Thermoregulatory instability – Neck pain and inability to maintain consistent body temperature

Ross Hauser, MD

At our center, we see many people with many conditions and symptoms of a neurologic-like nature. The common link that we see in our patients is the link of craniocervical instability and cervical spine degenerative disease and instability. If you are reading this article it is likely that you have some type of neck pain and a long list of medical conditions. One of these conditions may be the inability to regulate your body temperature.

For some, it started after cervical fusion surgery. For others, it was after a neck injury

Many people have very successful cervical fusions. Some people however may develop complications. Some of these complications are challenging and difficult to understand. In this article, I hope to help with understanding the possible reason you suffer from these conditions is a continued post-surgical craniocervical instability and cervical spine instability. For those of you who have not had a neck fusion, I hope to show that cervical neck ligament damage from injury can be a cause.

It started after a cervical fusion.

This is the type of story we hear:

I have had multiple cervical fusions and a cervical disc replacement. I am now experiencing a lot of symptoms. They come and go and vary in their intensity: Headaches, nausea, extreme fatigue, irregular heartbeat, lightheadedness, hand tremors, trouble swallowing, itchy spots on the left side some, right side mostly, trouble regulating body temperature, cracking in the neck when turning.

What can we do for a patient like this? If they are a good candidate for treatment, focus on the cervical spine and neck instability. This is explained below with links to supportive articles and research on this website.

Thermoregulatory dysfunction – this person’s thermostat is broken

The above story tells us of someone who is suffering from many symptoms. In treating the cervical spine we may find a way to treat all the symptoms at once as opposed to picking out the conditions individually and addressing symptom suppression. But we need some science and research to help guide your understanding of how this may be achieved in some patients.

A 2018 paper published in Handbook of Clinical Neurology (1) from the Department of Neurology, University of Maryland School of Medicine sought to help fellow neurosurgeons understand a phenomenon of thermoregulatory dysfunction in people who had just or recently suffered from an ischemic stroke, hemorrhagic stroke, and/or traumatic brain injury. Thermoregulatory dysfunction is a problem that its name well describes. The person who has it cannot maintain proper body core temperature. For some people when they are exposed to the cold, their body gets very cold. When they are exposed to heat, they can get very hot, or conversely get cold. Sometimes the person gets hot or cold without an apparent external stimulating factor. In simplest terms, this person’s thermostat is broken.

What causes this?

In the world of the neurologist dealing with an immediate health crisis of injury or stroke: “Temperature instability following brain injury likely involves hypothalamic injury, pathologic changes in cerebral blood flow, metabolic derangement (chemical imbalance), and a neurogenic inflammatory response (nerve inflammation).”

Let’s get an important point across now. Many people run a very high fever soon after their stroke or injury event, these problems need immediate medical care. The people we see and for whom this article is intended are the people who suffer symptoms such as temperature instability on a chronic basis with varying degrees of severity.

In the world of a cervical spine specialist who deals with people with chronic, years ongoing neurologic type symptoms that may reveal themselves as temperature instability, we have to look at chronic hypothalamic mis-messaging, pathologic changes in cerebral blood flow (the patient does not get enough blood to the brain), metabolic derangement (chemical imbalance often brought on by prolonged opioid use), and a neurogenic inflammatory response (nerve inflammation – something, like a disc or vertebrae is pinching the nerve).

Chronic thermoregulatory instability and herniated cervical discs

In this article, we are focusing on the patient who has thermoregulatory instability, a problem with fluctuating body temperatures as a chronic condition, and as a symptom among many symptoms that may lead to a diagnosis of cervical spine instability causing.

Let’s go back to the above paper. In an acute injury or stroke, the doctors point out three main regulatory symptoms that can be impacted.

These are also symptoms that can be very characteristic in the patients that has suffered from long term-cervical spine instability. Let’s briefly go through each system, but before we do, let’s put another face to this problem.

C5-C6 cervical disc herniation failed surgery and the symptoms and conditions that include fluctuating temperatures

This is another type of story we hear when someone contacts us for the first time. While this person has had a very unique medical journey, their story as you are probably seeing by now has a familiar tone to it. It may be your story. If you are reading this article because you suffer from temperature fluctuations and a skin temperature that wildly ranges from one side of your body to the other, this story will also have a familiar tone to it.

After the C5-C6 fusion – My body core temperatures goes up and down all day.

