Turkiye Klinikleri Journal of Medical Sciences

.: ORIGINAL RESEARCH
Kronik İnmeli Hastalarda Transkraniyal Doğru Akım Stimülasyon Tedavisinin Üst Ekstremite Motor Fonksiyonları Üzerine Olan Etkisi: Prospektif Randomize Kontrollü Bir Çalışma
The Effect of Transcranial Direct Current Stimulation Therapy on Upper Extremity Motor Functions in Patients with Chronic Stroke: A Prospective Randomized Controlled Study
Elif ÖZCANa, Tuğba GÖKBELb, Çiğdem ÇEKMECEc, Nigar DURSUNb
aKocaeli Üniversitesi Sağlık Bilimleri Enstitüsü, İş ve Uğraşı Terapi Bölümü, Kocaeli, Türkiye
bKocaeli Üniversitesi Tıp Fakültesi, Fiziksel Tıp ve Rehabilitasyon ABD, Kocaeli, Türkiye
cKocaeli Üniversitesi Sağlık Hizmetleri Meslek Yüksekokulu, Terapi ve Rehabilitasyon Bölümü, Kocaeli, Türkiye
Turkiye Klinikleri J Med Sci. 2022;42(2):101-10
doi: 10.5336/medsci.2021-87662
Article Language: TR
Full Text
ÖZET
Amaç: Bu prospektif, randomize kontrollü çalışmanın amacı, kronik inmeli hastalarda anodal transkraniyal doğru akım stimülasyon (TDAS) tedavisinin, plejik üst ekstremite motor fonksiyonları üzerine olan etkinliğini değerlendirmektir. Gereç ve Yöntemler: Üst ekstremite spastisitesine yönelik olarak botulinum toksin A (BoNT-A) tedavisi uygulanmış 20 kronik inmeli hasta, TDAS (n=10) ve kontrol (n=10) grupları olmak üzere 1:1 oranında randomize edildi. Her iki grup toplam 10 seans iş ve uğraşı terapi (İUT) programına alındı. TDAS grubuna, İUT ile eş zamanlı olarak anodal TDAS tedavisi uygulandı. Plejik üst ekstremite motor fonksiyonları Jebsen-Taylor El Fonksiyon Testi (JTEFT), Kutu Blok Testi (KBT) ve Modifiye Frenchay Skala'sı (MFS) ile değerlendirildi. Bulgular: Her iki grupta demografik özellikler ve tedavi öncesi tüm klinik değerlendirmeler benzer bulundu (p>0,05, tüm parametreler için). Tedavi sonrasında TDAS grubunda JTEFT ve MFS'nin tüm alt parametrelerinde (tüm parametreler için p<0,01), ve KBT'de (p<0,01) istatistiksel olarak anlamlı gelişmeler elde edildi. Kontrol grubunda ise KBT (p=0,011), JTEFT'nin 3 ve MFS'nin 7 parametresinde (anlamlı parametreler için p<0,05) anlamlılık saptandı. Tedavi sonrası TDAS grubunun KBT (p<0,001), MFS tüm alt parametre (tüm parametreler için p<0,05) sonuçlarındaki gelişmeler kontrol grubununkilerden anlamlı derecede yüksekti. Ayrıca tedavi sonrasında JTEFT'nin beslenme (p=0,011), geniş hafif objeleri kavrama (p=0,003) ve geniş ağır objeleri kavrama (p=0,049) sürelerindeki kısalma TDAS grubunda kontrol grubuna oranla anlamlı derecede daha iyiydi. Sonuç: Bu çalışmada, BoNT-A uygulamasını takiben İUT ile kombine edilen anodal TDAS tedavisinin, kronik inmeli hastaların plejik üst ekstremite motor fonksiyonları üzerine ilave yararlar sağladığı gösterilmiştir.

