Comparative Cohort Study of the Use of Immersive Technologies in the Complex Psychological Rehabilitation of Patients with Motor Disorders

Full Text

Justification
The development of information and communication technologies, which has accompanied medicine since the end of the twentieth century, has led to a significant expansion of ideas about the possibilities of modernizing the work of specialists in “helping” professions.
Science-intensive (high) technologies are based on new scientific and technical knowledge and serve as the basis for the production of new high-tech products and services, including the use of electronics and robotics.
One of the directions of scientific and practical developments at present are immersive technologies, among which it is customary to distinguish: VR (virtual reality) - virtual reality - a completely simulated artificial reality that completely replaces reality for a person; AR (augmented reality) - augmented reality - constructed on the basis of the existing physical reality with the addition or imposition of virtual 3D objects on it; MR (mixed reality) - mixed reality - represented by devices that combine the capabilities of VR and AR in various combinations.
The ability to use immersive technologies for solving diverse problems has made it possible to widely spread them in various fields of health care, which allows high-precision diagnostics and complex operations to be carried out, providing access to the necessary data and information in real time. For rehabilitation specialists, there are opportunities to improve the efficiency of restoration of lost functions due to the possibility of programming the necessary learning environment, gamification of the process, the formation of motivation, expanding the possibilities of communication with the patient and receiving stable feedback in an instant response mode [1, 2, 3].
Currently, VR and AR technologies are most often used in neurorehabilitation in patients after stroke [4, 5, 6] - literature data indicate the possibility of recovery with their help the function of walking and coordinating skills, the function of the upper limb [7, 8].

Modern approaches to the rehabilitation of patients with pathology of the central nervous system and movement disorders are based primarily on neuroplasticity as a property of the brain to carry out its own reorganization for adaptive purposes, which in the process of neurorehabilitation is manifested by the restoration of functional capabilities [9, 10]. It has been proven that traditional (mechanized) methods of neurorehabilitation have significant limitations, since their high cost and technical complexity do not allow conducting classes outside a medical institution [11]. V.B. Nikishina et al. (2018) developed a hardware-software complex "Visual Medicine" for restorative education of stroke patients using computer vision algorithms [11]. The technology is represented by specialized software, a computer, a webcam and includes a set of exercises based on the theory of systemic structure and dynamic localization of higher mental functions by A.R. Luria [12] and the development of function in ontogenesis L.S. Vygotsky [13]. The methodology is based on the principles of developmental teaching, the sequence of movements is set from simple to more complex. The exercise is recorded by a video camera, which allows, based on the feedback function, to form the necessary motor skill in the patient.
There is conflicting information in the literature regarding the use of VR and AR in psychotherapy and psychocorrection. There are some reports on their use in the correction of affective disorders after stroke, but they are often phenomenological in nature and represent a single description of a clinical case [14, 15].
In recent decades, there has been an increase in the number of studies showing the effectiveness of the use of immersive technologies in the treatment of a number of disorders in the context of improving the general psychological state of patients. Most of them focused on the treatment of anxiety and phobic disorders, social phobias, post-traumatic stress disorder, nicotine or alcohol dependence, treatment of pain in cancer patients and chronic pain, phantom pain or fear of painful medical procedures [16-21].

Immersive technologies aimed at pain therapy are represented mainly by the so-called VR-glasses, or VR-helmet, for example, in patients with burn injury [22]. Researchers believe that a positive effect in this case is achieved by switching attention, which helps to reduce pain, stimulate physical activity and increase the level of patient motivation to move [23]. Data on the use of virtual reality tools in the medical rehabilitation of patients with pathology of the musculoskeletal system is insufficient today, they are usually of a heterogeneous nature, relate to local pain syndromes - pain in the neck, shoulder or knee in the case of arthroplasty or endoprosthetics [24, 25]. In addition, the analysis of existing publications showed that when using VR tools to relieve pain, the psychoemotional aspects of the formation of pain syndrome were not taken into account.
As for the direct influence of VR and AR means on the emotional state of patients, at the moment technologies have been developed, the specific point of application of which is the psychoemotional sphere. In particular, the hardware-software complex "PRAK" is intended for individual psychocorrection by the method of light and sound stimulation of the brain. The main idea of ​​the method is to influence the brain with a certain sound and light frequency, which leads to a change in the bioelectric activity of the brain. The device is equipped with a binaural beat generator, headphones, a screen for viewing visual content. Binaural beats are used as a sedative to help sleep [26]. There are isolated reports of a significant increase in the level of analgesia when exposed to binaural beats while the patient is under anesthesia [27]. Proven effectiveness, non-invasive nature, ease of use, the possibility of combining with drug therapy and minimal contraindications for use make PRAK one of the promising tools for increasing the effectiveness of the rehabilitation process, however, the evidence base for the use of a technique based on modulation of binaural-acoustic beats in the work of a medical psychologist. the analysis of literary sources was not found.

