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CRAWLING (KLAPP) EXERCISES IN ADOLESCENT IDIOPATHIC SCOLIOSIS

Year 2023, Volume: 3 Issue: 3, 66 - 70, 30.09.2023

Gizem Güneş Tuğba Kuru Çolak

Abstract

Crawling (Klapp) exercises in the treatment of scoliosis are often recommended to patients by physiotherapists in clinical practice.
In the early 1900s, Klapp exercises are "crawling" exercises that were first developed by Professor Raudolf Klapp by observing animals. It basically involves stretching the muscles located on the convex side of the lateral flexion deformity. When medical search engines were scanned, no study was found in which crawling exercises were applied to individuals with a diagnosis of scoliosis. Scoliosis diagnoses of individuals included in the two existing studies in the literature were not confirmed by radiographic examination.
In the line of current literature, it can be said that crawling exercises cannot be effective on the three-dimensional deformity of the bone structure in scoliosis. According to anatomy and biomechanical informations, it will not be correct and effective to say that the entire muscle structure on the concave side is shortened and to create an exercise model with this thought in mind due to the differences in the attachment points of the soft tissues that take part in the stabilization of the spine, such as muscles and ligaments.
In this sense, we recommend updating the training curricula of physiotherapists and increasing the knowledge level of physiotherapists working in this field about evidence-based treatment approaches.

