Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study

Fatmanur Aybala Koçak; Belma Füsun Köseoğlu; Serap Tomruk Sütbeyaz

doi:10.28982/josam.689130

Research Article

Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study

Year 2020, Volume: 4 Issue: 2, 120 - 125, 01.02.2020

Fatmanur Aybala Koçak Belma Füsun Köseoğlu Serap Tomruk Sütbeyaz

https://doi.org/10.28982/josam.689130

Cited By: 1

Abstract

Aim: Since vitamin D deficiency is a growing problem worldwide, insufficient levels of vitamin D were reported in patients with spinal cord injury (SCI). It was stated that levels of vitamin D may be an indirect indicator of functional status in patients with SCI. The aim of this study was to investigate the relationship between vitamin D levels and mobilization, functionality, grip strength, and pulmonary function test parameters in patients with subacute SCI.
Methods: Fifty-eight patients with subacute motor complete thoracic (T) and lumbar SCI injuries [46 males, 12 females; mean age 32.0 (11.2) years] were included. The time to complete the verticalization program on the tilt table without any orthostatic symptoms was considered as the ‘time of mobilization.’ Grip strength (GS) was measured using a dynamometer, pulmonary function test (PFT) parameters were measured using a spirometer, and functional status was measured using the Functional Independence Measure (FIM). For determining the levels of vitamin D, 25-hydroxy-vitamin D [25(OH)D] was measured and levels below 20 ng/mL were considered as deficiency. The patients were divided into two groups according to 25(OH)D levels, <20 ng/mL and ≥20 ng/mL. The demographic features, mobilization, PFT, GS, and FIM scores were compared according to the levels of 25(OH)D. The patients were divided into two other groups according to neurologic levels: levels between T6-10 and levels T11 and below, and then intragroup comparisons according to the levels of 25(OH)D were performed.
Results: The mean 25(OH)D level of the patients was found as 19.8 (8.3) ng/mL. When all patients were evaluated, time of mobilization was longer and FIM scores were lower in the 25(OH)D deficient group than in the other group (P<0.001 and P=0.038, respectively). When patients were evaluated separately according to their neurologic levels, time of mobilization was longer in the 25(OH)D deficient group, both in patients with a lesion level between T6-10 and the lesion levels T11 and below (P<0.001 and P=0.009, respectively). There was no statistically significant difference between the groups in terms of other clinical evaluations according to the neurologic levels of the patients.
Conclusion: Among the patients with SCI, time of mobilization of patients with vitamin D deficiency was longer than those of patients with non-deficient vitamin D levels, regardless of the neurologic level. Although the results of this study showed no statistically significant difference there may also be a relationship between vitamin D levels and pulmonary functions, GS, and FIM scores.

Keywords

Paraplegia, 25-hydroxy-vitamin D, Orthostatic hypotension, Lung function, Functional independence measure