In general, the main advantages of immersive technologies include, first of all, the ability to create safe contact with traumatic reality during psychocorrectional sessions and psychotherapeutic interventions [28, 29]. It is fundamentally important that due to the effects of presence and immersion, any experience can be as close to life as possible, however, it is completely safe and “dosed”, since the degree of exposure to virtual stimuli, their volume and intensity are controllable. In addition, the development of the necessary skills becomes available for a person even outside of face-to-face meetings with a doctor or psychotherapist [30]. Due to the ability of virtual environments to develop and maintain self-efficacy by repeatedly experiencing an individual's situation of success, similar to the effects of cognitive-behavioral psychotherapy, the use of immersive technologies forms the experience of personal achievement, positively affects self-esteem and ensures a person's readiness to more confidently and competently solve life problems in the future [ 31].
Thus, the literature data indicate the possibility of using high-tech means to solve a number of problems facing a medical psychologist in a short-term rehabilitation process, which makes it expedient to study the effectiveness of their inclusion in the complex of psychological rehabilitation.

Objective of the study: to assess the effectiveness of the inclusion of immersive technologies in the complex psychological rehabilitation of patients with impaired motor functions.

Methods
Study design
The design was planned as a controlled, empirical, randomized, open-label study. The grouping of the groups was carried out as follows: after being included in the study, the respondents were randomized using a random number generator into nine groups (three for each type of high-tech impact): the main group, the comparison group and the control group. In the course of work, the size of the groups in a number of cases changed downward. This concerned mainly control groups and comparison groups, and was associated with organizational reasons. In the final grouping of groups in order to achieve their comparability in terms of gender, age, degree of impairment of motor functions (p> 0.05), statistical criteria of equivalence were used: Fisher's criterion - in the case of binary variables, the Mann-Whitney criterion - in the case of quantitative variables. If a discrepancy was found, the random number generator was again used to achieve group comparability in terms of the relevant relevant parameters.
In accordance with the requirements for the organization of applied research, the work was organized through the implementation of the ascertaining, formative and control stage.
Compliance criteria
Inclusion criteria for the study: availability of indications for consultation with a medical psychologist; availability to productive speech contact; lack of pronounced cognitive impairment; availability of voluntary informed consent; rating on the Rankin scale from 2 to 4 points; correspondence of the severity of movement disorders to "weak" or "significant" disorders of structures, functions, activity and participation according to the International Classification of Functioning, Disabilities and Health; in the presence of pain syndrome, the average intensity of pain (1-3 points on the 5-point VAS).

Conditions of conducting
The study was carried out in branch No. 3 of the State Autonomous Healthcare Institution of the city of Moscow "Moscow Scientific and Practical Center for Medical Rehabilitation, Rehabilitation and Sports Medicine of the Moscow Department of Healthcare" within the framework of the research topic "Development of a patient-oriented model of medical and psychological rehabilitation" (state registration No. AAAA -A20-120060490050-1).

Study duration
Terms of the study: 03.2020 - 04.2021.
Description of the medical intervention
In all groups, a standard medical rehabilitation program was implemented in accordance with the nosology of movement disorders in the form of exercises with exercise therapy instructors in therapeutic gymnastics and mechanotherapy, massage and, in the absence of contraindications, physiotherapeutic procedures. Psychological support was carried out as follows:
 Patients of the control groups during their stay in the hospital were involved only in psychodiagnostic activities, as a result of which they were designated targets of psychocorrectional influence with the possibility of receiving appropriate services after completing the main course of medical rehabilitation;
 psychocorrection for patients included in the comparison groups was carried out within the framework of the standard format of interventions: "Patient's School", relaxation techniques, psychological counseling;
 Patients of the main groups, in addition to the activities of the standard psychocorrectional format, received psychocorrectional support by including one of the high-tech VR and AR tools in the individual rehabilitation plan.

