Klinik Araştırma
BibTex RIS Kaynak Göster

Investigating the Relationship Between Physical and Psychological Parameters in Participants with Multiple Sclerosis

Yıl 2024, , 241 - 250, 26.08.2024
https://doi.org/10.56061/fbujohs.1456898

Öz

This study investigates the associations among disease duration, balance, anxiety, and depression in individuals with Multiple Sclerosis (MS), along with how these parameters correlate with quality of life. Sixty-three participants with a mean age of 45.65±11.04 years were included. Spearman correlation analysis assessed these correlations. The Hospital Anxiety and Depression Scale (HADS) measured anxiety and depression symptoms, the Berg Balance Scale (BBS) assessed balance, and the Multiple Sclerosis Quality of Life-54 Questionnaire (MSQOL-54) evaluated quality of life. A negative and significant relationship was found between participants' disease duration and balance (r =-0.362, p = 0.004). However, no significant relationships were observed between disease duration and anxiety, depression, and quality of life (p> 0.05). Negative correlations were identified between balance and anxiety (r =-0.330, p = 0.008) and between balance and depression (r =-0.311, p = 0.013). Additionally, a positive correlation was observed between balance and quality of life, while negative correlations were identified between quality of life and both anxiety and depression. Given that MS profoundly affects individuals, a holistic evaluation is crucial for a comprehensive understanding. Future studies are encouraged to adopt a holistic approach, incorporating assessments of cognitive states and exploring interrelationships between these parameters.