References

1. Amrein K, Scherkl M, Hoffmann M, Neuwersch-Sommeregger S, Kostenberger M, Tmava Berisha A, et al. Vitamin D deficiency 2.0: an update on the current status worldwide. Eur J Clin Nutr. 2020. Epub 2020/01/22. doi: 10.1038/s41430-020-0558-y.
2. Aoun A, Maalouf J, Fahed M, El Jabbour F. When and How to Diagnose and Treat Vitamin D Deficiency in Adults: A Practical and Clinical Update. J Diet Suppl. 2019:1-19. doi:10.1080/19390211.2019.1577935.
3. Charoenngam N, Shirvani A, Holick MF. Vitamin D for skeletal and non-skeletal health: What we should know? J Clin Orthop Trauma. 2019;10(6):1082-93. doi:10.1016/j.jcot.2019.07.004.
4. Celep G, Durmaz ZH, Dörtok Demir H, Erdoğan Y. Vitamin D status in infancy: What is the solution? J Surg Med. 2019;3(8):579-82. doi: 10.28982/josam.555486.
5. Holick MF. The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Rev Endocr Metab Disord. 2017;18(2):153-65. doi: 10.1007/s11154-017-9424-1.
6. Nemunaitis GA, Mejia M, Nagy JA, Johnson T, Chae J, Roach MJ. A descriptive study on vitamin D levels in individuals with spinal cord injury in an acute inpatient rehabilitation setting. PM R. 2010;2(3):202-8 doi: 10.1016/j.pmrj.2010.01.010.
7. Lamarche J, Mailhot G. Vitamin D and spinal cord injury: should we care? Spinal Cord. 2016;54(12):1060-75. doi: 10.1038/sc.2016.131.
8. Özgirgin N, Koyuncu E, Nakipoğlu Yüzer GF, Taşoğlu Ö, Yenigün D. Is spinal cord injury a risk factor for vitamin D deficiency? Turk J Phys Med Rehab. 2016;62(1):57-63. doi:10.5606/tftrd.2016.39260.
9. Barbonetti A, D'Andrea S, Martorella A, Felzani G, Francavilla S, Francavilla F. Low vitamin D levels are independent predictors of 1-year worsening in physical function in people with chronic spinal cord injury: a longitudinal study. Spinal Cord. 2018;56(5):494-501. doi: 10.1038/s41393-017-0058-7.
10. Barbonetti A, Sperandio A, Micillo A, D'Andrea S, Pacca F, Felzani G, et al. Independent Association of Vitamin D With Physical Function in People With Chronic Spinal Cord Injury. Arch Phys Med Rehabil. 2016;97(5):726-32. doi: 10.1016/j.apmr.2016.01.002.
11. Hagen EM. Acute complications of spinal cord injuries. World J Orthop. 2015;6(1):17-23. doi: 10.5312/wjo.v6.i1.17.
12. Tesini S, Frotzler A, Bersch I, Tobon A. Prevention of Orthostatic Hypotension with Electric Stimulation in Persons with Acute Spinal Cord Injury. Biomed Tech (Berl). 2013;58 Suppl 1. doi:10.1515/bmt-2013-4029.
13. Annweiler C, Schott AM, Rolland Y, Beauchet O. Vitamin D deficiency is associated with orthostatic hypotension in oldest-old women. J Intern Med. 2014;276(3):285-95. doi:10.1111/joim.12201.
14. Jang W, Park J, Kim JS, Youn J, Oh E, Kwon KY, et al. Vitamin D deficiency in Parkinson's disease patients with orthostatic hypotension. Acta Neurol Scand. 2015;132(4):242-50. doi:10.1111/ane.12390.
15. McCarroll KG, Robinson DJ, Coughlan A, Healy M, Kenny RA, Cunningham C. Vitamin D and orthostatic hypotension. Age Ageing. 2012;41(6):810-3. doi: 10.1093/ageing/afs088.
16. Ometto F, Stubbs B, Annweiler C, Duval GT, Jang W, Kim HT, et al. Hypovitaminosis D and orthostatic hypotension: a systematic review and meta-analysis. J Hypertens. 2016;34(6):1036-43. doi: 10.1097/HJH.0000000000000907.
17. Soysal P, Yay A, Isik AT. Does vitamin D deficiency increase orthostatic hypotension risk in the elderly patients? Arch Gerontol Geriatr. 2014;59(1):74-7. doi:10.1016/j.archger.2014.03.008.
18. Veronese N, Trevisan C, Bolzetta F, De Rui M, Zambon S, Musacchio E, et al. Hypovitaminosis D predicts the onset of orthostatic hypotension in older adults. J Am Soc Hypertens. 2016;10(9):724-32. doi: 10.1016/j.jash.2016.06.038.
19. Nas K, Yazmalar L, Sah V, Aydin A, Ones K. Rehabilitation of spinal cord injuries. World J Orthop. 2015;6(1):8-16. doi: 10.5312/wjo.v6.i1.8.
20. Brumpton BM, Langhammer A, Henriksen AH, Camargo CA, Jr., Chen Y, Romundstad PR, et al. Vitamin D and Lung Function Decline in Adults With Asthma: The HUNT Study. Am J Epidemiol. 2016;183(8):739-46. doi: 10.1093/aje/kwv243.
21. Ford ES. Lung function, 25-hydroxyvitamin D concentrations and mortality in US adults. Eur J Clin Nutr. 2015;69(5):572-8. doi: 10.1038/ejcn.2014.162.
22. Solidoro P, Bellocchia M, Facchini F. The immunobiological and clinical role of vitamin D in obstructive lung diseases. Minerva Medica. 2016;107:12-9.
23. Garshick E, Walia P, Goldstein RL, Teylan MA, Lazzari AA, Tun CG, et al. Associations between vitamin D and pulmonary function in chronic spinal cord injury. J Spinal Cord Med. 2019;42(2):171-7. doi: 10.1080/10790268.2018.1432305.
24. Walia P, Goldstein RL, Teylan M, Lazzari AA, Hart JE, Tun CG, et al. Associations between vitamin D, adiposity, and respiratory symptoms in chronic spinal cord injury. J Spinal Cord Med. 2018;41(6):667-75. doi: 10.1080/10790268.2017.1374020.
25. Gunduz B, Erhan B. Update for Examination Sheet of International Standards for Neurological Classification of Spinal Cord Injury. Turk J Phys Med Rehab. 2015;61(1):91-4. doi: 10.5152/tftrd.2015.34682.
26. Gündüz B, Turna I. Rehabilitation of the patient with spinal cord injury. TOTBID Dergisi. 2018;17:581-91. doi: 10.14292/totbid.dergisi.2018.77.
27. Roth E, Davidoff G, Haughton J, Ardner M. Functional assessment in spinal cord injury: a comparison of the Modified Barthel Index and the ‘adapted’ Functional Independence Measure. Clin Rehabil. 1990;4:277-85.
28. Küçükdeveci AA, G. Y, Elhan AH, Sonel B, Tennant A. Adaptation of the Functional Independence Measure for use in Turkey. Clin Rehabil. 2001;15(3):311-9.
29. Güzelküçük Ü, Duman İ, Yılmaz B, Tan AK. Midodrine Treatment of Orthostatic Hypotension in Patients with Acute Tetraplegia. Turk J Phys Med Rehab. 2012;58(Suppl 1):56-7.
30. Ordu Gökkaya NK. Pulmonary Dysfunction As a Member of Autonomic Dysfunction Family: From a Different Window. Turk J Phys Med Rehab. 2012;58(Suppl 1):16-20.
31. Malas FU, Koseoglu F, Kara M, Ece H, Aytekin M, Ozturk GT, et al. Diaphragm ultrasonography and pulmonary function tests in patients with spinal cord injury. Spinal Cord. 2019;57(8):679-83. doi: 10.1038/s41393-019-0275-3.
32. Flueck JL, Schlaepfer MW, Perret C. Effect of 12-Week Vitamin D Supplementation on 25(OH)D Status and Performance in Athletes with a Spinal Cord Injury. Nutrients. 2016;8(10). doi:10.3390/nu8100586.