Keywords

exercise physiotherapy scoliosis

References

  • 1. Aulisa AG, Guzzanti V, Falciglia F, Giordano M, Galli M, Aulisa L. Brace treatment of Idiopathic Scoliosis is effective for a curve over 40 degrees, but is the evaluation of Cobb angle the only parameter for the indication of treatment? Eur J Phys Rehabil Med. 2019;55(2):231-240. https://doi.org/10.23736/s1973-9087.18.04782-2
  • 2. Babaee T, Moradi V, Hashemi H, Shariat A, Anastasio AT, Khosravi M, Bagheripour B. Does Bracing Control the Progression of Adolescent Idiopathic Scoliosis in Curves Higher Than 40°? A Systematic Review and Meta-analysis. Asian Spine J. 2023;17(1): 203-212. https://doi.org/10.31616/asj.2022.0162
  • 3. Berdishevsky H. Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann's disease evaluated by radiologic imaging-a case report. Scoliosis Spinal Disord. 2016;11(Suppl 2):40. https://doi.org/10.1186/s13013-016-0094-7
  • 4. Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M'Hango A, Betts T, de Mauroy JC, Durmala, J. Physiotherapy scoliosis-specific exercises - a comprehensive review of seven major schools. Scoliosis Spinal Disord. 2016;11:20. https://doi.org/10.1186/s13013-016-0076-9
  • 5. Van Rooyen C, Du Plessis LZ, Geldenhuys L, Myburgh E, Coetzee W, Vermeulen N, Joubert F, Burger M. The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis. S Afr J Physiother 2019;75(1):904. doi: 10.4102/sajp.v75i1.904.
  • 6. Canavese F, Dimeglio A, Bonnel F, Corradin M, Pereira B, Marcoul A, Charles YP. Thoracic cage volume and dimension assessment by optoelectronic molding in normal children and adolescents during growth. Surgical and Radiologic Anatomy. 2019;41:287-296.
  • 7. Ciazynski D, Czernicki K, Durmala J. Knowledge about idiopathic scoliosis among students of physiotherapy. Stud Health Technol Inform, 2008;140:281-285.
  • 8. Crawling Exercises for Scoliosis. Hospital (Lond 1886), 1920;68(1785):536.
  • 9. Dantas DDS, De Assis SJC, Baroni MP, Lopes JM, Cacho EWA, Cacho RDO, Pereira SA. Klapp method effect on idiopathic scoliosis in adolescents: blind randomized controlled clinical trial. Journal of physical therapy science, 22017;9(1):1-7. https://doi.org/10.1589/jpts.29.1
  • 10. Dayer R, Haumont T, Belaieff W, Lascombes P. Idiopathic scoliosis: etiological concepts and hypotheses. J Child Orthop, 2013;7(1):11-16. https://doi.org/10.1007/s11832-012-0458-3 11. Dolan LA, Weinstein SL, Abel MF, Bosch PP, Dobbs MB, Farber TO, Halsey MF, Hresko MT, Krengel WF, Mehlman CT. Bracing in adolescent idiopathic scoliosis trial (BrAIST): development and validation of a prognostic model in untreated adolescent idiopathic scoliosis using the simplified skeletal maturity system. Spine deformity, 2019;7(6):890-898. e894.
  • 12. Edgar MA. The natural history of unfused scoliosis. Orthopedics. 1987;10(6):931-939. https://doi.org/10.3928/0147-7447-19870601-12
  • 13. Fischinger B. Escoliose em fisioterapia. In Escoliose em fisioterapia, 1984, p. 158-158. 14. Gou Y, Lei H, Zeng Y, Tao J, Kong W, Wu J. The effect of Pilates exercise training for scoliosis on improving spinal deformity and quality of life: Meta-analysis of randomized controlled trials. Medicine (Baltimore). 2021;100(39):e27254. https://doi.org/10.1097/md.0000000000027254
  • 15. Iunes DH, Cecílio MB, Dozza MA, Almeida PR. Quantitative photogrammetric analysis of the Klapp method for treating idiopathic scoliosis. Rev Bras Fisioter. 2010;14(2):133-140.
  • 16. The Klapp Treatment of Scoliosis. Hospital (Lond 1886). 1911;49(1278):463-465.
  • 17. Kuru Çolak T, Akçay B, Apti A. Effects of Pilates exercises on idiopathic scoliosis: a scoping review of the literature. Spine deformity. 2023;11:797-804.
  • 18. Lee CF, Fong DYT, Cheung KMC, Cheng JCY, Ng BKW, Lam TP, Yip PSF, Luk KDK. A new risk classification rule for curve progression in adolescent idiopathic scoliosis. The Spine Journal. 2012;12(11):989-995. https://doi.org/10.1016/j.spinee.2012.05.009