Anahtar Kelimeler: İnme; iş ve uğraşı terapisi; transkraniyal doğru akım stimülasyonu; üst ekstremite
ABSTRACT
Objective: The aim of this prospective, randomized, controlled study was to evaluate the effectiveness of anodal transcranial direct current stimulation (TDCS) applications on the upper extremity motor functions of patients with stroke. Material and Methods: Twenty patients with chronic stroke who received botulinum toksin A (BoNT-A) treatment for upper limb spasticity were randomly assigned in a 1:1 ratio into two groups as anodal TDCS (n=10), or control (n=10). Both groups participated in an occupational therapy (OT) program for 10 days. Simultaneous anodal TDCS treatment with OT was applied to the TDCS group. The plegic upper extremity motor functions were evaluated by Jebsen-Taylor Hand Function Test (JTHFT), Box and Block Test (BBT) and Modified Frenchay Scale (MFS). Results: Demographic characteristics and baseline clinical assessments were found to be similar in both groups (p>0.05 for all parameters). After the treatment, statistically significant improvements were obtained in all sub-parameters of JTHFT, and MFS (p<0.01 for all parameters) and BBT (p<0.01) in the TDCS group. Whereas in the control group significance was present in BBT (p=0.011), 3 parameters of JTEFT, and 7 of MFS (p<0.05 for these parameters). The magnitude of improvement in BBT (p<0.001), and in all parameters of MFS of the TDCS group (p<0.05, all of the parameters) were significantly higher than those of the control group after treatment. Besides decrease in the time spent for feding (p=0.011), lifting large light objects (p=0.003) and large heavy objects (p=0.049) of the TDCS group was significantly better than those of the control group. Conclusion: In this study, TDCS combined with OT programs following the BoNT-A injection was shown to provide additional benefits on motor functions of the plegic upper extremity of chronic stroke patients.