D vitamininin omurilik yaralanmalı hastalarda mobilizasyon, solunum fonksiyon testleri, kavrama gücü ve fonksiyonellik üzerine etkisi: Kesitsel bir çalışma

Year 2020, Volume: 4 Issue: 2, 120 - 125, 01.02.2020

Fatmanur Aybala Koçak Belma Füsun Köseoğlu Serap Tomruk Sütbeyaz

https://doi.org/10.28982/josam.689130

Cited By: 1

Abstract

Amaç: D vitamini eksikliği dünya çapında büyüyen bir problem olduğundan, omurilik yaralanmalı (OY) hastalarda da yetersiz D vitamini seviyeleri bildirilmiştir. D vitamini düzeylerinin, OY hastalarda fonksiyonel durumun dolaylı bir göstergesi olabileceği belirtilmiştir. Bu çalışmanın amacı, subakut dönemdeki OY hastalarda D vitamini düzeyleri ile mobilizasyon, fonksiyonel durum, el kavrama gücü ve solunum fonksiyon testi (SFT) parametreleri arasındaki ilişkiyi araştırmaktır.
Yöntemler: Subakut motor komplet torakal (T) ve lomber OY 58 hasta [46 erkek, 12 kadın; yaş ortalaması 32.0 (11.2) yıl] çalışmaya dahil edildi. Herhangi bir ortostatik semptom olmadan tilt masası ile vertikalizasyon programını tamamlama süresi “mobilizasyon zamanı” olarak değerlendirildi. El kavrama gücü dinamometre ile, SFT spirometre ile, fonksiyonel durum ise Fonksiyonel Bağımsızlık Ölçeği (FBÖ) ile değerlendirildi. D vitamini düzeylerini belirlemek için 25-hidroksi-vitamin D [25(OH)D] ölçümü yapıldı ve 20ng/mL’nin altındaki değerler eksiklik olarak değerlendirildi. Hastalar 25(OH)D seviyeleri <20 ng/mL olan ve 25(OH)D seviyeleri ≥20 ng/mL olan olmak üzere iki gruba ayrıldırlar. Demografik özellikler, mobilizasyon, SFT, el kavrama gücü ve FBÖ skorlarları 25(OH)D düzeylerine göre karşılaştırıldı. Hastalar nörolojik seviyelerine göre de farklı iki gruba ayrıldılar: Seviye T6-T10 arası ve seviye T11 ve altı. Sonrasında 25(OH)D düzeylerine göre grup içi karşılaştırmalar yapıldı.
Bulgular: Hastaların ortalama 25(OH)D düzeyleri 19.8 (8.3) ng/mL olarak bulundu. Tüm hastalar değerlendirildiğinde, 25(OH)D eksikliği olan grupta diğer gruba göre “mobilizasyon zamanı” daha uzundu ve FBÖ skorları daha düşüktü (sırasıyla P<0,001 and P=0,038). Hastalar nörolojik düzeylerine göre ayrı ayrı değerlendirildiğinde; hem lezyon seviyesi T6-T10 arası olan grupta hem de lezyon seviyesi T11 ve altı olan grupta; 25(OH)D eksikliği olan hastalarda “mobilizasyon zamanı” daha uzundu (sırasıyla P<0,001 and P=0,009). Hastalar nörolojik düzeylerine göre ayrıldıklarında diğer klinik değerlendirmeleri açısından; gruplar arasında istatistiksel olarak anlamlı fark yoktu.
Sonuç: OY hastalarda; nörolojik seviyeden bağımsız olarak D vitamini eksikliği olan hastaların mobilizasyon süresi olmayan hastalara göre daha uzundur. Bu çalışmanın sonuçları istatistiksel olarak anlamlı bir fark göstermese de, D vitamini düzeyleri ile solunum fonksiyonları, el kavrama gücü ve FBÖ skorları arasında da bir ilişki olabilir.

Keywords

Parapleji, 25-hidroksi-vitamin D, Ortostatik hipotansiyon, Akciğer fonksiyonu, Fonksiyonel bağımsızlık ölçeği