Study outcomes
Stable indicators of higher efficiency of psychocorrectional measures with the inclusion of immersive technologies in comparison with the comparison groups and control groups with a high degree of reliability of the results obtained (p ≤ 0.05).
Subgroup analysis
The study included 336 patients undergoing medical rehabilitation for movement disorders determined by a stroke or chronic pathology of the large joints and spine DDZ.
81 patients were included in the study of the effectiveness of using the computer program "Visual Medicine" for training hand movement by the neuroprobe method in patients with acute cerebrovascular accident (ACVI). In order to study the competitive capabilities of the "Visual Medicine" program, in the comparison group, the instructor of physiotherapy exercises trained hand movements using the hardware-software complex "Devirta - Accuracy".
The effectiveness of the inclusion of the "HTC Vive Focus Plus EEA Virtual Reality System" in the psychological correction of pain syndrome against the background of chronically proceeding RSD of large joints and the spine was studied in two stages. At the first stage, the subjective perception of pain was studied in 60 patients with pain syndrome, at the second stage, the effectiveness of the inclusion of VR technology in the psycho-rehabilitation of patients was assessed, 70 people took part in the study. All patients received similar pain therapy in the form of non-steroidal anti-inflammatory drugs.
In the study of the possibility of using the programs of resonant-acoustic vibrations (PRAC) in the "relaxation" mode when organizing psychological support of patients, 125 people with motor impairments were included: with the consequences of stroke (n = 65) and with the consequences of DDS of large joints and the spine (n = 60 ). The proportional representation of the nosology of movement disorders during randomization was taken into account and did not differ in the groups according to Fisher's criterion (p> 0.05).
All groups were statistically comparable in terms of gender and age characteristics.

Outcome registration methods
The effectiveness of psychocorrectional measures when using the computer program "Visual Medicine" in patients with previous stroke was assessed based on the analysis of the dynamics of higher mental functions, according to the data of neuropsychological screening according to Luria, carried out before and after the end of rehabilitation measures. The conclusion about the positive dynamics was made by the fact of detecting a statistically significant shift in indicators, and not by the quantitative level of their change.
The effectiveness of the inclusion of the "HTC Vive Focus Plus EEA Virtual Reality System" in the psychological correction of pain syndrome against the background of chronically occurring RSD of large joints and the spine was shown by using the McGill Pain Questionnaire, Visual Analogue Scale of Well-Being Assessment (VAS) Tampa Scales ".
In the study of the possibility of using the programs of resonant-acoustic vibrations (PRAC) in the "relaxation" mode when organizing psychological support for patients, the dynamics of the psychoemotional state, general well-being and pain syndrome of patients was recorded using the data of the "Somatization" scale of the psychodiagnostic questionnaire "SCL-90-R", The Tampa Scale, the Visual Analogue Wellness Scale (VAS), and the Facial Pain Scale.

Statistical analysis
Mathematical and statistical processing of the obtained data was carried out using the "Statistics 10.0" software package, as well as the analytical capabilities of the Microsoft Office Excel program. To randomize the samples, we used the capabilities of the Excel random number generator.
If the data corresponded to the normal distribution, the Student's T-test was used to analyze the significance of differences in the level of expression of a quantitative trait in unrelated samples; The choice of descriptive statistics also varied according to the presence / absence of a normal distribution: the mean (M) and standard deviation (SD) or median (med), mode (mode) and interquartile range were used. To assess the dynamics of the studied parameters as a result of experimental exposure, the analysis of the significance of differences in the level of expression of a quantitative trait in related samples was used according to the Student's T-test (in the case of a normal distribution), according to the Wilcoxon T-test (in the absence of a normal distribution). In order to compactly represent both numerical and nominative data, cluster analysis using the K-means and hierarchical tree method was used. The reliability of clustering was assessed using one-way analysis of variance. The revealed connections and differences were considered significant when the level of statistical significance was reached p≤0.05.