Again I would like to remind you the reader that many people have very successful cervical fusion surgeries. These are not the people that we see at our center. We see people who have stories that sound like this.

This is the type of person who contacts us. In the case of wildly swinging temperature ranges, this condition and symptoms are almost always treated as an afterthought because some of these people have so many problems that they lose track of them. You may be just like them, you have many issues and sometimes you simply lose track of all the things impacting your quality of life.

Later in this article, we will discuss how we may help this patient. But make no mistake, it was a long medical journey that brought this person to this point, it will be another journey to chip away at these symptoms and restore a better quality of life.

Cerebral blood flow, metabolic derangement, and a neurogenic inflammatory response. Problems of the cervical spine.

In the patients described above by the neurologists following a stroke or traumatic injury, the three main components of the cause of thermoregulatory instability are discussed. Let’s discuss these three main issues now in the context of cervical spine instability and an MRI that may show cervical spine herniations and cervical disc disease.

First, the research – cervical spine instability and body and skin temperature dysfunction are connected.

A paper published in 1998 (2) attempted to evaluate the characteristics of the thermovision image (a camera that takes a temperature) in pain syndromes associated with instability of the cervical segment of the spine, to identify the variables and the impact of the characteristics of the thermovision image in the process of rehabilitation, and to specify the suitability of thermovision testing in the evaluation of rehabilitation.

In other words, what these doctors were trying to do was standardize a way that you could take different body temperature readings of people who had cervical spine degenerative disease, plot out a body map of the patient and the different temperature ranges and the variables that caused them, and then you may be able to figure out how to treat this person’s cervical spine problems from the clues the skin temperature ranges gave them.

The results from tests performed in 71 patients indicate that patients with instability of the cervical segment of the spine, in comparison to healthy subjects, are characterized by the high asymmetry of the neck and severe cervical hyperthermia.

In other words part of the test subjects neck were hot, other parts were not. If you treated the neck pain successfully, you would be able to demonstrate this by making all parts of the neck have the same skin temperature reading.

Hot and cold skin patches across the body can help show where cervical spine degeneration is

Before we go further into this segment, skin temperature regulation or skin temperature dysfunction can be valuable tools in helping the patient with cervical neck pain and the symptoms and neurologic-type symptoms it is causing the patient. They are not the only tools. We also use other diagnostic aids as described below.

Thermatomal changes in cervical disc herniations

The title of an October 1999 paper is “Thermatomal changes in cervical disc herniations.” (3) Let’s explore this paper:

“Subjective symptoms of a cool or warm sensation in the arm could be shown objectively by using of thermography with the detection of thermal change in the case of radiculopathy, including cervical disc herniation. However, the precise location of each thermal change at cervical disc herniation has not been established in humans. This study used digital infrared thermographic imaging for 50 controls and 115 cervical disc herniation patients, analyzed the data statistically . . . and defined the areas of thermatomal change in cervical disc herniation C3/4, C4/5, C5/6, C6/7, and C7/T1.”

Building on similar research in the 1998 study, these doctors mapped out areas in the arm where temperatures of the arm swung between hot and cold.  They theorized that if you trace the nerve root back from these spots of temperature inversion in the arm, you can trace a route back to the problem area in the cervical spine and where a nerve may be impinged. For instance they found that:

But this can be a tricky science, in 2020 researchers published these observations in the journal Medicine (4).

“In general, in digital infrared thermographic imaging of patients with unilateral (one-sided) spinal radicular pain, the thermal pattern of the extremities of the side of (the degenerative disc lesions) shows hypothermia (cold skin) compared to the opposite, intact side. However, sometimes, digital infrared thermographic imaging shows hyperthermia (hot skin) on the side of the lesion, and this variation can cause confusion.”

What the researchers did was try to explain this flip-flop in temperature asymmetry.

They compared the data of both hypothermia and hyperthermia patients to clarify the factors determining different thermal characteristics in spinal radiculopathy. Two hundred twenty-four patients were divided into two groups:

They found: In patients with trauma history, acute phase of pain, and severe radicular pain, hyperthermia in digital infrared thermographic imaging is not unusual and careful interpretation of the digital infrared thermographic imaging results is necessary for proper diagnosis and treatment decisions in spinal radiculopathy.

In other words, in chronic neck pain people, hot and cold can go either way.

What are we seeing in this image?

Below is a video presentation with Ross Hauser, MD and Brian Hutcheson, DC of the Hauser Neck Center at Caring Medical Florida. This still frame from that video demonstrates how skin temperatures can vary from one side of the body to the other and from above and below the waist.

