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Динамика восстановления функции плечевого сустава у больных в остром периоде церебрального инсульта
Динамика восстановления функции плечевого сустава у больных в остром периоде церебрального инсульта
Кауркин С.Н., Скворцов Д.В., Иванова Г.Е. Динамика восстановления функции плечевого сустава у больных в остром периоде церебрального инсульта. Consilium Medicum. 2016; 18 (9): 62–67. DOI: 10.26442/2075-1753_2016.9.62-67
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Аннотация
Введение. Нарушение функции плечевого сустава – одно из распространенных патологических состояний, которые существенно ограничивают возможность пациента к самообслуживанию.
Организация исследования. Обследовано три группы: 20 здоровых, 50 больных с церебральным инсультом, сопровождающимся парезом верхней конечности, из них 25 проходили традиционное лечение и 25 – такой же курс добавления тренировок с биологической обратной связью (БОС) для движений в плечевом суставе. Проведено исследование кинематики движений в плечевых суставах в сочетании с электромиографической (ЭМГ) регистрацией на 3–4 и 21-й день.
Результаты и заключение. Обнаружено, что обе группы больных имеют снижение амплитуд движений в плечевом суставе паретичной стороны, с сохранением в норме временной цикличности движения. Отчасти снижаются амплитуды движений и на здоровой стороне. В отличие от кинематики основные действующие мышцы на стороне поражения характеризуются не только уменьшением амплитуды ЭМГ, но и более поздним максимумом активности. Обнаружен феномен аномальной двухфазовой активности мышц на стороне пареза. По окончании лечения амплитуды движений в пораженном плечевом суставе возрастают, но остаются достоверно меньше таковых в норме. Величина запаздывания максимума ЭМГ-активности уменьшается. Снижается также количество аномальных вариантов ЭМГ-активности. Уменьшение таких вариантов больше в группе, получающей БОС-тренировки. Предложенная методика исследования функции плечевых суставов является чувствительной и в отличие от клинических шкал позволяет определить количественно и качественно функциональную динамику.
Ключевые слова: церебральный инсульт, гемипарез, плечевой сустав, кинематика, биологическая обратная связь.
Организация исследования. Обследовано три группы: 20 здоровых, 50 больных с церебральным инсультом, сопровождающимся парезом верхней конечности, из них 25 проходили традиционное лечение и 25 – такой же курс добавления тренировок с биологической обратной связью (БОС) для движений в плечевом суставе. Проведено исследование кинематики движений в плечевых суставах в сочетании с электромиографической (ЭМГ) регистрацией на 3–4 и 21-й день.
Результаты и заключение. Обнаружено, что обе группы больных имеют снижение амплитуд движений в плечевом суставе паретичной стороны, с сохранением в норме временной цикличности движения. Отчасти снижаются амплитуды движений и на здоровой стороне. В отличие от кинематики основные действующие мышцы на стороне поражения характеризуются не только уменьшением амплитуды ЭМГ, но и более поздним максимумом активности. Обнаружен феномен аномальной двухфазовой активности мышц на стороне пареза. По окончании лечения амплитуды движений в пораженном плечевом суставе возрастают, но остаются достоверно меньше таковых в норме. Величина запаздывания максимума ЭМГ-активности уменьшается. Снижается также количество аномальных вариантов ЭМГ-активности. Уменьшение таких вариантов больше в группе, получающей БОС-тренировки. Предложенная методика исследования функции плечевых суставов является чувствительной и в отличие от клинических шкал позволяет определить количественно и качественно функциональную динамику.
Ключевые слова: церебральный инсульт, гемипарез, плечевой сустав, кинематика, биологическая обратная связь.
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Introduction. Impaired function of the shoulder joint is one of the most common medical conditions that significantly limit the ability of the patient to self-service as a result of stroke.