References

1. Amrein K, Scherkl M, Hoffmann M, Neuwersch-Sommeregger S, Kostenberger M, Tmava Berisha A, et al. Vitamin D deficiency 2.0: an update on the current status worldwide. Eur J Clin Nutr. 2020. Epub 2020/01/22. doi: 10.1038/s41430-020-0558-y.
2. Aoun A, Maalouf J, Fahed M, El Jabbour F. When and How to Diagnose and Treat Vitamin D Deficiency in Adults: A Practical and Clinical Update. J Diet Suppl. 2019:1-19. doi:10.1080/19390211.2019.1577935.
3. Charoenngam N, Shirvani A, Holick MF. Vitamin D for skeletal and non-skeletal health: What we should know? J Clin Orthop Trauma. 2019;10(6):1082-93. doi:10.1016/j.jcot.2019.07.004.
4. Celep G, Durmaz ZH, Dörtok Demir H, Erdoğan Y. Vitamin D status in infancy: What is the solution? J Surg Med. 2019;3(8):579-82. doi: 10.28982/josam.555486.
5. Holick MF. The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Rev Endocr Metab Disord. 2017;18(2):153-65. doi: 10.1007/s11154-017-9424-1.
6. Nemunaitis GA, Mejia M, Nagy JA, Johnson T, Chae J, Roach MJ. A descriptive study on vitamin D levels in individuals with spinal cord injury in an acute inpatient rehabilitation setting. PM R. 2010;2(3):202-8 doi: 10.1016/j.pmrj.2010.01.010.
7. Lamarche J, Mailhot G. Vitamin D and spinal cord injury: should we care? Spinal Cord. 2016;54(12):1060-75. doi: 10.1038/sc.2016.131.
8. Özgirgin N, Koyuncu E, Nakipoğlu Yüzer GF, Taşoğlu Ö, Yenigün D. Is spinal cord injury a risk factor for vitamin D deficiency? Turk J Phys Med Rehab. 2016;62(1):57-63. doi:10.5606/tftrd.2016.39260.
9. Barbonetti A, D'Andrea S, Martorella A, Felzani G, Francavilla S, Francavilla F. Low vitamin D levels are independent predictors of 1-year worsening in physical function in people with chronic spinal cord injury: a longitudinal study. Spinal Cord. 2018;56(5):494-501. doi: 10.1038/s41393-017-0058-7.
10. Barbonetti A, Sperandio A, Micillo A, D'Andrea S, Pacca F, Felzani G, et al. Independent Association of Vitamin D With Physical Function in People With Chronic Spinal Cord Injury. Arch Phys Med Rehabil. 2016;97(5):726-32. doi: 10.1016/j.apmr.2016.01.002.
11. Hagen EM. Acute complications of spinal cord injuries. World J Orthop. 2015;6(1):17-23. doi: 10.5312/wjo.v6.i1.17.
12. Tesini S, Frotzler A, Bersch I, Tobon A. Prevention of Orthostatic Hypotension with Electric Stimulation in Persons with Acute Spinal Cord Injury. Biomed Tech (Berl). 2013;58 Suppl 1. doi:10.1515/bmt-2013-4029.
13. Annweiler C, Schott AM, Rolland Y, Beauchet O. Vitamin D deficiency is associated with orthostatic hypotension in oldest-old women. J Intern Med. 2014;276(3):285-95. doi:10.1111/joim.12201.
14. Jang W, Park J, Kim JS, Youn J, Oh E, Kwon KY, et al. Vitamin D deficiency in Parkinson's disease patients with orthostatic hypotension. Acta Neurol Scand. 2015;132(4):242-50. doi:10.1111/ane.12390.
15. McCarroll KG, Robinson DJ, Coughlan A, Healy M, Kenny RA, Cunningham C. Vitamin D and orthostatic hypotension. Age Ageing. 2012;41(6):810-3. doi: 10.1093/ageing/afs088.
16. Ometto F, Stubbs B, Annweiler C, Duval GT, Jang W, Kim HT, et al. Hypovitaminosis D and orthostatic hypotension: a systematic review and meta-analysis. J Hypertens. 2016;34(6):1036-43. doi: 10.1097/HJH.0000000000000907.