  • 19. Lenz M, Oikonomidis S, Harland A, Fürnstahl P, Farshad M, Bredow J, Eysel P, Scheyerer MJ. Scoliosis and Prognosis-a systematic review regarding patient-specific and radiological predictive factors for curve progression. Eur Spine J. 2023;30(7):1813-1822. https://doi.org/10.1007/s00586-021-06817-0
  • 20. Malfair D, Flemming AK, Dvorak, MF, Munk PL, Vertinsky AT, Heran MK, Graeb DA. Radiographic Evaluation of Scoliosis: Review. AJR 2010;194(6):8–22.
  • 21. McAviney J, Mee J, Fazalbhoy A, Du Plessis J, Brown BT. A systematic literature review of spinal brace/orthosis treatment for adults with scoliosis between 1967 and 2018: clinical outcomes and harms data. BMC Musculoskelet Disord, 2020;21(1):87. https://doi.org/10.1186/s12891-020-3095-x
  • 22. Menger RP, Sin AH. Adolescent and Idiopathic Scoliosis. StatPearls Publishing, 2023, Florida, USA.
  • 23. Miller MD, Thompson SR, Hart J. Review of orthopaedics e-book. Elsevier Health Sciences, 2012, USA
  • 24. Morrison DG, Chan A, Hill D, Parent EC, Lou EH. Correlation between Cobb angle, spinous process angle (SPA) and apical vertebrae rotation (AVR) on posteroanterior radiographs in adolescent idiopathic scoliosis (AIS). European Spine Journal. 2015;24:306-312.
  • 25. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O'Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3. https://doi.org/10.1186/s13013-017-0145-8
  • 26. Rigo M, Reiter C, Weiss HR. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil, 2003;6(3-4):209-214. https://doi.org/10.1080/13638490310001642054
  • 27. Rrecaj-Malaj S, Beqaj S, Krasniqi V, Qorolli M, Tufekcievski A. Outcome of 24 Weeks of Combined Schroth and Pilates Exercises on Cobb Angle, Angle of Trunk Rotation, Chest Expansion, Flexibility and Quality of Life in Adolescents with Idiopathic Scoliosis. Med Sci Monit Basic Res, 2020;26:e920449. https://doi.org/10.12659/msmbr.920449
  • 28. Seleviciene V, Cesnaviciute A, Strukcinskiene B, Marcinowicz L, Strazdiene N, Genowska A. Physiotherapeutic Scoliosis-Specific Exercise Methodologies Used for Conservative Treatment of Adolescent Idiopathic Scoliosis, and Their Effectiveness: An Extended Literature Review of Current Research and Practice. Int J Environ Res Public Health. 2022;19(15):9240. https://doi.org/10.3390/ijerph19159240
  • 29. Sitoula P, Verma K, Holmes L, Gabos PG, Sanders JO, Yorgova P, Neiss G, Rogers K, Shah SA. Prediction of curve progression in idiopathic scoliosis. Spine. 2015:40(13);1006-1013.
  • 30. Stirling AJ, Howel D, Millner PA, SAFA'A S, Sharples D, Dickson RA. Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study. JBJS. 1996:78(9);1330-1336.
  • 31. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. Jama. 2003;289(5):559-567. https://doi.org/10.1001/jama.289.5.559
  • 32. Weiss H.R., Schroth Lehnert C., Moramarco M., & K., M. (2015). Schroth Therapy. Lambert Academic Publishing.
  • 33. Weiss HR, Hollaender M, Klein R. ADL based scoliosis rehabilitation--the key to an improvement of time-efficiency? Stud Health Technol Inform. 2006;123:594-598.
  • 34. Weiss HR, Moramarco MM, Borysov M, Ng SY, Lee SG, Nan X, Moramarco KA. Postural Rehabilitation for Adolescent Idiopathic Scoliosis during Growth. Asian Spine J. 2016;10(3):570-581. https://doi.org/10.4184/asj.2016.10.3.570
  • 35. Weiss HR, Negrini S, Rigo M, Kotwicki T, Hawes MC, Grivas TB, Maruyama T, Landauer F. Indications for conservative management of scoliosis (guidelines). Scoliosis 2006;1:5. https://doi.org/10.1186/1748-7161-1-5
  • 36. Weiss HR, Seibel S. Hemidystrophic Thorax Mimicking Scoliosis. Open Orthop J. 2018;12:252-260. https://doi.org//10.2174/1874325001812010252
  • 37. Weiss HR, Tournavitis N, Seibel S, Kleban A. A Prospective Cohort Study of AIS Patients with 40° and More Treated with a Gensingen Brace (GBW): Preliminary Results. Open Orthop J. 2017;11:1558-1567. https://doi.org/10.2174/1874325001711011558
  • 38. Widjaja BS, Varani R. Impact of Gensingen brace treatment on Lenke 5 curvatures and chronic low back pain in late adolescent and adult scoliosis patients. S Afr J Physiother. 2022;78(1):1585. https://doi.org/10.4102/sajp.v78i1.1585