Organization of the study. The study involved three groups: 20 healthy, 50 patients with cerebral stroke with hemiparesis of the upper extremity, of which 25 got standard treatment and 25 had additional course of training with biofeedback for movement in the shoulder joint. A study of the kinematics of movements in the shoulder joints in combination with electromyography (EMG) recording were made on the 3–4th day and 21-th day.
Results and conclusion. It was found that both groups of patients have a decrease in range of motion in the shoulder joint paretic hand, and support normal cyclical movement of time. A part of patients shown reduced range of motion not only on affected, but also on the healthy side. In contrast to the kinematics basic acting muscles on the affected side are characterized not only a decrease in EMG-amplitude, but also the later peak activity. Parts of patient were shown the phenomenon of anomalous, two-phase activity of muscles on the side of paresis. After treatment, ranges of motion in the affected shoulder joint are increasing, but remain significantly lower than those in normal. The magnitude of the EMG-activity of the maximum delay is reduced. The numbers of abnormal variants of EMG-activity were coming to be less after treatment. The group receiving biofeedback training demonstrated better functional result. The proposed method of investigation function of the shoulder joint is more sensitive compare to clinical scales to determine quantitatively and qualitatively the functional dynamics.
Key words: stroke, hemiparesis, shoulder joint, kinematics, biofeedback.
Organization of the study. The study involved three groups: 20 healthy, 50 patients with cerebral stroke with hemiparesis of the upper extremity, of which 25 got standard treatment and 25 had additional course of training with biofeedback for movement in the shoulder joint. A study of the kinematics of movements in the shoulder joints in combination with electromyography (EMG) recording were made on the 3–4th day and 21-th day.
Results and conclusion. It was found that both groups of patients have a decrease in range of motion in the shoulder joint paretic hand, and support normal cyclical movement of time. A part of patients shown reduced range of motion not only on affected, but also on the healthy side. In contrast to the kinematics basic acting muscles on the affected side are characterized not only a decrease in EMG-amplitude, but also the later peak activity. Parts of patient were shown the phenomenon of anomalous, two-phase activity of muscles on the side of paresis. After treatment, ranges of motion in the affected shoulder joint are increasing, but remain significantly lower than those in normal. The magnitude of the EMG-activity of the maximum delay is reduced. The numbers of abnormal variants of EMG-activity were coming to be less after treatment. The group receiving biofeedback training demonstrated better functional result. The proposed method of investigation function of the shoulder joint is more sensitive compare to clinical scales to determine quantitatively and qualitatively the functional dynamics.
Key words: stroke, hemiparesis, shoulder joint, kinematics, biofeedback.
Полный текст
Список литературы
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14. Huang S, Luo C, Ye S, Liu F et al. Motor impairment evaluation for upper limb in stroke patients on the basis of a microsensor. Int J Rehabil Res 2012; 35: 161–9.
15. Kleine BU, Schumann NP, Bradl I et al. Surface EMG of shoulder and back muscles and posture analysis in secretaries typing at visual display units. Int Arch Occup Environ Health 1999; 72 (6): 387–94.
16. Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath Concept in stroke rehabilitation: what is the evidence? Stroke 2009; 40 (4): e89-e97.
17. Kwakkel G, Kollen BJ, Van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb:impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34 (9): 2181–6.
18. Lang CE, Wagner JM, Edwards DF, Dromerick AW. Upper extremity use in people with hemiparesis in the first few weeks after stroke. JNPT 2007; 31: 56–63.
19. Morris JH, Van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013; 35 (4): 291–9.
20. Murphy M, Willens HJ, Sunnerhagen KS. Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass. Neurorehabil Neural Repair 2011; 1: 71–80.
21. Nijland RH, Van Wegen EE, Harmeling-van der Wel BC, Kwakkel G. Presence of finger extension and shoulder abduction within 72 hours after stroke predicts functional recovery: early prediction of functional outcome after stroke: the EPOS cohort study. Stroke 2010; 41: 745–50.