As we discuss above and will show with independent research, understanding skin temperature can help us understand your symptoms and where these symptoms can be coming from. In other words, understanding skin temperature can help get to the underlying cause of your problems if are centered in your cervical spine and neck pain.

Cerebral blood flow and distorted nerve signals – the hypothalamus, the trigeminal nerve, and trigeminal ganglion

The patients we see have a myriad of symptoms that, when deeply investigated, all lead to a common point. Such is the case of patients with cervical neck pain, neurologic-type symptoms, and a long medical journal of seemingly no answers.

It started with a whiplash and a concussion.

Here is one such journey. In the examples above, the person suggested that their problems started after a cervical spine fusion. Here is an example where there was no surgery but a bad whiplash and concussion.

I suffered from a whiplash injury and concussion. Months later I started suffering from Trigeminal Neuralgia, Occipital Neuralgia, and migraine. I had vision problems, dilated pupils, swallowing difficulties, parts of my body would get very hot, other parts of my body would get very cold. I would have a lot of sweating on one side, none on the other.  I have rapid heart rate, lightheadedness, digestion problems leading to constipation and insomnia. I am in spasm most of the time as I have muscle tightness from my neck through my shoulders. I am in severe and constant pain.

In the problems of thermoregulatory instability, the common point of symptoms including migraine, cluster headache, facial pain, neck pain, sleep deprivation, excessive sweating, and problems of blood flow in and out of the brain may be traced to one explanation of miscommunication between the hypothalamus, the trigeminal nerve and trigeminal ganglion. Another explanation is arterial and venous compression by the cervical vertebrae. We will explore the first explanation, bad signals between the hypothalamus, the trigeminal nerve, and trigeminal ganglion.

The hypothalamus

Describing what the hypothalamus is and all the regulatory functions it is responsible for would take pages and pages. In the context of this article the hypothalamus and its function will be described as it relates to blood flow and temperature regulation.

The hypothalamus is a gland at the base of the brain that sends out hormones and signals to regulate many body functions. Among them are receiving and sending pain signals, temperature regulation or thermoregulation signals, and vasodilation the regulation of blood flow. In fact, the nerve cells or neurons that control vasodilation originate in the hypothalamus.

The trigeminal nerve and ganglia

A brief word on the dorsal root ganglion

Let’s have the medical publication Stat Pearls (updated October 2020) explain this for us. (5)

“The dorsal root ganglion (DRG) has a significant clinical application, particularly in its association with neuropathic pain. DRG neurons emerge from the dorsal root of the spinal nerves, carrying sensory messages from various receptors, including those for pain and temperature towards the central nervous system for a response.”

Clearly what is said is that the dorsal root ganglion sends messages about pain and temperature and waits for nervous system response. If the communication network is working well, clear instructions and regulation of temperature are given. If the communication network is impaired, you have the possibility of temperature dysregulation problems.

What are we seeing in this image? How the temperature regulation communication network may be impaired

We see that the trigeminal nerve can be compressed or impinged upon by the C1-C2-C3 vertebrae. Cervical spine instability that allows for this compression of the trigeminal nerve can create miscommunication and distortion of messages between the hypothalamus, the trigeminal ganglia, and dorsal root ganglia. In simplest terms, miscommunication or distorted messages can misfire the nerves and create the problems and symptoms mentioned throughout this article including temperature dysregulation and vasodilation, the problems of distorted blood flow messages.

Arterial and venous compression

While cervical spine instability can cause a disruption in the way our brain, brain stem, and nerves communicate signals with one another, cervical spine instability can also cause a disruption of blood flow in and out of the brain. This can explain the many problems of headache, brain fog, dizziness, and other obvious problems related to a “lack of oxygen,” but it may also help us explain other conditions such as body temperature fluctuations from one side to the other.

What are we seeing in this image? How nerves and arteries interweave themselves through the cervical spine

As you can see and probably know from your own first-hand experience with symptoms and conditions, if the C1 or any of the cervical vertebrae shifts or becomes hypermobile, the can compress nerves and arteries. The compression of arteries and veins can lead to many of the symptoms described in this article including the problems of temperature dysfunction.

What are we seeing in this image?

This is a patient’s DMX image captured. The DMX is an x-ray movie. A video is just below this image. In this x-ray, when the patient looks down, a 6 mm space opens between the C1-C2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed. This includes arteries, nerves, and veins.