Keywords: Stroke; occupational therapy; transcranial direct current stimulation; upper extremity
REFERENCES:
  1. Winstein CJ, Merians AS, Sullivan KJ. Motor learning after unilateral brain damage. Neuropsychologia. 1999;37(8):975-87. [Crossref]  [PubMed] 
  2. Taub E, Miller NE, Novack TA, Cook EW 3rd, Fleming WC, Nepomuceno CS, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74(4):347-54. [PubMed] 
  3. Yıldırım Şık B, Dursun N, Dursun E, Sade I, Şahin E. Transcranial direct current stimulation: the effects on plegic upper extremity motor function of patients with stroke. J Neurol Sci. 2015;32(2):320-34. [Link] 
  4. Figlewski K, Blicher JU, Mortensen J, Severinsen KE, Nielsen JF, Andersen H. Transcranial direct current stimulation potentiates improvements in functional ability in patients with chronic stroke receiving constraint-induced movement therapy. Stroke. 2017;48(1):229-32. [Crossref]  [PubMed] 
  5. Navarro-López V, Del Valle-Gratacós M, Fernández-Matías R, Carratalá-Tejada M, Cuesta-Gómez A, Molina-Rueda F. The long-term maintenance of upper limb motor improvements following transcranial direct current stimulation combined with rehabilitation in people with stroke: a systematic review of randomized sham-controlled trials. Sensors (Basel). 2021;21(15):5216. [Crossref]  [PubMed]  [PMC] 
  6. Allman C, Amadi U, Winkler AM, Wilkins L, Filippini N, Kischka U, et al. Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after stroke. Sci Transl Med. 2016;8(330):330re1. [Crossref]  [PubMed]  [PMC] 
  7. Edwards DJ, Cortes M, Rykman-Peltz A, Chang J, Elder J, Thickbroom G, et al. Clinical improvement with intensive robot-assisted arm training in chronic stroke is unchanged by supplementary tDCS. Restor Neurol Neurosci. 2019;37(2):167-80. [Crossref]  [PubMed] 
  8. Khedr EM, Shawky OA, El-Hammady DH, Rothwell JC, Darwish ES, Mostafa OM, et al. Effect of anodal versus cathodal transcranial direct current stimulation on stroke rehabilitation: a pilot randomized controlled trial. Neurorehabil Neural Repair. 2013;27(7):592-601. [Crossref]  [PubMed] 
  9. Koh CL, Lin JH, Jeng JS, Huang SL, Hsieh CL. Effects of transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: a randomized controlled trial. Arch Phys Med Rehabil. 2017;98(12):2477-84. [Crossref]  [PubMed] 
  10. Llorens R, Fuentes MA, Borrego A, Latorre J, Alca-iz M, Colomer C, et al. Effectiveness of a combined transcranial direct current stimulation and virtual reality-based intervention on upper limb function in chronic individuals post-stroke with persistent severe hemiparesis: a randomized controlled trial. J Neuroeng Rehabil. 2021;18(1):108. [Crossref]  [PubMed]  [PMC] 
  11. Wei YY, Koh CL, Hsu MJ, Lo SK, Chen CH, Lin JH. Effects of transcranial direct current stimulation combined with neuromuscular electrical stimulation on upper extremity motor function in patients with stroke. Am J Phys Med Rehabil. 2022;101(2):145-51. [Crossref]  [PubMed] 
  12. Reis SB, Bernardo WM, Oshiro CA, Krebs HI, Conforto AB. Effects of robotic therapy associated with noninvasive brain stimulation on upper-limb rehabilitation after stroke: systematic review and meta-analysis of randomized clinical trials. Neurorehabil Neural Repair. 2021;35(3):256-66. [Crossref]  [PubMed] 
  13. Lawrence ES, Coshall C, Dundas R, Stewart J, Rudd AG, Howard R, et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001;32(6):1279-84. [Crossref]  [PubMed] 
  14. Schaechter JD. Motor rehabilitation and brain plasticity after hemiparetic stroke. Prog Neurobiol. 2004;73(1):61-72. [Crossref]  [PubMed] 
  15. Winstein CJ, Rose DK, Tan SM, Lewthwaite R, Chui HC, Azen SP. A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: A pilot study of immediate and long-term outcomes. Arch Phys Med Rehabil. 2004;85(4):620-8. [Crossref]  [PubMed] 
  16. Classen J, Liepert J, Wise SP, Hallett M, Cohen LG. Rapid plasticity of human cortical movement representation induced by practice. J Neurophysiol. 1998;79(2):1117-23. [Crossref]  [PubMed] 
  17. Brainin M, Norrving B, Sunnerhagen KS, Goldstein LB, Cramer SC, Donnan GA, et al; International PSS Disability Study Group. Poststroke chronic disease management: towards improved identification and interventions for poststroke spasticity-related complications. Int J Stroke. 2011;6(1):42-6. [Crossref]  [PubMed] 