Kaynakça

  • Algahtani, H., Shirah, B., & Alassiri, A. (2017). Tumefactive demyelinating lesions: a comprehensive review. Multiple Sclerosis and Related Disorders, 14, 72-79. https://doi.org/10.1016/j.msard.2017.04.003
  • Alghwiri, A. A., Khalil, H., Al-Sharman, A., & El-Salem, K. (2018). Depression is a predictor for balance in people with multiple sclerosis. Multiple Sclerosis and Related Disorders, 24, 28-31. https://doi.org/10.1016/j.msard.2018.05.013
  • Baumstarck, K., Pelletier, J., Butzkueven, H., Fernandez, O., Flachenecker, P., Idiman, E., Stecchi, S., Boucekine, M., Auquier, P., & Group, M. S. (2013). Health‐related quality of life as an independent predictor of long‐term disability for patients with relapsing–remitting multiple sclerosis. European Journal of Neurology, 20(6), 907-e979. https://doi.org/10.1111/ene.12087
  • Cameron, M. H., & Lord, S. (2010). Postural control in multiple sclerosis: implications for fall prevention. Current neurology and neuroscience reports, 10, 407-412. https://doi.org/10.1007/s11910-010-0128-0
  • Cattaneo, D., De Nuzzo, C., Fascia, T., Macalli, M., Pisoni, I., & Cardini, R. (2002). Risks of falls in subjects with multiple sclerosis. Archives of physical medicine and rehabilitation, 83(6), 864-867. https://doi.org/10.1053/apmr.2002.32825
  • Cavanaugh, J. T., Gappmaier, V. O., Dibble, L. E., & Gappmaier, E. (2011). Ambulatory activity in individuals with multiple sclerosis. Journal of neurologic physical therapy, 35(1), 26-33. https://doi.org/10.1097/npt.0b013e3182097190
  • Chwastiak, L. A., & Ehde, D. M. (2007). Psychiatric issues in multiple sclerosis. Psychiatric Clinics of North America, 30(4), 803-817. https://doi.org/10.1016/j.psc.2007.07.003
  • Comber, L., Galvin, R., & Coote, S. (2017). Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis. Gait & posture, 51, 25-35. https://doi.org/10.1016/j.gaitpost.2016.09.026
  • Filippi, M., Rocca, M. A., Ciccarelli, O., De Stefano, N., Evangelou, N., Kappos, L., Rovira, A., Sastre-Garriga, J., Tintorè, M., & Frederiksen, J. L. (2016). MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines. The Lancet Neurology, 15(3), 292-303. https://doi.org/10.1016/s1474-4422(15)00393-2
  • Giovannetti, A. M., Brambilla, L., Torri Clerici, V., Antozzi, C., Mantegazza, R., Černiauskaitė, M., & Confalonieri, P. (2017). Difficulties in adjustment to multiple sclerosis: vulnerability and unpredictability of illness in the foreground. Disability and Rehabilitation, 39(9), 897-903. https://doi.org/10.3109/09638288.2016.1170212
  • Hainaut, J.-P., Caillet, G., Lestienne, F. G., & Bolmont, B. (2011). The role of trait anxiety on static balance performance in control and anxiogenic situations. Gait & posture, 33(4), 604-608. https://doi.org/10.1016/j.gaitpost.2011.01.017
  • Hanna, M., & Strober, L. B. (2020). Anxiety and depression in Multiple Sclerosis (MS): Antecedents, consequences, and differential impact on well-being and quality of life. Multiple Sclerosis and Related Disorders, 44, 102261. https://doi.org/10.1016/j.msard.2020.102261
  • Idiman, E., Uzunel, F., Ozakbas, S., Yozbatiran, N., Oguz, M., Callioglu, B., Gokce, N., & Bahar, Z. (2006). Cross-cultural adaptation and validation of multiple sclerosis quality of life questionnaire (MSQOL-54) in a Turkish multiple sclerosis sample. Journal of the neurological sciences, 240(1-2), 77-80. https://doi.org/10.1016/j.jns.2005.09.009
  • Jamroz-Wiśniewska, A., Papuć, E., Bartosik-Psujek, H., Belniak, E., Mitosek-Szewczyk, K., & Stelmasiak, Z. (2007). Validation of selected aspects of psychometry of the Polish version of the Multiple Sclerosis Impact Scale 29 (MSIS-29). Neurologia i Neurochirurgia Polska, 41(3), 215-222.
  • Jones, B. (2014). Patients' Perspectives in Multiple Sclerosis: Uncertainty and Anxiety Hinder Psychological Wellbeing. [Unpublished doctoral dissertation]..University of Surrey (United Kingdom).
  • Jones, K. H., Ford, D. V., Jones, P. A., John, A., Middleton, R. M., Lockhart-Jones, H., Peng, J., Osborne, L. A., & Noble, J. G. (2013). How people with multiple sclerosis rate their quality of life: an EQ-5D survey via the UK MS register. PLoS One, 8(6), e65640. https://doi.org/10.1371/journal.pone.0065640