results
Subjects (participants) of the study (1)
Augmented reality technologies in psychological rehabilitation of stroke patients
According to the results of neuropsychological screening, carried out in 81 patients with motor disorders in the form of upper limb hemiparesis, all included in the study revealed a predominant violation of the spatially dynamic organization of the motor act. This was manifested in the difficulty of reproducing the spatial position of the hands, as well as reciprocal coordination. Patients demonstrated a delayed inhibition of the previous action: they simultaneously performed two antagonist actions. After preliminary diagnosis, the patients were randomly assigned to the study group (n = 41), the comparison group (n = 14), and the control group (n = 26).
Key Study Findings (1)
The repeated assessment of praxis functions, carried out after the implementation of rehabilitation measures, showed positive dynamics in terms of the organization of serial motor activity, which was manifested in a decrease in the number of perseverative actions when performing graphic tests, a decrease in the number of episodes of missing elements of the motor program, an increase in the pace and quality of motor functional neuropsychological tests. The restoration of dynamic, kinesthetic, optical-spatial and constructive praxis was also noted. The patients of the main group more accurately reproduced the postures of the hands according to the tactile and visual patterns, they carried out motor programs more efficiently in comparison with the patients of the control group and the comparison group. The rate of performing tests in the main group was significantly higher than in the control group; movements were performed with greater accuracy than in the comparison group. It should be noted that the restoration of the studied characteristics of the state of higher mental functions (HMF) for all indicators, with a high degree of reliability (p≤0.05), occurred in the main group in 100% of cases, in the comparison group - in 50% and in the control group. - in 30% of cases. Thus, the rehabilitation efficiency and positive competitive capabilities of the "Visual Medicine" program in relation to the hardware-software complex "Devirta-Accuracy" were confirmed.

Subjects (participants) of the study (2)
Virtual reality in the correction of pain syndrome in patients with DDS of large joints and spine
Based on the analysis of data from the McGill Pain Inquirer sensory scale, a semantic space for subjective pain perception (n = 60) was constructed - hierarchical cluster analysis was applied using the Complete Linkage method, and Euclidean distance was used as a measure of proximity. As a result of clustering, two groups of patients were identified: the first (n = 33), characterizing their pain reliably (p≤0.05) with a larger number of descriptor words than the second (n = 27). At the same time, the intensity of pain in the clusters according to the Mann-Whitney criterion did not differ significantly (p> 0.05), and the rank index reflecting the expressive component of the description of pain in patients of the first cluster significantly (p = 0.0000) exceeded that of the second cluster.
Further, the frequency series of pain descriptors for each cluster was ranked in descending order and divided into quartiles in such a way that the I quartile constituted the core of the semantic field of subjective pain perception, and from II to IV - the periphery. At the same time, descriptors, which were selected in at least 30.0% of cases, were considered essential for the formation of the semantic field of pain perception. As a result of the analysis, it was shown that the "periphery" of subjective perception of pain included characteristics describing sensations characteristic of mixed (neuropathic and dysfunctional) pain, and the "core" - characteristics of nociceptive pain. Thus, the first cluster included patients with a mixed nature of pain sensations, the second - with nociceptive ones.

Key Study Findings (2)
Analysis of the significance of differences in the level of severity of characteristics reflecting the dynamics of pain sensations, subjective assessment of well-being and the level of severity of kinesiophobia according to the Wilcoxon criterion revealed that as a result of rehabilitation measures in patients of all surveyed groups (n = 70), well-being significantly improved, according to VAS (p ≤0.05), the intensity of pain sensations decreased (p≤0.05), while only in the main group there was a significant positive dynamics (p≤0.05) in the level of severity of the psychological component of CF. For further analysis, we used the data from the Pain Diaries, which reflect the daily dynamics of subjective pain sensations - the results are shown in Table 1.