In this x-ray, when the patient looks down, a 6 mm space opens between the C1-c2. When the patient looks up, 0 mm, no space. Everything between those two surfaces is compressed.

Digital motion X-Ray C1 – C2

The digital motion x-ray is explained and demonstrated below

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
  • This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate correction of this problem.

The problems of temperature asymmetry and cervical spine instability

In our nearly three decades in helping people with chronic pain, we have seen, from the start, that mysterious symptoms and missing diagnoses often plague people with upper cervical instability and compression of the brainstem. Solving the problem of a missing diagnosis of cervical spine issues causing these mysterious symptoms may be found in dysregulation of temperature control in the body.

While cervical spine and neck instability offers us a good explanation as to the causes of these symptoms, cervical spine and neck instability can also be an umbrella term used to describe many factors. You may have C0-C1 instability, causing some of these symptoms. You may have problems from C3-C7 fusion causing segmental changes in your cervical spine which cause symptoms. You may have compression of any one or all of the cervical nerves. You may have carotid artery compression. You may also have internal jugular vein stenosis. You may also have a combination of some, many, or all these problems depending on the severity of your neck instability. It can of course be overwhelming.

Here is an example: A patient has just completed real-time testing at our center. Real-time meaning we know the results as the test is being performed, this is explained further below. We will sit with the patient and their spouse or partner and then tell them that we believe many of their symptoms are coming from compression of their jugular vein, the compression is being caused by pressure from the cervical vertebrae or a problem with the styloid process at the base of the skull and possible carotid artery syndrome.

We have a very detailed article that goes further into understanding venous compression and internal jugular vein stenosis that helps explain the problems of blood flow. Also see our article Dynamic Analysis of Blood Flow Measurements to the Brain, Brainstem, Cervical Spinal Cord, and Cranial Nerves.

What are we seeing in this image?

A cervical venous system that makes its way to the brain. As you can see if the C1 or any of the cervical vertebrae shifts or becomes hypermobile, they can compress the veins. The compression of veins can lead to blood flow problems and many of the symptoms described in this article including the problems of temperature dysfunction.

Treatments: Addressing cervical ligament laxity and craniocervical instability and cervical spine degenerative disease and instability

Throughout this article, we explored the possibility that cervical spine instability was responsible for the problems, conditions, and symptoms described here including the problems of temperature dysfunction. In this section, we will now explore possible answers to solving your medical mysteries by addressing the laxity of the cervical spine ligaments and a destructive cervical spine curve.

Atlantoaxial instability: C1 and C2 hypermobility causes cervical spine instability and artery, vein, and nerve compression

Atlantoaxial instability is the abnormal, excessive movement of the joint between the atlas (C1) and axis (C2). The bundle of ligaments that support this joint is strong bands that provide strength and stability while allowing the flexibility of head movement and allow unimpeded access (prevention of herniation or “pinch”) of blood vessels that travel through them to the brain.

In a 2015 paper appearing in the Journal of Prolotherapy(6) our research team wrote that cervical ligament injury should be more widely viewed as the underlying pathophysiology (the cause of) atlantoaxial instability and the primary cause of cervical myelopathy (disease) including the problems I have written about in this article.

The problems of Atlantoaxial instability are not problems that sit in isolation. A patient that suffers from Atlantoaxial instability will likely be seen to suffer from many problems as they all relate to upper cervical neck ligament damage and cervical instability. As demonstrated below this includes cervical subluxation, (misalignment of the cervical vertebrae). One of the causes of Internal jugular vein stenosis is this cervical misalignment and its “pinching,” or “herniation,” not of a disc, but of the arteries and veins. This creates the situation of ischemia (damage to the blood vessels) or in the case of this article internal jugular vein ischemia.

The case for identifying loss of cervical lordosis as the cause of your symptoms

The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. The curve of your cervical spine is in correct anatomical alignment.

When the cervical spine ligaments are weakened, they cannot hold the cervical spine in proper alignment or in its proper anatomical curve. Your head begins to move in a destructive, degenerative manner on top of your neck. This is when cervical artery and jugular vein compression can occur.

In our 2014 research lead by Danielle R. Steilen-Matias, MMS, PA-C, published in The Open Orthopaedics Journal (7), we demonstrated that when the neck ligaments are injured, they become elongated and loose, which causes excessive movement of the cervical vertebrae. In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to, nerve irritation, vertebrobasilar insufficiency with associated vertigo and dizziness, tinnitus, facial pain, arm pain, migraine headaches, and jugular vein compression.