17. Soysal P, Yay A, Isik AT. Does vitamin D deficiency increase orthostatic hypotension risk in the elderly patients? Arch Gerontol Geriatr. 2014;59(1):74-7. doi:10.1016/j.archger.2014.03.008.
18. Veronese N, Trevisan C, Bolzetta F, De Rui M, Zambon S, Musacchio E, et al. Hypovitaminosis D predicts the onset of orthostatic hypotension in older adults. J Am Soc Hypertens. 2016;10(9):724-32. doi: 10.1016/j.jash.2016.06.038.
19. Nas K, Yazmalar L, Sah V, Aydin A, Ones K. Rehabilitation of spinal cord injuries. World J Orthop. 2015;6(1):8-16. doi: 10.5312/wjo.v6.i1.8.
20. Brumpton BM, Langhammer A, Henriksen AH, Camargo CA, Jr., Chen Y, Romundstad PR, et al. Vitamin D and Lung Function Decline in Adults With Asthma: The HUNT Study. Am J Epidemiol. 2016;183(8):739-46. doi: 10.1093/aje/kwv243.
21. Ford ES. Lung function, 25-hydroxyvitamin D concentrations and mortality in US adults. Eur J Clin Nutr. 2015;69(5):572-8. doi: 10.1038/ejcn.2014.162.
22. Solidoro P, Bellocchia M, Facchini F. The immunobiological and clinical role of vitamin D in obstructive lung diseases. Minerva Medica. 2016;107:12-9.
23. Garshick E, Walia P, Goldstein RL, Teylan MA, Lazzari AA, Tun CG, et al. Associations between vitamin D and pulmonary function in chronic spinal cord injury. J Spinal Cord Med. 2019;42(2):171-7. doi: 10.1080/10790268.2018.1432305.
24. Walia P, Goldstein RL, Teylan M, Lazzari AA, Hart JE, Tun CG, et al. Associations between vitamin D, adiposity, and respiratory symptoms in chronic spinal cord injury. J Spinal Cord Med. 2018;41(6):667-75. doi: 10.1080/10790268.2017.1374020.
25. Gunduz B, Erhan B. Update for Examination Sheet of International Standards for Neurological Classification of Spinal Cord Injury. Turk J Phys Med Rehab. 2015;61(1):91-4. doi: 10.5152/tftrd.2015.34682.
26. Gündüz B, Turna I. Rehabilitation of the patient with spinal cord injury. TOTBID Dergisi. 2018;17:581-91. doi: 10.14292/totbid.dergisi.2018.77.
27. Roth E, Davidoff G, Haughton J, Ardner M. Functional assessment in spinal cord injury: a comparison of the Modified Barthel Index and the ‘adapted’ Functional Independence Measure. Clin Rehabil. 1990;4:277-85.
28. Küçükdeveci AA, G. Y, Elhan AH, Sonel B, Tennant A. Adaptation of the Functional Independence Measure for use in Turkey. Clin Rehabil. 2001;15(3):311-9.
29. Güzelküçük Ü, Duman İ, Yılmaz B, Tan AK. Midodrine Treatment of Orthostatic Hypotension in Patients with Acute Tetraplegia. Turk J Phys Med Rehab. 2012;58(Suppl 1):56-7.
30. Ordu Gökkaya NK. Pulmonary Dysfunction As a Member of Autonomic Dysfunction Family: From a Different Window. Turk J Phys Med Rehab. 2012;58(Suppl 1):16-20.
31. Malas FU, Koseoglu F, Kara M, Ece H, Aytekin M, Ozturk GT, et al. Diaphragm ultrasonography and pulmonary function tests in patients with spinal cord injury. Spinal Cord. 2019;57(8):679-83. doi: 10.1038/s41393-019-0275-3.
32. Flueck JL, Schlaepfer MW, Perret C. Effect of 12-Week Vitamin D Supplementation on 25(OH)D Status and Performance in Athletes with a Spinal Cord Injury. Nutrients. 2016;8(10). doi:10.3390/nu8100586.