  • Klevan, G., Jacobsen, C., Aarseth, J., Myhr, K. M., Nyland, H., Glad, S., Lode, K., Figved, N., Larsen, J., & Farbu, E. (2014). Health related quality of life in patients recently diagnosed with multiple sclerosis. Acta Neurologica Scandinavica, 129(1), 21-26. https://doi.org/10.1111/ane.12142
  • LaRocca, N. G. (2011). Impact of walking impairment in multiple sclerosis: perspectives of patients and care partners. The Patient: Patient-Centered Outcomes Research, 4, 189-201. https://doi.org/10.2165/11591150-000000000-00000
  • Margoni, M., Preziosa, P., Rocca, M. A., & Filippi, M. (2023). Depressive symptoms, anxiety and cognitive impairment: emerging evidence in multiple sclerosis. Translational Psychiatry, 13(1), 264. https://doi.org/10.1038/s41398-023-02555-7
  • McNicholas, N., Tubridy, N., Hutchinson, M., & McGuigan, C. (2021). Perceived and objective cognitive impairment in newly diagnosed versus established multiple sclerosis: impact of disease duration. Irish Journal of Medical Science (1971-), 190, 1149-1154. https://doi.org/10.1007/s11845-020-02404-2
  • Middleton, A., Fritz, S. L., & Lusardi, M. (2015). Walking speed: the functional vital sign. Journal of aging and physical activity, 23(2), 314-322. https://doi.org/10.1123/japa.2013-0236
  • Nilsagård, Y., Lundholm, C., Denison, E., & Gunnarsson, L.-G. (2009). Predicting accidental falls in people with multiple sclerosis—a longitudinal study. Clinical rehabilitation, 23(3), 259-269. https://doi.org/10.1177/0269215508095087
  • Pacheco-Unguetti, A. P., Acosta, A., Callejas, A., & Lupiáñez, J. (2010). Attention and anxiety: Different attentional functioning under state and trait anxiety. Psychological science, 21(2), 298-304. https://doi.org/10.1177/0956797609359624
  • Paker, N., Bugdayci, D., Midik, M., Celik, B., & Kesiktas, N. (2013). Reliability of the Turkish version of the hospital anxiety and depression scale in the people with traumatic spinal cord injury. NeuroRehabilitation, 33(2), 337-341. https://doi.org/10.3233/nre-130964
  • Patti, F., Russo, P., Pappalardo, A., Macchia, F., Civalleri, L., Paolillo, A., & Group, F. S. (2007). Predictors of quality of life among patients with multiple sclerosis: an Italian cross-sectional study. Journal of the neurological sciences, 252(2), 121-129. https://doi.org/10.1016/j.jns.2006.10.017
  • Sahin, F., Yilmaz, F., Ozmaden, A., Kotevoglu, N., Sahin, T., & Kuran, B. (2008). Reliability and validity of the Turkish version of the Berg Balance Scale. Journal of geriatric physical therapy, 31(1), 32-37. https://doi.org/10.1519/00139143-200831010-00006
  • Siegert, R. J., & Abernethy, D. (2005). Depression in multiple sclerosis: a review. Journal of Neurology, Neurosurgery & Psychiatry, 76(4), 469-475. https://doi.org/10.1136/jnnp.2004.054635
  • Solomon, A. J., Arrambide, G., Brownlee, W. J., Flanagan, E. P., Amato, M. P., Amezcua, L., Banwell, B. L., Barkhof, F., Corboy, J. R., & Correale, J. (2023). Differential diagnosis of suspected multiple sclerosis: an updated consensus approach. The Lancet Neurology, 22(8), 750-768. https://doi.org/10.1016/s1474-4422(23)00148-5
  • Sosnoff, J. J., Socie, M. J., Boes, M. K., Sandroff, B. M., Pula, J. H., Suh, Y., Weikert, M., Balantrapu, S., Morrison, S., & Motl, R. W. (2011). Mobility, balance and falls in persons with multiple sclerosis. PLoS One, 6(11), e28021. https://doi.org/10.1371/journal.pone.0028021
  • Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., Correale, J., Fazekas, F., Filippi, M., & Freedman, M. S. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology, 17(2), 162-173. https://doi.org/10.1016/s1474-4422(17)30470-2
  • Tingey, J. L. (2020). Intolerance of uncertainty and resilience predict self-efficacy trajectories of individuals newly diagnosed with multiple sclerosis Seattle Pacific University]. https://doi.org/10.1037/rep0000487
  • Vickrey, B., Hays, R., Harooni, R., Myers, L., & Ellison, G. (1995). A health-related quality of life measure for multiple sclerosis. Quality of life research, 4(3), 187-206. https://doi.org/10.1007/bf02260859
  • Yamout, B., Issa, Z., Herlopian, A., El Bejjani, M., Khalifa, A., Ghadieh, A., & Habib, R. (2013). Predictors of quality of life among multiple sclerosis patients: a comprehensive analysis. European Journal of Neurology, 20(5), 756-764. https://doi.org/10.1111/ene.12046
  • Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta psychiatrica scandinavica, 67(6), 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