  18. Nudo RJ, Wise BM, SiFuentes F, Milliken GW. Neural substrates for the effects of rehabilitative training on motor recovery after ischemic infarct. Science. 1996;272(5269):1791-4. [Crossref]  [PubMed] 
  19. Simonetta-Moreau M. Non-invasive brain stimulation (NIBS) and motor recovery after stroke. Ann Phys Rehabil Med. 2014;57(8):530-42. [Crossref]  [PubMed] 
  20. Hara Y. Brain plasticity and rehabilitation in stroke patients. J Nippon Med Sch. 2015;82(1):4-13. [Crossref]  [PubMed] 
  21. Guggisberg AG, Koch PJ, Hummel FC, Buetefisch CM. Brain networks and their relevance for stroke rehabilitation. Clin Neurophysiol. 2019;130(7):1098-124. [Crossref]  [PubMed]  [PMC] 
  22. Carvalho R, Azevedo E, Marques P, Dias N, Cerqueira JJ. Physiotherapy based on problem-solving in upper limb function and neuroplasticity in chronic stroke patients: A case series. J Eval Clin Pract. 2018;24(3):552-60. [Crossref]  [PubMed] 
  23. Van Hoornweder S, Vanderzande L, Bloemers E, Verstraelen S, Depestele S, Cuypers K, et al. The effects of transcranial direct current stimulation on upper-limb function post-stroke: A meta-analysis of multiple-session studies. Clin Neurophysiol. 2021;132(8):1897-918. [Crossref]  [PubMed] 
  24. Hao Z, Wang D, Zeng Y, Liu M. Repetitive transcranial magnetic stimulation for improving function after stroke. Cochrane Database Syst Rev. 2013;2013(5):CD008862. [Crossref]  [PubMed]  [PMC] 
  25. Marquez J, van Vliet P, McElduff P, Lagopoulos J, Parsons M. Transcranial direct current stimulation (tDCS): does it have merit in stroke rehabilitation? A systematic review. Int J Stroke. 2015;10(3):306-16. [Crossref]  [PubMed] 
  26. Nitsche MA, Paulus W. Sustained excitability elevations induced by transcranial DC motor cortex stimulation in humans. Neurology. 2001;57(10):1899-901. [Crossref]  [PubMed] 
  27. Hummel F, Celnik P, Giraux P, Floel A, Wu WH, Gerloff C, et al. Effects of non-invasive cortical stimulation on skilled motor function in chronic stroke. Brain. 2005;128(Pt 3):490-9. [Crossref]  [PubMed] 
  28. Mortensen J, Figlewski K, Andersen H. Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial. Disabil Rehabil. 2016;38(7):637-43. [Crossref]  [PubMed] 
  29. Bai X, Guo Z, He L, Ren L, McClure MA, Mu Q. Different therapeutic effects of transcranial direct current stimulation on upper and lower limb recovery of stroke patients with motor dysfunction: a meta-analysis. Neural Plast. 2019;2019:1372138. [Crossref]  [PubMed]  [PMC] 
  30. Backhaus W, Anziano M, Hummel FC. Transcranial direct current stimulation and its effects on upper extremity neurorehabilitative training in stroke: a meta-Analysis. Neurol Disord Stroke Int. 2018;1(1):1003. [Link] 
  31. Butler AJ, Shuster M, O'Hara E, Hurley K, Middlebrooks D, Guilkey K. A meta-analysis of the efficacy of anodal transcranial direct current stimulation for upper limb motor recovery in stroke survivors. J Hand Ther. 2013;26(2):162-70; quiz 171. [Crossref]  [PubMed] 
  32. Rocha S, Silva E, Foerster Á, Wiesiolek C, Chagas AP, Machado G, et al. The impact of transcranial direct current stimulation (tDCS) combined with modified constraint-induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind randomized controlled trial. Disabil Rehabil. 2016;38(7):653-60. [Crossref]  [PubMed] 
  33. Cho HS, Cha HG. Effect of mirror therapy with tDCS on functional recovery of the upper extremity of stroke patients. J Phys Ther Sci. 2015;27(4):1045-7. [Crossref]  [PubMed]  [PMC] 
  34. Fuentes MA, Borrego A, Latorre J, Colomer C, Alca-iz M, Sánchez-Ledesma MJ, et al. Combined transcranial direct current stimulation and virtual reality-based paradigm for upper limb rehabilitation in ındividuals with restricted movements. A Feasibility Study with a Chronic Stroke Survivor with Severe Hemiparesis. J Med Syst. 2018;42(5):87. [Crossref]  [PubMed] 
  35. Shaheiwola N, Zhang B, Jia J, Zhang D. Using tDCS as an add-on treatment prior to FES therapy in improving upper limb function in severe chronic stroke patients: a randomized controlled study. Front Hum Neurosci. 2018;12:233. [Crossref]  [PubMed]  [PMC] 