22. Oonagh M, Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
23. Pollock A, Farmer S, Brady M, Langhorne P. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; 11.
24. Rundquist P, Dumit M, Hartley J et al. Three-dimensional shoulder complex kinematics in individuals with upper extremity impairment from chronic stroke. Disabil Rehabil 2011; p. 1–6.
25. Rymer WZ, Katz RT. Mechanism of spastic hypertonia. Phys Med Rehab 1994; 8: 442–53.
26. Roetenberg D, Luinge HJ, Baten CT. Compensation of magnetic disturbances improves inertial and magnetic sensing of human body segment orientation. IEEE Trans Neural Syst Rehabil Eng 2005; 13 (3): 395–405.
27. Thrane G, Emaus N, Askim T, Anke A. Arm use in patients with subacute stroke monitored by accelerometry: Association with motor impairment and influence on self-dependence. J Rehabil Med 2011; 43 (4): 299–304.
28. Van der Pas SC, Verbunt JA, Breukelaar DE et al. Assessment of arm activity using triaxialaccelerometryin patients with a stroke. Arch Phys Med 2011; 92 (9): 1437–42.
29. Veerbeek JM, Kwakkel G, Van Wegen EE et al. Early prediction of outcome of activities of daily living after stroke: a systematic review. Stroke 2011; 42: 1482–8.
2. Skvortsova V.I. Snizhenie zabolevaemosti, smertnosti i invalidnosti ot insul'tov v Rossiiskoi Federatsii. M.: Litera, 2007. [in Russian]
3. Canning CG, Ada L, O'Dwyer NJ. Abnormal muscle activation characteristics associated with loss of dexterity after stroke. J Neurol Sci 2000; 176 (1): 45–56.
4. Cesqui B, Tropea P, Micera S, Krebs H. EMG-based pattern recognition approach in post stroke robot-aided rehabilitation: a feasibility study. J Neuroeng Rehabil 2013; 10: 75.
5. Darling W, Cole K. Muscle activation patterns and kinetics of human index finger movements. J Neurophysiol 1990; 63: 1098–108.
6. Dejnabadi H, Jolles BM, Aminian K. A new approach to accurate measurement of uniaxialjoint angles based on a combination of accelerometers and gyroscopes. IEEE Trans Biomed 2005; p. 1478–84.
7. El-Zayat BF, Efe T, Heidrich A et al. Objective assessment of shoulder mobility with a new 3D gyroscope – a validation study. BMC Musculoskelet Disord 2011; 12: 16.
8. Ertzgaard P, Ohberg F, Gerdle B, Grip H. A new way of assessing arm function in activity using kinematic Exposure Variation Analysis and portable inertial sensors – A validity study. Manual Ther 2016; 21: 241–9.
9. Fugl-Meyer A, Jaasko L, Leyman I et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975; 7: 3–31.
10. Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
11. Gordon N, Gulanick M, Costa F et al. Physical activity and exercise recommendations for stroke survivors. Circulation 2004; 109: 2031–41.
12. Heart Disease and Stroke Statistics-2013 Update: A Report From the American Heart, Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231.
13. Hsiu-Yun H, Cheng-Feng L, Fong-Chin S et a;. Clinical application of computerized evaluation and re-education biofeedback prototype for sensorimotor control of the hand in stroke patients. J Neuroeng Rehabil 2012; 9: 26.
14. Huang S, Luo C, Ye S, Liu F et al. Motor impairment evaluation for upper limb in stroke patients on the basis of a microsensor. Int J Rehabil Res 2012; 35: 161–9.
15. Kleine BU, Schumann NP, Bradl I et al. Surface EMG of shoulder and back muscles and posture analysis in secretaries typing at visual display units. Int Arch Occup Environ Health 1999; 72 (6): 387–94.
16. Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath Concept in stroke rehabilitation: what is the evidence? Stroke 2009; 40 (4): e89-e97.