Multipl Sklerozlu Bireylerde Fiziksel ve Psikolojik Parametreler Arasındaki İlişkinin Araştırılması

Yıl 2024, , 241 - 250, 26.08.2024
https://doi.org/10.56061/fbujohs.1456898

Öz

Bu çalışma, Multipl Skleroz (MS) hastalığına sahip bireylerde hastalık süresi, denge, anksiyete ve depresyon arasındaki ilişkileri, ayrıca bu parametrelerin yaşam kalitesi ile nasıl ilişkilendiğini araştırmaktadır. Ortalama yaşı 45.65±11.04 olan 63 katılımcı dahil edildi. Spearman korelasyon analizi bu ilişkileri değerlendirdi. Hastane Anksiyete ve Depresyon Ölçeği (HADS) anksiyete ve depresyon belirtilerini ölçerken, Berg Denge Ölçeği (BBS) dengeyi değerlendirdi ve Multiple Sclerosis Quality of Life-54 Anketi (MSQOL-54) yaşam kalitesini değerlendirdi. Katılımcıların hastalık süresi ile denge arasında negatif ve anlamlı bir ilişki bulundu (r =-0.362, p = 0.004). Ancak, hastalık süresi ile anksiyete, depresyon ve yaşam kalitesi arasında anlamlı bir ilişki gözlemlenmedi (p> 0.05). Denge ile anksiyete (r =-0.330, p = 0.008) ve depresyon (r =-0.311, p = 0.013) arasında negatif korelasyonlar belirlendi. Ayrıca, denge ile yaşam kalitesi arasında pozitif bir korelasyon gözlemlendi, yaşam kalitesi ile anksiyete ve depresyon arasında ise negatif korelasyonlar belirlendi. MS'nin bireyleri derinden etkilediği göz önüne alındığında, kapsamlı bir anlayış için bütünsel bir değerlendirme önemlidir. Gelecekteki çalışmalar, bilişsel durumları değerlendiren ve bu parametreler arasındaki ilişkileri araştıran bütünsel bir yaklaşım benimsemeye teşvik edilmektedir.