Login



Contact


Ortadoğu Reklam Tanıtım Yayıncılık Turizm Eğitim İnşaat Sanayi ve Ticaret A.Ş.

.: Address

Turkocagi Caddesi No:30 06520 Balgat / ANKARA
Phone: +90 312 286 56 56
Fax: +90 312 220 04 70
E-mail: info@turkiyeklinikleri.com

.: Manuscript Editing Department

Phone: +90 312 286 56 56/ 2
E-mail: yaziisleri@turkiyeklinikleri.com

.: English Language Redaction

Phone: +90 312 286 56 56/ 145
E-mail: tkyayindestek@turkiyeklinikleri.com

.: Marketing Sales-Project Department

Phone: +90 312 286 56 56/ 142
E-mail: reklam@turkiyeklinikleri.com

.: Subscription and Public Relations Department

Phone: +90 312 286 56 56/ 118
E-mail: abone@turkiyeklinikleri.com

.: Customer Services

Phone: +90 312 286 56 56/ 118
E-mail: satisdestek@turkiyeklinikleri.com

1. TERMS OF USE

1.1. To use the web pages with http://www.turkiyeklinikleri.com domain name or the websites reached through the sub domain names attached to the domain name (They will be collectively referred as "SITE"), please read the conditions below. If you do not accept these terms, please cease to use the "SITE." "SITE" owner reserves the right to change the information on the website, forms, contents, the "SITE," "SITE" terms of use anytime they want.

1.2. The owner of the "SITE" is Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. (From now on it is going to be referred as "Turkiye Klinikleri", shortly) and it resides at Turkocagi cad. No:30, 06520 Balgat Ankara. The services in the "SITE" are provided by "Turkiye Klinikleri."

1.3. Anyone accessing the "SITE" with or without a fee whether they are a natural person or a legal identity is considered to agree these terms of use. In this contract hereby, "Turkiye Klinikleri" may change the stated terms anytime. These changes will be published in the "SITE" periodically and they will be valid when they are published. Any natural person or legal identity benefiting from and reaching to the "SITE" are considered to be agreed to any change on hereby contract terms done by "Turkiye Klinikleri."

1.4. The "Terms of Use" hereby is published in the website with the last change on March 30th 2014 and the "SITE" is activated by enabling the access to everyone. The "Terms of Use" hereby is also a part of the any "USER Contract" was and/or will be done with the users using "Turkiye Klinikleri" services with or without a fee an inseparable.

2. DEFINITIONS

2.1. "SITE": A website offering different kind of services and context with a certain frame determined by "Turkiye Klinikleri" and it is accessible on-line on http://www.turkiyeklinikleri.com domain name and/or subdomains connected to the domain name.

2.2. USER: A natural person or a legal identity accessing to the "SITE" through online settings.

2.3. LINK: A link enabling to access to another website through the "SITE", the files, the context or through another website to the "SITE", the files and the context.

2.4. CONTEXT: Any visual, literary and auditory images published in the "Turkiye Klinikleri", "SITE" and/or any website or any accessible information, file, picture, number/figures, price, etc.

2.5. "USER CONTRACT": An electronically signed contract between a natural or a legal identity benefiting from special services "Turkiye Klinikleri" will provide and "Turkiye Klinikleri".

3. SCOPE OF THE SERVICES

3.1. "Turkiye Klinikleri" is completely free to determine the scope and quality of the services via the "SITE".

3.2. To benefit the services of "Turkiye Klinikleri" "SITE", the "USER" must deliver the features that will be specified by "Turkiye Klinikleri". "Turkiye Klinikleri" may change this necessity any time single-sided.

3.3. Not for a limited number, the services "Turkiye Klinikleri" will provide through the "SITE" for a certain price or for free are;

- Providing scientific articles, books and informative publications for health industry.

- Providing structural, statistical and editorial support to article preparation stage for scientific journals.

4. GENERAL PROVISIONS

4.1. "Turkiye Klinikleri" is completely free to determine which of the services and contents provided in the "SITE" will be charged.

4.2. People benefiting from the services provided by "Turkiye Klinikleri" and using the website can use the "SITE" only according to the law and only for personal reasons. Users have the criminal and civil liability for every process and action they take in the "SITE". Every USER agrees, declares and undertakes that they will not proceed by any function or action infringement of rights of "Turkiye Klinikleri"s and/or other third parties', they are the exclusive right holder on usage, processing, storage, made public and revealing any written, visual or auditory information reported to Turkiye Klinikleri" and/or "SITE" to the third parties. "USER" agrees and undertakes that s/he will not duplicate, copy, distribute, process, the pictures, text, visual and auditory images, video clips, files, databases, catalogs and lists within the "SITE", s/he will not be using these actions or with other ways to compete with "Turkiye Klinikleri", directly or indirectly.