Adölesan İdiyopatik Skolyozda Emekleme (KLAPP) Egzersizleri (KLAPP)

Year 2023, Volume: 3 Issue: 3, 66 - 70, 30.09.2023

Gizem Güneş Tuğba Kuru Çolak

Abstract

Skolyoz tedavisinde emekleme (Klapp) egzersizleri klinik uygulamada fizyoterapistler tarafından sıklıkla hastalara önerilmektedir.
1900’lü yılların başlarında Klapp egzersizleri ilk kez Profesör Raudolf Klapp tarafından hayvanlar gözlemlenerek geliştirilmiş “emekleme” egzersizleridir. Temelinde lateral fleksiyon deformitesinin konveks tarafında yer alan kasların gerilmesini içerir. Medikal arama motorları tarandığında emekleme egzersizlerinin skolyoz tanılı bireylerde uygulandığı herhangi bir araştırmaya rastlanamamıştır. Literatürde yer alan mevcut iki çalışmaya dahil edilen bireylerin skolyoz tanıları radyografik inceleme ile doğrulanmamıştır.
Günümüzde mevcut literatür bilgileri ışığında, emekleme egzersizlerinin skolyozda kemik yapıda meydana gelen üç boyutlu deformite üzerine etkili olamayacağı söylenebilir. Anatomi ve biyomekanik bilgiler ışığında ise kas ve ligaman gibi omurga stabilizayonunda görev alan yumuşak dokuların yapışma yerlerindeki farklılıklar nedeniyle konkav taraftaki tüm kas yapısının kısaldığını söylemek ve bu düşünce ile egzersiz modeli oluşturmak doğru ve etkili olmayacaktır.
Bu anlamda fizyoterapistlerin eğitim müfredatlarının güncellenmesini ve bu alanda çalışan fizyoterapistlerin kanıta dayalı tedavi yaklaşımları ile ilgili bilgi düzeylerinin arttırılmasını önermekteyiz.

