPS-I in a case of stroke hemiplegia: A case report. Int J Health Scı Res. 2017;7(9):340-6. [Link] 
  32. Karos K, Meulders A, Gatzounis R, Seelen HAM, Geers RPG, Vlaeyen JWS, et al. Fear of pain changes movement: Motor behaviour following the acquisition of pain-related fear. Eur J Pain. 2017;21(8):1432-42. [Crossref] [PubMed] 
  33. Jo S, Choi W, Jung J, Park J, Lee S. Convergence study on the relationship between kinesiophobia and fear of falling in patients with stroke. Journal of the Korea Convergence Society. 2019;10(10):33-41. [Link] 

.: 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