4.3. The services provided and the context published within the "SITE" by third parties is not under the responsibility of "Turkiye Klinikleri", institutions collaborated with "Turkiye Klinikleri", "Turkiye Klinikleri" employee and directors, "Turkiye Klinikleri" authorized salespeople. Commitment to accuracy and legality of the published information, context, visual and auditory images provided by any third party are under the full responsibility of the third party. "Turkiye Klinikleri" does not promise and guarantee the safety, accuracy and legality of the services and context provided by a third party.

4.4. "USER"s cannot act against "Turkiye Klinikleri", other "USER"s and third parties by using the "SITE". "Turkiye Klinikleri" has no direct and/or indirect responsibility for any damage a third party suffered or will suffer regarding "USER"s actions on the "SITE" against the rules of the hereby "Terms of Use" and the law.

4.5. "USER"s accept and undertake that the information and context they provided to the "SITE" are accurate and legal. "Turkiye Klinikleri" is not liable and responsible for promising and guaranteeing the verification of the information and context transmitted to "Turkiye Klinikleri" by the "USER"s, or uploaded, changed and provided through the "SITE" by them and whether these information are safe, accurate and legal.

4.6. "USER"s agree and undertake that they will not perform any action leading to unfair competition, weakening the personal and commercial credit of "Turkiye Klinikleri" and a third party,  encroaching and attacking on personal rights within the "SITE" in accordance with the Turkish Commercial Code Law.

4.7. "Turkiye Klinikleri" reserves the right to change the services and the context within the "SITE"  anytime. "Turkiye Klinikleri" may use this right without any notification and timelessly. "USER"s have to make the changes and/or corrections "Turkiye Klinikleri" required immediately. Any changes and/or corrections that are required by "Turkiye Klinikleri", may be made by "Turkiye Klinikleri" when needed. Any harm, criminal and civil liability resulted or will result from changes and/or corrections required by "Turkiye Klinikleri" and were not made on time by the "USER"s belongs completely to the users.

4.8. "Turkiye Klinikleri" may give links through the "SITE" to other websites and/or "CONTEXT"s and/or folders that are outside of their control and owned and run by third parties. These links are provided for ease of reference only and do not hold qualification for support the respective web SITE or the admin or declaration or guarantee for the information inside. "Turkiye Klinikleri" does not hold any responsibility over the web-sites connected through the links on the "SITE", folders and context, the services or products on the websites provided through these links or their context.

4.9. "Turkiye Klinikleri" may use the information provided to them by the "USERS" through the "SITE" in line with the terms of the "PRIVACY POLICY" and "USER CONTRACT". It may process the information or classify and save them on a database. "Turkiye Klinikleri" may also use the USER's or visitor's identity, address, e-mail address, phone number, IP number, which sections of the "SITE" they visited, domain type, browser type, date and time information to provide statistical evaluation and customized services.

5. PROPRIETARY RIGHTS

5.1. The information accessed through this "SITE" or provided by the users legally and all the elements (including but not limited to design, text, image, html code and other codes) of the "SITE" (all of them will be called as studies tied to "Turkiye Klinikleri"s copyrights) belongs to "Turkiye Klinikleri". Users do not have the right to resell, process, share, distribute, display or give someone permission to access or to use the "Turkiye Klinikleri" services, "Turkiye Klinikleri" information and the products under copyright protection by "Turkiye Klinikleri". Within hereby "Terms of Use" unless explicitly permitted by "Turkiye Klinikleri" nobody can reproduce, process, distribute or produce or prepare any study from those under "Turkiye Klinikleri" copyright protection.

5.2. Within hereby "Terms of Use", "Turkiye Klinikleri" reserves the rights for "Turkiye Klinikleri" services, "Turkiye Klinikleri" information, the products associated with "Turkiye Klinikleri" copyrights, "Turkiye Klinikleri" trademarks, "Turkiye Klinikleri" trade looks or its all rights for other entity and information it has through this website unless it is explicitly authorized by "Turkiye Klinikleri".