Keywords

egzersiz fizyoterapi skolyoz

References

  • 1. Aulisa AG, Guzzanti V, Falciglia F, Giordano M, Galli M, Aulisa L. Brace treatment of Idiopathic Scoliosis is effective for a curve over 40 degrees, but is the evaluation of Cobb angle the only parameter for the indication of treatment? Eur J Phys Rehabil Med. 2019;55(2):231-240. https://doi.org/10.23736/s1973-9087.18.04782-2
  • 2. Babaee T, Moradi V, Hashemi H, Shariat A, Anastasio AT, Khosravi M, Bagheripour B. Does Bracing Control the Progression of Adolescent Idiopathic Scoliosis in Curves Higher Than 40°? A Systematic Review and Meta-analysis. Asian Spine J. 2023;17(1): 203-212. https://doi.org/10.31616/asj.2022.0162
  • 3. Berdishevsky H. Outcome of intensive outpatient rehabilitation and bracing in an adult patient with Scheuermann's disease evaluated by radiologic imaging-a case report. Scoliosis Spinal Disord. 2016;11(Suppl 2):40. https://doi.org/10.1186/s13013-016-0094-7
  • 4. Berdishevsky H, Lebel VA, Bettany-Saltikov J, Rigo M, Lebel A, Hennes A, Romano M, Białek M, M'Hango A, Betts T, de Mauroy JC, Durmala, J. Physiotherapy scoliosis-specific exercises - a comprehensive review of seven major schools. Scoliosis Spinal Disord. 2016;11:20. https://doi.org/10.1186/s13013-016-0076-9
  • 5. Van Rooyen C, Du Plessis LZ, Geldenhuys L, Myburgh E, Coetzee W, Vermeulen N, Joubert F, Burger M. The effectiveness of Schroth exercises in adolescents with idiopathic scoliosis: A systematic review and meta-analysis. S Afr J Physiother 2019;75(1):904. doi: 10.4102/sajp.v75i1.904.
  • 6. Canavese F, Dimeglio A, Bonnel F, Corradin M, Pereira B, Marcoul A, Charles YP. Thoracic cage volume and dimension assessment by optoelectronic molding in normal children and adolescents during growth. Surgical and Radiologic Anatomy. 2019;41:287-296.
  • 7. Ciazynski D, Czernicki K, Durmala J. Knowledge about idiopathic scoliosis among students of physiotherapy. Stud Health Technol Inform, 2008;140:281-285.
  • 8. Crawling Exercises for Scoliosis. Hospital (Lond 1886), 1920;68(1785):536.
  • 9. Dantas DDS, De Assis SJC, Baroni MP, Lopes JM, Cacho EWA, Cacho RDO, Pereira SA. Klapp method effect on idiopathic scoliosis in adolescents: blind randomized controlled clinical trial. Journal of physical therapy science, 22017;9(1):1-7. https://doi.org/10.1589/jpts.29.1
  • 10. Dayer R, Haumont T, Belaieff W, Lascombes P. Idiopathic scoliosis: etiological concepts and hypotheses. J Child Orthop, 2013;7(1):11-16. https://doi.org/10.1007/s11832-012-0458-3 11. Dolan LA, Weinstein SL, Abel MF, Bosch PP, Dobbs MB, Farber TO, Halsey MF, Hresko MT, Krengel WF, Mehlman CT. Bracing in adolescent idiopathic scoliosis trial (BrAIST): development and validation of a prognostic model in untreated adolescent idiopathic scoliosis using the simplified skeletal maturity system. Spine deformity, 2019;7(6):890-898. e894.
  • 12. Edgar MA. The natural history of unfused scoliosis. Orthopedics. 1987;10(6):931-939. https://doi.org/10.3928/0147-7447-19870601-12
  • 13. Fischinger B. Escoliose em fisioterapia. In Escoliose em fisioterapia, 1984, p. 158-158. 14. Gou Y, Lei H, Zeng Y, Tao J, Kong W, Wu J. The effect of Pilates exercise training for scoliosis on improving spinal deformity and quality of life: Meta-analysis of randomized controlled trials. Medicine (Baltimore). 2021;100(39):e27254. https://doi.org/10.1097/md.0000000000027254
  • 15. Iunes DH, Cecílio MB, Dozza MA, Almeida PR. Quantitative photogrammetric analysis of the Klapp method for treating idiopathic scoliosis. Rev Bras Fisioter. 2010;14(2):133-140.
  • 16. The Klapp Treatment of Scoliosis. Hospital (Lond 1886). 1911;49(1278):463-465.
  • 17. Kuru Çolak T, Akçay B, Apti A. Effects of Pilates exercises on idiopathic scoliosis: a scoping review of the literature. Spine deformity. 2023;11:797-804.
  • 18. Lee CF, Fong DYT, Cheung KMC, Cheng JCY, Ng BKW, Lam TP, Yip PSF, Luk KDK. A new risk classification rule for curve progression in adolescent idiopathic scoliosis. The Spine Journal. 2012;12(11):989-995. https://doi.org/10.1016/j.spinee.2012.05.009
  • 19. Lenz M, Oikonomidis S, Harland A, Fürnstahl P, Farshad M, Bredow J, Eysel P, Scheyerer MJ. Scoliosis and Prognosis-a systematic review regarding patient-specific and radiological predictive factors for curve progression. Eur Spine J. 2023;30(7):1813-1822. https://doi.org/10.1007/s00586-021-06817-0
  • 20. Malfair D, Flemming AK, Dvorak, MF, Munk PL, Vertinsky AT, Heran MK, Graeb DA. Radiographic Evaluation of Scoliosis: Review. AJR 2010;194(6):8–22.