Table 1 - Level of reliability of differences (p-level) in pain intensity according to self-observation diaries

As can be seen from the data presented, the intensity of pain has a tendency to decrease in all groups by the tenth compared to the first day of hospitalization.
Analysis of the significance of differences according to the Mann-Whitney criterion in the daily recorded level of pain, revealed that the dynamics of pain in the comparison group and in the control group were identical (p> 0.05) throughout the study period, and did not differ from the main group until the seventh day. starting from which the dynamics in the groups, first at the level of a statistical trend (p = 0.06), and then significantly (p≤0.05), differs: in the control group and the comparison group, the decline ends, in the main group it continues, reaching lower values.
The selection within the main, comparison and control groups of subgroups of patients with nociceptive and mixed characteristics of pain based on the results obtained at the first stage, made it possible to find that a pronounced positive dynamics in the control group was achieved due to an improvement in the condition in patients with nociceptive pain - in the groups, where classes with a medical psychologist were included in the program of psychological correction (the main group and the comparison group), a significant improvement in well-being was observed in all examined patients, regardless of the characteristics of pain. There was also an absence of a significant decrease (p> 0.05) in indicators on the scales "Pain intensity" and "Psychological component of kinesiophobia" in the comparison group, where traditional psychological methods were used, and in the control group, where classes with a medical psychologist were not included in the rehabilitation plan. ... At the same time, in the main group, as a result of rehabilitation measures, the intensity of pain, as well as the psychological component of kinesiophobia, significantly (p≤0.05) decreased, but this concerned only patients with mixed pain. The results are shown in Table 2.

Table 2 - Analysis of the significance of differences in the level of severity of psychological indicators before and after rehabilitation measures in comparison with the characteristics of pain

Subjects (participants) of the study (3)

Resonant-acoustic vibration programs in psychological support of patients with motor dysfunctions

When studying the psychological status of the examined patients before the start of rehabilitation measures (n = 125), it was shown that in terms of the characteristics of general well-being and psychoemotional state, regardless of the nosology of motor disorders (p> 0.05 according to the Mann-Whitney criterion), there is a high level of somatization of anxious and depressive experiences, as well as a pronounced fear of movement, kinesiophobia. Pain sensations of moderate intensity were recorded only in the group of patients with DDS of large joints and spine.

Main research findings (3)

The assessment of the dynamics of the corrected parameters was carried out without taking into account the nosology of motor disorders, the Wilcoxon T-test was used, the results are presented in Table 3.

Table 3 - Dynamics of indicators of psychoemotional state in the process of rehabilitation in groups

It was found that statistically significant positive dynamics of the characteristics of the psychoemotional state of patients as a result of the rehabilitation measures was recorded for the overwhelming number of the studied parameters in all groups. Noteworthy is the difference in the indicators of the level of statistical significance of the Wilcoxon test: in the main group for a number of indicators, the value of p significantly exceeds the analogous values ​​in the control group and the comparison group. So, the subjective assessment of well-being, according to the VAS, significantly improved in all groups, however, where the hardware-software complex of resonant-acoustic vibrations (PRAC) was included in the psychological support, the dynamics was recorded at the level of p = 0.0000 compared to p = 0.05 - in the comparison group and p = 0.03 - in the control group; the psychological component of kinesiophobia in the main group decreased with dynamics at the level of p = 0.0004, in the comparison group - p = 0.02, in the control group - p = 0.04; indices of somatization in the examined patients decreased in the main group at the level of p = 0.000, in the comparison group - p = 0.0001, in the control group - p = 0.03.
Significant changes in pain as a result of psychocorrectional measures were recorded only in the main group of patients with RSD of the joints and spine, where pain decreased in a median value from 3 to 2 points at the level of statistical significance of the Wilcoxon T-test p = 0. 04. The results are in Table 4.
Table 4 - Dynamics of pain syndrome in patients with DDD during rehabilitation in groups

Thus, when trying to further extrapolate the revealed patterns regarding the positive dynamics of the psychoemotional state as a result of corrective measures in patients with impaired movement function in the process of medical rehabilitation, more stable results can be obtained when the programs of resonant acoustic vibrations (PRAK) are included in the psychological support in the mode "relaxation".
Discussion
In the course of the study, the effectiveness of the inclusion of high-tech means of virtual and augmented reality in the complex of psychological rehabilitation of patients with impaired motor functions of various etiologies was shown with a high degree of reliability. The use of the "Visual Medicine" program was effective in restoring dynamic, kinesthetic, optical-spatial, constructive praxis in patients with movement disorders as a result of a stroke; application of "HTC Vive Focus Plus EEA Virtual Reality System" - in relation to psychological correction of neuropathic and mixed pain in patients with chronic pathology of the musculoskeletal system; the use of programs of resonant-acoustic vibrations (PRAK) in the "relaxation" mode - to achieve stable positive dynamics in the correction of the psychoemotional state in patients with impaired movement function.