17. Kwakkel G, Kollen BJ, Van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb:impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34 (9): 2181–6.
18. Lang CE, Wagner JM, Edwards DF, Dromerick AW. Upper extremity use in people with hemiparesis in the first few weeks after stroke. JNPT 2007; 31: 56–63.
19. Morris JH, Van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013; 35 (4): 291–9.
20. Murphy M, Willens HJ, Sunnerhagen KS. Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass. Neurorehabil Neural Repair 2011; 1: 71–80.
21. Nijland RH, Van Wegen EE, Harmeling-van der Wel BC, Kwakkel G. Presence of finger extension and shoulder abduction within 72 hours after stroke predicts functional recovery: early prediction of functional outcome after stroke: the EPOS cohort study. Stroke 2010; 41: 745–50.
22. Oonagh M, Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
23. Pollock A, Farmer S, Brady M, Langhorne P. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; 11.
24. Rundquist P, Dumit M, Hartley J et al. Three-dimensional shoulder complex kinematics in individuals with upper extremity impairment from chronic stroke. Disabil Rehabil 2011; p. 1–6.
25. Rymer WZ, Katz RT. Mechanism of spastic hypertonia. Phys Med Rehab 1994; 8: 442–53.
26. Roetenberg D, Luinge HJ, Baten CT. Compensation of magnetic disturbances improves inertial and magnetic sensing of human body segment orientation. IEEE Trans Neural Syst Rehabil Eng 2005; 13 (3): 395–405.
27. Thrane G, Emaus N, Askim T, Anke A. Arm use in patients with subacute stroke monitored by accelerometry: Association with motor impairment and influence on self-dependence. J Rehabil Med 2011; 43 (4): 299–304.
28. Van der Pas SC, Verbunt JA, Breukelaar DE et al. Assessment of arm activity using triaxialaccelerometryin patients with a stroke. Arch Phys Med 2011; 92 (9): 1437–42.
29. Veerbeek JM, Kwakkel G, Van Wegen EE et al. Early prediction of outcome of activities of daily living after stroke: a systematic review. Stroke 2011; 42: 1482–8.
2. Скворцова В.И. Снижение заболеваемости, смертности и инвалидности от инсультов в Российской Федерации. М.: Литера, 2007. / Skvortsova V.I. Snizhenie zabolevaemosti, smertnosti i invalidnosti ot insul'tov v Rossiiskoi Federatsii. M.: Litera, 2007. [in Russian]
3. Canning CG, Ada L, O'Dwyer NJ. Abnormal muscle activation characteristics associated with loss of dexterity after stroke. J Neurol Sci 2000; 176 (1): 45–56.
4. Cesqui B, Tropea P, Micera S, Krebs H. EMG-based pattern recognition approach in post stroke robot-aided rehabilitation: a feasibility study. J Neuroeng Rehabil 2013; 10: 75.
5. Darling W, Cole K. Muscle activation patterns and kinetics of human index finger movements. J Neurophysiol 1990; 63: 1098–108.
6. Dejnabadi H, Jolles BM, Aminian K. A new approach to accurate measurement of uniaxialjoint angles based on a combination of accelerometers and gyroscopes. IEEE Trans Biomed 2005; p. 1478–84.
7. El-Zayat BF, Efe T, Heidrich A et al. Objective assessment of shoulder mobility with a new 3D gyroscope – a validation study. BMC Musculoskelet Disord 2011; 12: 16.
8. Ertzgaard P, Ohberg F, Gerdle B, Grip H. A new way of assessing arm function in activity using kinematic Exposure Variation Analysis and portable inertial sensors – A validity study. Manual Ther 2016; 21: 241–9.
9. Fugl-Meyer A, Jaasko L, Leyman I et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975; 7: 3–31.
10. Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
11. Gordon N, Gulanick M, Costa F et al. Physical activity and exercise recommendations for stroke survivors. Circulation 2004; 109: 2031–41.