6. CHANGES IN THE TERMS OF USE

"Turkiye Klinikleri" in its sole discretion may change the hereby "Terms of Use" anytime announcing within the "SITE". The changed terms of the hereby "Terms of Use" will become valid when they are announced. Hereby "Terms of Use" cannot be changed by unilateral declarations of users.

7. FORCE MAJEURE

"Turkiye Klinikleri" is not responsible for executing late or never of this hereby "Terms of Use", privacy policy and "USER Contract" in any situation legally taken into account as force majeure. Being late or failure of performance or non-defaulting of this and similar cases like this will not be the case from the viewpoint of "Turkiye Klinikleri", and "Turkiye Klinikleri" will not have any damage liability for these situations. "Force majeure" term will be regarded as outside of the concerned party's reasonable control and any situation that "Turkiye Klinikleri" cannot prevent even though it shows due diligence. Also, force majeure situations include but not limited to natural disasters, rebellion, war, strike, communication problems, infrastructure and internet failure, power cut and bad weather conditions.

8. LAW AND AUTHORISATION TO FOLLOW

Turkish Law will be applied in practicing, interpreting the hereby "Terms of Use" and managing the emerging legal relationships within this "Terms of Use" in case of finding element of foreignness, except for the rules of Turkish conflict of laws. Ankara Courts and Enforcement Offices are entitled in any controversy happened or may happen due to hereby contract.

9. CLOSING AND AGREEMENT

Hereby "Terms of Use" come into force when announced in the "SITE" by "Turkiye Klinikleri". The users are regarded to agree to hereby contract terms by using the "SITE". "Turkiye Klinikleri" may change the contract terms and the changes will be come into force by specifying the version number and the date of change on time it is published in the "SITE".

 

30.03.2014

Privacy Policy

We recommend you to read the terms of use below before you visit our website. In case you agree these terms, following our rules will be to your favor. Please read our Terms of Use thoroughly.

www.turkiyeklinikleri.com website belongs to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. and is designed in order to inform physicians in the field of health

www.turkiyeklinikleri.com cannot reach to user’s identity, address, service providers or other information. The users may send this information to the website through forms if they would like to. However, www.turkiyeklinikleri.com may collect your hardware and software information. The information consists of your IP address, browser type, operating system, domain name, access time, and related websites. www.turkiyeklinikleri.com cannot sell the provided user information (your name, e-mail address, home and work address, phone number) to the third parties, publish it publicly, or keep it in the website. Gathered information has a directing feature to be a source for the website’s visitor profile, reporting and promotion of the services.

www.turkiyeklinikleri.com uses the taken information:

-To enhance, improve and maintain the quality of the website

-To generate visitor’s profile and statistical data

-To determine the tendency of the visitors on using our website

-To send print publications/correspondences

-To send press releases or notifications through e-mail

-To generate a list for an event or competition

By using www.turkiyeklinikleri.com you are considered to agree that;

-Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. cannot be hold responsible for any user’s illegal and immoral behavior,

-Terms of use may change from time to time,

-It is not responsible for other websites’ contents it cannot control or the harms they may cause although it uses the connection they provided.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. may block the website to users in the following events:

-Information with wrong, incomplete, deceiving or immoral expressions is recorded to the website,

-Proclamation, advertisement, announcement, libelous expressions are used against natural person or legal identity,

-During various attacks to the website,

-Disruption of the website because of a virus.

Written, visual and audible materials of the website, including the code and the software are under protection by legal legislation.

Without the written consent of Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. the information on the website cannot be downloaded, changed, reproduced, copied, republished, posted or distributed.

All rights of the software and the design of the website belong to Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc.

Ortadoğu Advertisement Presentation Publishing Tourism Education Architecture Industry and Trade Inc. will be pleased to hear your comments about our terms of use. Please share the subjects you think may enrich our website or if there is any problem regarding our website.

info@turkiyeklinikleri.com