  • 21. McAviney J, Mee J, Fazalbhoy A, Du Plessis J, Brown BT. A systematic literature review of spinal brace/orthosis treatment for adults with scoliosis between 1967 and 2018: clinical outcomes and harms data. BMC Musculoskelet Disord, 2020;21(1):87. https://doi.org/10.1186/s12891-020-3095-x
  • 22. Menger RP, Sin AH. Adolescent and Idiopathic Scoliosis. StatPearls Publishing, 2023, Florida, USA.
  • 23. Miller MD, Thompson SR, Hart J. Review of orthopaedics e-book. Elsevier Health Sciences, 2012, USA
  • 24. Morrison DG, Chan A, Hill D, Parent EC, Lou EH. Correlation between Cobb angle, spinous process angle (SPA) and apical vertebrae rotation (AVR) on posteroanterior radiographs in adolescent idiopathic scoliosis (AIS). European Spine Journal. 2015;24:306-312.
  • 25. Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, Diers H, Grivas TB, Knott P, Kotwicki T, Lebel A, Marti C, Maruyama T, O'Brien J, Price N, Parent E, Rigo M, Romano M, Stikeleather L, Wynne J, Zaina F. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. Scoliosis Spinal Disord. 2018;13:3. https://doi.org/10.1186/s13013-017-0145-8
  • 26. Rigo M, Reiter C, Weiss HR. Effect of conservative management on the prevalence of surgery in patients with adolescent idiopathic scoliosis. Pediatr Rehabil, 2003;6(3-4):209-214. https://doi.org/10.1080/13638490310001642054
  • 27. Rrecaj-Malaj S, Beqaj S, Krasniqi V, Qorolli M, Tufekcievski A. Outcome of 24 Weeks of Combined Schroth and Pilates Exercises on Cobb Angle, Angle of Trunk Rotation, Chest Expansion, Flexibility and Quality of Life in Adolescents with Idiopathic Scoliosis. Med Sci Monit Basic Res, 2020;26:e920449. https://doi.org/10.12659/msmbr.920449
  • 28. Seleviciene V, Cesnaviciute A, Strukcinskiene B, Marcinowicz L, Strazdiene N, Genowska A. Physiotherapeutic Scoliosis-Specific Exercise Methodologies Used for Conservative Treatment of Adolescent Idiopathic Scoliosis, and Their Effectiveness: An Extended Literature Review of Current Research and Practice. Int J Environ Res Public Health. 2022;19(15):9240. https://doi.org/10.3390/ijerph19159240
  • 29. Sitoula P, Verma K, Holmes L, Gabos PG, Sanders JO, Yorgova P, Neiss G, Rogers K, Shah SA. Prediction of curve progression in idiopathic scoliosis. Spine. 2015:40(13);1006-1013.
  • 30. Stirling AJ, Howel D, Millner PA, SAFA'A S, Sharples D, Dickson RA. Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study. JBJS. 1996:78(9);1330-1336.
  • 31. Weinstein SL, Dolan LA, Spratt KF, Peterson KK, Spoonamore MJ, Ponseti IV. Health and function of patients with untreated idiopathic scoliosis: a 50-year natural history study. Jama. 2003;289(5):559-567. https://doi.org/10.1001/jama.289.5.559
  • 32. Weiss H.R., Schroth Lehnert C., Moramarco M., & K., M. (2015). Schroth Therapy. Lambert Academic Publishing.
  • 33. Weiss HR, Hollaender M, Klein R. ADL based scoliosis rehabilitation--the key to an improvement of time-efficiency? Stud Health Technol Inform. 2006;123:594-598.
  • 34. Weiss HR, Moramarco MM, Borysov M, Ng SY, Lee SG, Nan X, Moramarco KA. Postural Rehabilitation for Adolescent Idiopathic Scoliosis during Growth. Asian Spine J. 2016;10(3):570-581. https://doi.org/10.4184/asj.2016.10.3.570
  • 35. Weiss HR, Negrini S, Rigo M, Kotwicki T, Hawes MC, Grivas TB, Maruyama T, Landauer F. Indications for conservative management of scoliosis (guidelines). Scoliosis 2006;1:5. https://doi.org/10.1186/1748-7161-1-5
  • 36. Weiss HR, Seibel S. Hemidystrophic Thorax Mimicking Scoliosis. Open Orthop J. 2018;12:252-260. https://doi.org//10.2174/1874325001812010252
  • 37. Weiss HR, Tournavitis N, Seibel S, Kleban A. A Prospective Cohort Study of AIS Patients with 40° and More Treated with a Gensingen Brace (GBW): Preliminary Results. Open Orthop J. 2017;11:1558-1567. https://doi.org/10.2174/1874325001711011558
  • 38. Widjaja BS, Varani R. Impact of Gensingen brace treatment on Lenke 5 curvatures and chronic low back pain in late adolescent and adult scoliosis patients. S Afr J Physiother. 2022;78(1):1585. https://doi.org/10.4102/sajp.v78i1.1585
There are 36 citations in total.

Details

Primary Language Turkish
Subjects Public Health (Other)
Journal Section Reviews
Authors

Gizem Güneş 0009-0006-6122-9847

Tuğba Kuru Çolak 0000-0002-3263-2278

Publication Date September 30, 2023
Submission Date June 22, 2023
Published in Issue Year 2023 Volume: 3 Issue: 3

Cite

APA Güneş, G., & Kuru Çolak, T. (2023). Adölesan İdiyopatik Skolyozda Emekleme (KLAPP) Egzersizleri (KLAPP). Journal of Health Sciences and Management, 3(3), 66-70.
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