The results of the effective use of high-tech virtual and augmented reality tools in the complex psychological support of patients in the process of medical rehabilitation is advisable, first of all, to increase the productivity of a medical psychologist, to structure his work while maintaining quality and a personalized approach in order to increase the throughput of the psychological service through the simultaneous use of several electronic devices. The main task of psychological support in this case is solved at the stage of psychodiagnostics, which allows you to create individual psychorehabilitation programs for each patient. The introduction of VR tools into the practice of psychological work, on the one hand, allows for a differentiated correction of the psychological consequences of impaired motor functions of various etiologies, and on the other hand, it strengthens productive interaction in the doctor-patient dyad by increasing the assessment of the level of self-efficacy in patients. The inclusion of VR and AR allows you to optimize the structure of psychocorrectional work due to the possibility of fast and safe modeling of space, the implementation of the necessary manipulations within the framework of an individual approach and the formation of sustainable skills for the effective independent use of similar instruments in the post-hospital period. The results obtained in this study do not disagree with the data available in the literature regarding the possibility of using immersive technologies and supplement them with an evidence-based statistical base reflecting the capabilities of specific hardware and software systems.

Research limitations
The differentiated approach to the organization of psycho-rehabilitation of patients with motor dysfunctions was based, first of all, on the need to take into account the fundamental difference in psychological reactions in adaptation to a situation of acute or chronic illness, and therefore the surveyed contingent was represented by two nosologies of motor disorders: stroke and movement disorders against the background of chronically proceeding DDS of large joints and the spine and did not include other nosological groups that are of undoubted interest and prospects for further research.

Conclusion
As a result of the work carried out, the clinical efficacy of the use of immersive technologies in relation to the psychological consequences of impaired motor functions in patients with previous ACVE and DDD of large joints and spine was proved. Prospects for further research may be associated with clarifying the mechanisms of the impact of immersive technologies on various components of the current psychoemotional state of patients with movement disorders, expanding the list of nosological forms and their psychological correlates. The results obtained make a significant contribution to solving the problem of optimizing the work of a medical psychologist in a rehabilitation hospital, allow the revealed patterns to be extended to the subsequent stages of psycho-rehabilitation and to integrate them into the general scientific and methodological context.

About the authors

Anastasia A. Kukshina

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: kukshina@list.ru
ORCID iD: 0000-0002-2290-3687
SPIN-code: 3167-5702

MD, PhD

Россия, 53/1 Zemlyanoy val, 105120, Moscow

Anastasia V. Kotel'nikova

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: pav.kotelnikov@ya.ru
ORCID iD: 0000-0003-1584-4815
SPIN-code: 7493-6708

PhD in Psychology, Associate Professor

Россия, 53/1 Zemlyanoy val, 105120, Moscow

Alexandr N. Razumov

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: razumov@mail.ru
ORCID iD: 0000-0001-8549-0106
SPIN-code: 8793-5173

MD, PhD, Professor, Academician of RAS

Россия, 53/1 Zemlyanoy val, 105120, Moscow

Irena V. Pogonchenkova

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: irena1707@yandex.ru
ORCID iD: 0000-0001-5123-5991
SPIN-code: 8861-7367

MD, PhD, Associate Professor

Россия, 53/1 Zemlyanoy val, 105120 Moscow, Russia

Elena A. Turova

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: aturova55@gmail.com
ORCID iD: 0000-0002-4397-3270
SPIN-code: 9516-5283

MD, PhD, Professor

Россия, 53/1 Zemlyanoy val, 105120, Moscow

Marina A. Rassulova

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Email: drrassulovama@yandex.ru
ORCID iD: 0000-0002-9566-9799
SPIN-code: 9763-9952

MD, PhD, Professor

Россия, 53/1 Zemlyanoy val, 105120, Moscow

Nadejda P. Lyamina

Moscow Centre for Research and Practice in Medical Rehabilitation, Restorative and Sports Medicine

Author for correspondence.
Email: lyana_n@mail.ru
ORCID iD: 0000-0001-6939-3234
SPIN-code: 4347-4426

MD, PhD, Professor

Россия, 53/1 Zemlyanoy val, 105120, Moscow

References

Supplementary files