Treating and stabilizing the cervical ligaments can alleviate these problems by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause including nerve, vein, and arterial compression.

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization is achieved and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments


Research on cervical instability and Prolotherapy

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to these studies as they relate to cervical instability and a myriad of related symptoms including the problems spoken of in this article.

We are going to go briefly outside of our own research and observation to present two independent studies. In our research that we will demonstrate below, we were able to get good outcomes with simple dextrose Prolotherapy injections that stimulated repair and restoration of the damaged cervical neck ligaments. This helped restore the normal anatomical alignment of the head and neck. In this research below, we will explore the proper alignment that came from chiropractic studies.

Cerebral blood flow changes

In 2019, published in the medical journal Brain Circulation,(8) Evan Katz, a private practitioner published the findings of his office in treating the Cervical lordosis of seven patients (five females and two males, 28–58 years). “The aim of this study is to evaluate cerebral blood flow changes on brain magnetic resonance angiogram (MRA) in patients with loss of cervical lordosis before and following correction of cervical lordosis.”

These are some of the study’s learning points:

  • Loss of lordosis of the cervical spine is associated with decreased vertebral artery hemodynamics. “Vertebral arteries proceed superiorly, in the transverse foramen of each cervical vertebra and merge to form the single midline basilar artery” which continues to the circle of Willis and cerebral arteries. Based on this close anatomical relationship between the cervical spine, the vertebral arteries, and cerebral vasculature, we hypothesized that improvement in cervical hyperlordosis increases collateral cerebral artery hemodynamics and circulation. This retrospective consecutive case series evaluates brain magnetic resonance angiogram (MRA) in patients with cervical hyperlordosis before and following correction of cervical lordosis.

Research on 21 patients with cervical instability and chronic neck pain


Prolotherapy is a regenerative injection technique that utilizes substances as simple as dextrose to repair and regenerate damaged ligaments.

In 2015, Caring Medical published findings in the European Journal of Preventive Medicine (9) investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots.

Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including the range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

  • Ninety-five percent of patients reported that Prolotherapy met their expectations with regard to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
  • Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
  • Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity.

Ross Hauser, MD, and Brian Hutcheson DC discuss chronic skin sensations that are pretty common symptoms and findings in cases of cervical instability.

Ross Hauser, MD, and Brian Hutcheson DC discuss chronic skin sensations that are pretty common symptoms and findings in cases of cervical instability. These include symptoms like abnormal temperature regulation over half of their body or certain areas that are hot or cold compared to the rest of the body as well as specific areas that are hypersensitive or numb compared to the rest of the body, and other odd skin sensations, including localized swelling, vibration, and severe itching that have not been resolved by other traditional treatments by a dermatologist, rheumatologist, neurologist, etc.

Please see my article: Symptoms and conditions of Craniocervical and Cervical Spine Instability for a more comprehensive review and discussion of treatments.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding thermoregulatory instability. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form


References

1 Gowda R, Jaffa M, Badjatia N. Thermoregulation in brain injury. Handbook of clinical neurology. 2018 Jan 1;157:789-97. [Google Scholar]
2 Jasiak-Tyrkalska B, Frańczuk B. Evaluation of thermovision images in pain syndrome associated with instability of the cervical segment of the spine. Przeglad Lekarski. 1998 Jan 1;55(5):246-9. [Google Scholar]
3. Zhang HY, Kim YS, Cho YE. Thermatomal changes in cervical disc herniations. Yonsei Medical Journal. 1999 Oct 1;40(5):401-12. [Google Scholar]
4. Park TY, Son S, Lim TG, Jeong T. Hyperthermia associated with spinal radiculopathy as determined by digital infrared thermographic imaging. Medicine. 2020 Mar 1;99(11):e19483. [Google Scholar]
5 Ahimsadasan, Nilah, and Anil Kumar. “Neuroanatomy, dorsal root ganglion.” (2018). [Google Scholar]
6 Hauser R, Steilen-Matias D, Fisher P. Upper cervical instability of traumatic origin treated with dextrose prolotherapy: a case report. Journal of Prolotherapy. 2015;7:e932-e935.
7 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
8 Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Brain circulation. 2019 Jan;5(1):19. [Google Scholar]

This article was published February 4, 2021

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