Kaynakça

  • Algahtani, H., Shirah, B., & Alassiri, A. (2017). Tumefactive demyelinating lesions: a comprehensive review. Multiple Sclerosis and Related Disorders, 14, 72-79. https://doi.org/10.1016/j.msard.2017.04.003
  • Alghwiri, A. A., Khalil, H., Al-Sharman, A., & El-Salem, K. (2018). Depression is a predictor for balance in people with multiple sclerosis. Multiple Sclerosis and Related Disorders, 24, 28-31. https://doi.org/10.1016/j.msard.2018.05.013
  • Baumstarck, K., Pelletier, J., Butzkueven, H., Fernandez, O., Flachenecker, P., Idiman, E., Stecchi, S., Boucekine, M., Auquier, P., & Group, M. S. (2013). Health‐related quality of life as an independent predictor of long‐term disability for patients with relapsing–remitting multiple sclerosis. European Journal of Neurology, 20(6), 907-e979. https://doi.org/10.1111/ene.12087
  • Cameron, M. H., & Lord, S. (2010). Postural control in multiple sclerosis: implications for fall prevention. Current neurology and neuroscience reports, 10, 407-412. https://doi.org/10.1007/s11910-010-0128-0
  • Cattaneo, D., De Nuzzo, C., Fascia, T., Macalli, M., Pisoni, I., & Cardini, R. (2002). Risks of falls in subjects with multiple sclerosis. Archives of physical medicine and rehabilitation, 83(6), 864-867. https://doi.org/10.1053/apmr.2002.32825
  • Cavanaugh, J. T., Gappmaier, V. O., Dibble, L. E., & Gappmaier, E. (2011). Ambulatory activity in individuals with multiple sclerosis. Journal of neurologic physical therapy, 35(1), 26-33. https://doi.org/10.1097/npt.0b013e3182097190
  • Chwastiak, L. A., & Ehde, D. M. (2007). Psychiatric issues in multiple sclerosis. Psychiatric Clinics of North America, 30(4), 803-817. https://doi.org/10.1016/j.psc.2007.07.003
  • Comber, L., Galvin, R., & Coote, S. (2017). Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis. Gait & posture, 51, 25-35. https://doi.org/10.1016/j.gaitpost.2016.09.026
  • Filippi, M., Rocca, M. A., Ciccarelli, O., De Stefano, N., Evangelou, N., Kappos, L., Rovira, A., Sastre-Garriga, J., Tintorè, M., & Frederiksen, J. L. (2016). MRI criteria for the diagnosis of multiple sclerosis: MAGNIMS consensus guidelines. The Lancet Neurology, 15(3), 292-303. https://doi.org/10.1016/s1474-4422(15)00393-2
  • Giovannetti, A. M., Brambilla, L., Torri Clerici, V., Antozzi, C., Mantegazza, R., Černiauskaitė, M., & Confalonieri, P. (2017). Difficulties in adjustment to multiple sclerosis: vulnerability and unpredictability of illness in the foreground. Disability and Rehabilitation, 39(9), 897-903. https://doi.org/10.3109/09638288.2016.1170212
  • Hainaut, J.-P., Caillet, G., Lestienne, F. G., & Bolmont, B. (2011). The role of trait anxiety on static balance performance in control and anxiogenic situations. Gait & posture, 33(4), 604-608. https://doi.org/10.1016/j.gaitpost.2011.01.017
  • Hanna, M., & Strober, L. B. (2020). Anxiety and depression in Multiple Sclerosis (MS): Antecedents, consequences, and differential impact on well-being and quality of life. Multiple Sclerosis and Related Disorders, 44, 102261. https://doi.org/10.1016/j.msard.2020.102261
  • Idiman, E., Uzunel, F., Ozakbas, S., Yozbatiran, N., Oguz, M., Callioglu, B., Gokce, N., & Bahar, Z. (2006). Cross-cultural adaptation and validation of multiple sclerosis quality of life questionnaire (MSQOL-54) in a Turkish multiple sclerosis sample. Journal of the neurological sciences, 240(1-2), 77-80. https://doi.org/10.1016/j.jns.2005.09.009
  • Jamroz-Wiśniewska, A., Papuć, E., Bartosik-Psujek, H., Belniak, E., Mitosek-Szewczyk, K., & Stelmasiak, Z. (2007). Validation of selected aspects of psychometry of the Polish version of the Multiple Sclerosis Impact Scale 29 (MSIS-29). Neurologia i Neurochirurgia Polska, 41(3), 215-222.
  • Jones, B. (2014). Patients' Perspectives in Multiple Sclerosis: Uncertainty and Anxiety Hinder Psychological Wellbeing. [Unpublished doctoral dissertation]..University of Surrey (United Kingdom).
  • Jones, K. H., Ford, D. V., Jones, P. A., John, A., Middleton, R. M., Lockhart-Jones, H., Peng, J., Osborne, L. A., & Noble, J. G. (2013). How people with multiple sclerosis rate their quality of life: an EQ-5D survey via the UK MS register. PLoS One, 8(6), e65640. https://doi.org/10.1371/journal.pone.0065640
  • Klevan, G., Jacobsen, C., Aarseth, J., Myhr, K. M., Nyland, H., Glad, S., Lode, K., Figved, N., Larsen, J., & Farbu, E. (2014). Health related quality of life in patients recently diagnosed with multiple sclerosis. Acta Neurologica Scandinavica, 129(1), 21-26. https://doi.org/10.1111/ane.12142
  • LaRocca, N. G. (2011). Impact of walking impairment in multiple sclerosis: perspectives of patients and care partners. The Patient: Patient-Centered Outcomes Research, 4, 189-201. https://doi.org/10.2165/11591150-000000000-00000