12. Heart Disease and Stroke Statistics-2013 Update: A Report From the American Heart, Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231.
13. Hsiu-Yun H, Cheng-Feng L, Fong-Chin S et a;. Clinical application of computerized evaluation and re-education biofeedback prototype for sensorimotor control of the hand in stroke patients. J Neuroeng Rehabil 2012; 9: 26.
14. Huang S, Luo C, Ye S, Liu F et al. Motor impairment evaluation for upper limb in stroke patients on the basis of a microsensor. Int J Rehabil Res 2012; 35: 161–9.
15. Kleine BU, Schumann NP, Bradl I et al. Surface EMG of shoulder and back muscles and posture analysis in secretaries typing at visual display units. Int Arch Occup Environ Health 1999; 72 (6): 387–94.
16. Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath Concept in stroke rehabilitation: what is the evidence? Stroke 2009; 40 (4): e89-e97.
17. Kwakkel G, Kollen BJ, Van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb:impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34 (9): 2181–6.
18. Lang CE, Wagner JM, Edwards DF, Dromerick AW. Upper extremity use in people with hemiparesis in the first few weeks after stroke. JNPT 2007; 31: 56–63.
19. Morris JH, Van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013; 35 (4): 291–9.
20. Murphy M, Willens HJ, Sunnerhagen KS. Kinematic variables quantifying upper-extremity performance after stroke during reaching and drinking from a glass. Neurorehabil Neural Repair 2011; 1: 71–80.
21. Nijland RH, Van Wegen EE, Harmeling-van der Wel BC, Kwakkel G. Presence of finger extension and shoulder abduction within 72 hours after stroke predicts functional recovery: early prediction of functional outcome after stroke: the EPOS cohort study. Stroke 2010; 41: 745–50.
22. Oonagh M, Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
23. Pollock A, Farmer S, Brady M, Langhorne P. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev 2014; 11.
24. Rundquist P, Dumit M, Hartley J et al. Three-dimensional shoulder complex kinematics in individuals with upper extremity impairment from chronic stroke. Disabil Rehabil 2011; p. 1–6.
25. Rymer WZ, Katz RT. Mechanism of spastic hypertonia. Phys Med Rehab 1994; 8: 442–53.
26. Roetenberg D, Luinge HJ, Baten CT. Compensation of magnetic disturbances improves inertial and magnetic sensing of human body segment orientation. IEEE Trans Neural Syst Rehabil Eng 2005; 13 (3): 395–405.
27. Thrane G, Emaus N, Askim T, Anke A. Arm use in patients with subacute stroke monitored by accelerometry: Association with motor impairment and influence on self-dependence. J Rehabil Med 2011; 43 (4): 299–304.
28. Van der Pas SC, Verbunt JA, Breukelaar DE et al. Assessment of arm activity using triaxialaccelerometryin patients with a stroke. Arch Phys Med 2011; 92 (9): 1437–42.
29. Veerbeek JM, Kwakkel G, Van Wegen EE et al. Early prediction of outcome of activities of daily living after stroke: a systematic review. Stroke 2011; 42: 1482–8.
________________________________________________
2. Skvortsova V.I. Snizhenie zabolevaemosti, smertnosti i invalidnosti ot insul'tov v Rossiiskoi Federatsii. M.: Litera, 2007. [in Russian]
3. Canning CG, Ada L, O'Dwyer NJ. Abnormal muscle activation characteristics associated with loss of dexterity after stroke. J Neurol Sci 2000; 176 (1): 45–56.
4. Cesqui B, Tropea P, Micera S, Krebs H. EMG-based pattern recognition approach in post stroke robot-aided rehabilitation: a feasibility study. J Neuroeng Rehabil 2013; 10: 75.
5. Darling W, Cole K. Muscle activation patterns and kinetics of human index finger movements. J Neurophysiol 1990; 63: 1098–108.