There are 32 citations in total.

Details

Primary Language	English
Subjects	Rehabilitation
Journal Section	Research article
Authors	Fatmanur Aybala Koçak 0000-0002-2224-3324 Belma Füsun Köseoğlu This is me 0000-0002-3463-009X Serap Tomruk Sütbeyaz 0000-0002-1992-7178
Publication Date	February 1, 2020
Published in Issue	Year 2020 Volume: 4 Issue: 2

Cite

APA	Koçak, F. A., Köseoğlu, B. F., & Tomruk Sütbeyaz, S. (2020). Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study. Journal of Surgery and Medicine, 4(2), 120-125. https://doi.org/10.28982/josam.689130
AMA	Koçak FA, Köseoğlu BF, Tomruk Sütbeyaz S. Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study. J Surg Med. February 2020;4(2):120-125. doi:10.28982/josam.689130
Chicago	Koçak, Fatmanur Aybala, Belma Füsun Köseoğlu, and Serap Tomruk Sütbeyaz. “Impact of Vitamin D on Mobilization, Pulmonary Function Tests, Grip Strength and Functionality in Patients With Spinal Cord Injury: A Cross-Sectional Study”. Journal of Surgery and Medicine 4, no. 2 (February 2020): 120-25. https://doi.org/10.28982/josam.689130.
EndNote	Koçak FA, Köseoğlu BF, Tomruk Sütbeyaz S (February 1, 2020) Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study. Journal of Surgery and Medicine 4 2 120–125.
IEEE	F. A. Koçak, B. F. Köseoğlu, and S. Tomruk Sütbeyaz, “Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study”, J Surg Med, vol. 4, no. 2, pp. 120–125, 2020, doi: 10.28982/josam.689130.
ISNAD	Koçak, Fatmanur Aybala et al. “Impact of Vitamin D on Mobilization, Pulmonary Function Tests, Grip Strength and Functionality in Patients With Spinal Cord Injury: A Cross-Sectional Study”. Journal of Surgery and Medicine 4/2 (February 2020), 120-125. https://doi.org/10.28982/josam.689130.
JAMA	Koçak FA, Köseoğlu BF, Tomruk Sütbeyaz S. Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study. J Surg Med. 2020;4:120–125.
MLA	Koçak, Fatmanur Aybala et al. “Impact of Vitamin D on Mobilization, Pulmonary Function Tests, Grip Strength and Functionality in Patients With Spinal Cord Injury: A Cross-Sectional Study”. Journal of Surgery and Medicine, vol. 4, no. 2, 2020, pp. 120-5, doi:10.28982/josam.689130.
Vancouver	Koçak FA, Köseoğlu BF, Tomruk Sütbeyaz S. Impact of vitamin D on mobilization, pulmonary function tests, grip strength and functionality in patients with spinal cord injury: A cross-sectional study. J Surg Med. 2020;4(2):120-5.

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