  • Margoni, M., Preziosa, P., Rocca, M. A., & Filippi, M. (2023). Depressive symptoms, anxiety and cognitive impairment: emerging evidence in multiple sclerosis. Translational Psychiatry, 13(1), 264. https://doi.org/10.1038/s41398-023-02555-7
  • McNicholas, N., Tubridy, N., Hutchinson, M., & McGuigan, C. (2021). Perceived and objective cognitive impairment in newly diagnosed versus established multiple sclerosis: impact of disease duration. Irish Journal of Medical Science (1971-), 190, 1149-1154. https://doi.org/10.1007/s11845-020-02404-2
  • Middleton, A., Fritz, S. L., & Lusardi, M. (2015). Walking speed: the functional vital sign. Journal of aging and physical activity, 23(2), 314-322. https://doi.org/10.1123/japa.2013-0236
  • Nilsagård, Y., Lundholm, C., Denison, E., & Gunnarsson, L.-G. (2009). Predicting accidental falls in people with multiple sclerosis—a longitudinal study. Clinical rehabilitation, 23(3), 259-269. https://doi.org/10.1177/0269215508095087
  • Pacheco-Unguetti, A. P., Acosta, A., Callejas, A., & Lupiáñez, J. (2010). Attention and anxiety: Different attentional functioning under state and trait anxiety. Psychological science, 21(2), 298-304. https://doi.org/10.1177/0956797609359624
  • Paker, N., Bugdayci, D., Midik, M., Celik, B., & Kesiktas, N. (2013). Reliability of the Turkish version of the hospital anxiety and depression scale in the people with traumatic spinal cord injury. NeuroRehabilitation, 33(2), 337-341. https://doi.org/10.3233/nre-130964
  • Patti, F., Russo, P., Pappalardo, A., Macchia, F., Civalleri, L., Paolillo, A., & Group, F. S. (2007). Predictors of quality of life among patients with multiple sclerosis: an Italian cross-sectional study. Journal of the neurological sciences, 252(2), 121-129. https://doi.org/10.1016/j.jns.2006.10.017
  • Sahin, F., Yilmaz, F., Ozmaden, A., Kotevoglu, N., Sahin, T., & Kuran, B. (2008). Reliability and validity of the Turkish version of the Berg Balance Scale. Journal of geriatric physical therapy, 31(1), 32-37. https://doi.org/10.1519/00139143-200831010-00006
  • Siegert, R. J., & Abernethy, D. (2005). Depression in multiple sclerosis: a review. Journal of Neurology, Neurosurgery & Psychiatry, 76(4), 469-475. https://doi.org/10.1136/jnnp.2004.054635
  • Solomon, A. J., Arrambide, G., Brownlee, W. J., Flanagan, E. P., Amato, M. P., Amezcua, L., Banwell, B. L., Barkhof, F., Corboy, J. R., & Correale, J. (2023). Differential diagnosis of suspected multiple sclerosis: an updated consensus approach. The Lancet Neurology, 22(8), 750-768. https://doi.org/10.1016/s1474-4422(23)00148-5
  • Sosnoff, J. J., Socie, M. J., Boes, M. K., Sandroff, B. M., Pula, J. H., Suh, Y., Weikert, M., Balantrapu, S., Morrison, S., & Motl, R. W. (2011). Mobility, balance and falls in persons with multiple sclerosis. PLoS One, 6(11), e28021. https://doi.org/10.1371/journal.pone.0028021
  • Thompson, A. J., Banwell, B. L., Barkhof, F., Carroll, W. M., Coetzee, T., Comi, G., Correale, J., Fazekas, F., Filippi, M., & Freedman, M. S. (2018). Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. The Lancet Neurology, 17(2), 162-173. https://doi.org/10.1016/s1474-4422(17)30470-2
  • Tingey, J. L. (2020). Intolerance of uncertainty and resilience predict self-efficacy trajectories of individuals newly diagnosed with multiple sclerosis Seattle Pacific University]. https://doi.org/10.1037/rep0000487
  • Vickrey, B., Hays, R., Harooni, R., Myers, L., & Ellison, G. (1995). A health-related quality of life measure for multiple sclerosis. Quality of life research, 4(3), 187-206. https://doi.org/10.1007/bf02260859
  • Yamout, B., Issa, Z., Herlopian, A., El Bejjani, M., Khalifa, A., Ghadieh, A., & Habib, R. (2013). Predictors of quality of life among multiple sclerosis patients: a comprehensive analysis. European Journal of Neurology, 20(5), 756-764. https://doi.org/10.1111/ene.12046
  • Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta psychiatrica scandinavica, 67(6), 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
Toplam 34 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Fizyoterapi, Rehabilitasyon
Bölüm Araştırma Makaleleri
Yazarlar

Sultan Baştürk 0000-0003-3314-3780

Gamze Ekici 0000-0002-7423-178X

Yayımlanma Tarihi 26 Ağustos 2024
Gönderilme Tarihi 22 Mart 2024
Kabul Tarihi 1 Mayıs 2024
Yayımlandığı Sayı Yıl 2024

Kaynak Göster

APA Baştürk, S., & Ekici, G. (2024). Investigating the Relationship Between Physical and Psychological Parameters in Participants with Multiple Sclerosis. Fenerbahçe Üniversitesi Sağlık Bilimleri Dergisi, 4(2), 241-250. https://doi.org/10.56061/fbujohs.1456898