6. Dejnabadi H, Jolles BM, Aminian K. A new approach to accurate measurement of uniaxialjoint angles based on a combination of accelerometers and gyroscopes. IEEE Trans Biomed 2005; p. 1478–84.
7. El-Zayat BF, Efe T, Heidrich A et al. Objective assessment of shoulder mobility with a new 3D gyroscope – a validation study. BMC Musculoskelet Disord 2011; 12: 16.
8. Ertzgaard P, Ohberg F, Gerdle B, Grip H. A new way of assessing arm function in activity using kinematic Exposure Variation Analysis and portable inertial sensors – A validity study. Manual Ther 2016; 21: 241–9.
9. Fugl-Meyer A, Jaasko L, Leyman I et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975; 7: 3–31.
10. Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil 2013; 10: 60.
11. Gordon N, Gulanick M, Costa F et al. Physical activity and exercise recommendations for stroke survivors. Circulation 2004; 109: 2031–41.
12. Heart Disease and Stroke Statistics-2013 Update: A Report From the American Heart, Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231.
13. Hsiu-Yun H, Cheng-Feng L, Fong-Chin S et a;. Clinical application of computerized evaluation and re-education biofeedback prototype for sensorimotor control of the hand in stroke patients. J Neuroeng Rehabil 2012; 9: 26.
14. Huang S, Luo C, Ye S, Liu F et al. Motor impairment evaluation for upper limb in stroke patients on the basis of a microsensor. Int J Rehabil Res 2012; 35: 161–9.
15. Kleine BU, Schumann NP, Bradl I et al. Surface EMG of shoulder and back muscles and posture analysis in secretaries typing at visual display units. Int Arch Occup Environ Health 1999; 72 (6): 387–94.
16. Kollen BJ, Lennon S, Lyons B et al. The effectiveness of the Bobath Concept in stroke rehabilitation: what is the evidence? Stroke 2009; 40 (4): e89-e97.
17. Kwakkel G, Kollen BJ, Van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb:impact of severity of paresis and time since onset in acute stroke. Stroke 2003; 34 (9): 2181–6.
18. Lang CE, Wagner JM, Edwards DF, Dromerick AW. Upper extremity use in people with hemiparesis in the first few weeks after stroke. JNPT 2007; 31: 56–63.
19. Morris JH, Van Wijck F, Joice S, Donaghy M. Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction. Disabil Rehabil 2013; 35 (4): 291–9.
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Авторы
С.Н.Кауркин*1, Д.В.Скворцов1,2, Г.Е.Иванова2
1 ФГБУ Федеральный научно-клинический центр специализированных видов медицинской помощи и медицинских технологий ФМБА России. 115682, Россия, Москва, Ореховый б-р, д. 28;
2 ФГБОУ ВО Российский национальный исследовательский медицинский университет им. Н.И.Пирогова Минздрава России. 17997, Россия, Москва, ул. Островитянова, д. 1
*kaurkins@bk.ru
1 ФГБУ Федеральный научно-клинический центр специализированных видов медицинской помощи и медицинских технологий ФМБА России. 115682, Россия, Москва, Ореховый б-р, д. 28;
2 ФГБОУ ВО Российский национальный исследовательский медицинский университет им. Н.И.Пирогова Минздрава России. 17997, Россия, Москва, ул. Островитянова, д. 1
*kaurkins@bk.ru
________________________________________________
S.N.Kaurkin*1, D.V.Skvortsov1,2, G.E.Ivanova2
1 Federal Research Center for Specialized Types of Medical Assistance and Medical Technologies of FMBA of Russia. 115682, Russian Federation, Moscow, Orekhovyi b-r, d. 28;
2 N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1
*kaurkins@bk.ru
1 Federal Research Center for Specialized Types of Medical Assistance and Medical Technologies of FMBA of Russia. 115682, Russian Federation, Moscow, Orekhovyi b-r, d. 28;
2 N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1
*kaurkins@bk.ru
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