The Utilization of Yoga as a Therapeutic Tool to Promote Physical Activity Behavior Change and Improved Postural Control in Individuals With Multiple Sclerosis

NCT04113135 | Withdrawn

• 1 other identifier: 19-0118
• Study Type: interventional
• Target: N/A
• Locations: 1 country
• Sites: 1

Brief Summary

This randomized control trial will investigate whether using yoga as physical activity improves quality of life, self-efficacy for physical activity, reactive balance, and dual tasking more than education, journaling, and meditation alone in people with Multiple Sclerosis.

Conditions

Multiple Sclerosis

Outcome Measures

Primary Outcomes (11)

• Mini BESTest (Change is being assessed)

  Participants will each complete the Mini Balance Evaluation Systems Test (MiniBEST). This assessment is a series of 14 tests measuring anticipatory balance, reactive postural control, sensory orientation, and dynamic gait. 16 The 14 tests will be analyzed together to determine reactive and anticipatory balance, as well as, dual task capabilities. Subjects will be tested with flat-heeled shoes or with shoes and socks off. 16 Each of the 14 items are scored on an ordinal scale from 0-2 with a total of 28 points possible. Higher scores indicate higher levels of function, with 0 indicating the lowest level of function and 2 indicating the highest level of function. Two of the 14 items (Item 3 and Item 6) have right and left assessments in which the lower of the two sides is calculated into the total. If an assistive device is used during an item the score is lowered by one point. If the participant requires physical assistance then the item is automatically scored a 0. 16

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• 9 hole peg test (Change is being assessed)

  Test of fine motor coordination where subjects are asked to use their hands to move 9 pegs from one side of a tray to another. This is a timed outcome.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Timed 25 ft walk (Change is being assessed)

  Subjects are asked to walk 25 ft over level surfaces and are timed

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Markus Self-Efficacy Scale (Change is being assessed)

  The Marcus Self Efficacy Scale is a survey which will be used to measure participants' beliefs about their ability to exercise. 23 This scale consists of five items that resemble barriers to exercise such as planning time, environmental factors, and physical or emotional well-being. 23 For each scenario, participants rate their confidence on an 11-point Likert scale; 0 is 'does not apply to me,' 1 is 'not at all confident' and 11 is 'very confident.' 23 Lower scores indicate lower self-efficacy and suggest less inclination to participate in exercise. According to Marcus et al, this scale scored a test-retest reliability of r=.90 over a two-week period.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Quality of Life Scale (Change is being assessed)

  The Quality of Life (QoL) survey consists of 32 items created by Gill et al. 24 This survey allows the participant to evaluate their quality of life based on the biopsychosocial model. The participants are asked to circle a number from 1 'poor' to 5 'excellent' based on their perception of their quality of life. Gill et al 24 recommended the QoL survey as a valuable tool in research based on its psychometric properties. Gill et al 25 re-evaluated the QoL survey for test-retest reliability and compared to other quality of life measurements. Gill et al 24 reported reliability of .793 for ADL and .950 for spirituality. In addition, the QoL survey demonstrated good test-retest reliability ranging from .677 to .816, and intraclass correlations from .676 to .809. 25

  Pre and post intervention(Week 1 of protocol and week 7 of protocol)

• Patient Determined Disease Steps (Change is being assessed)

  The Patient Determined Disease Steps (PDDS) will be completed by participants in order to determine their level of disability based on their method of ambulation. 26 This outcome measure is based on the Disease Steps scale created by Hohol et al 27 which sought to provide neurologists with a simple guide for therapeutic intervention and to assess patient progress. The PDDS consists of nine ordinal rankings from 0 (normal) to 8 (bedridden). The PDDS has a strong correlation with the Expanded Disability Status Scale (EDSS) which is the most widely accepted measure for MS disability; this confirms criterion validity. 26 According to Learmonth et al 26 the PDDS is a valid and useful patient-reported score system for assessing disability in individuals with MS.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Modified Fatigue Impact Scale (Change is being assessed)

  The Modified Fatigue Impact Scale (MFIS) is a self-reported survey which will be used to determine the impact of fatigue on an individual over the last four weeks. 28 This consists of twenty-one items rated on a 5-point Likert scale with 0 being 'never' and 4 being 'almost always'. Scores can be subdivided into physical, psychosocial, and cognitive subscales. Total scores range from 0-84 with higher scores indicating greater fatigue and MS related fatigue is identified as a score of 38 or greater. 28 The minimal clinically important change for the MFIS is 16 points short-term and 20 points long-term. 28 Learmonth et al 28 found the MFIS has an excellent test-retest reliability of 0.837 over a 6-month period. In addition, Amtmann et al 29 found that the MFIS has excellent internal consistency, demonstrated by a Cronbach's alpha greater than 0.93, and known groups validity.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Pittsburgh Sleep Quality Index (Change is being assessed)

  The Pittsburgh Sleep Quality Index (PSQI) is a 19 item self-rated questionnaire that will be completed by the participants. The PSQI will serve as a subjective measure of sleep for participants participating in the study, and allow for discrimination between "good" and "poor" sleepers. 30 The 19 individual items assessed help to generate seven component, consisting of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. 30 A global score is obtained from the seven components, ranging from 0-21, with higher scores reflecting poor sleep quality. 31 While the PSQI has not been specifically validated in people diagnosed with MS, it has been used to assess changes in sleep patterns in those diagnosed with MS in many different studies. 30,31

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Godin Leisure-Time Physical Activity Questionnaire (Change is being assessed)

  The Godin is a 3-question, self-report measure that assesses the frequency that individuals engage in bouts of PA at light, moderate, and strenuous levels. 34 The measure asks frequency of PA at each activity level and uses a formula to calculate a score (MET value) for weekly activity (9 x strenuous, 5 x moderate, and 3 x light). The higher the overall score, the greater the PA level. The MET scores can also be used to classify PA participation into three categories: "active" (24 and higher), "moderately active" (14-23), and "insufficiently active" (less than 14). More recently, research has proposed using only using the moderate and strenuous calculations to classify individuals as "active" (? 24 METS) and insufficiently active" (? 23 METS) to fall in line with PA guidelines in both the United States and Canada. 35-36 It has been used extensively with the MS population. 38

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Basic Demographics and Behavioral questionnaire (Change is being assessed)

  A basic background questionnaire will be used to gather information on participants age, gender, work history, history with MS, and leisure and physical activity behavior.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

• Bladder control scale

  The Bladder Control Scale (BLCS) is a survey consisting of four items that briefly assess bladder. control and the impact it has on the individual's quality of life. This survey was developed by Turnbull et al (1992) and is cited by the National Multiple Sclerosis user's manual and Beadnall et al. 32 The BLCS has a scoring system ranging from 0-22 with higher scores indicating more difficulty with bladder control. 32, 33 MS specialists were consulted during the development of this scale to ensure content validity. Beadnall et al 32 noted multiple studies showing the BLCS to be valid and having good reliability.

  Pre and post intervention (Week 1 of protocol and week 7 of protocol)

Study Arms (2)

Journaling, meditations, education, yoga intervention Arm

EXPERIMENTAL

Participants will be required to attend 1x/wk for 7 total sessions. The pre/post testing will take approximately 45 minutes to one hour. Session 1 for all participants will be comprised of an initial screening with a health history questionnaire regarding information about comorbidities, medications, and type of Multiple Sclerosis (MS) diagnosis, and completion of all outcome measurement tests as listed above. Following session one, subjects will be assigned to the control or experimental group utilizing the robust randomization application (RRApp) and the block randomization technique to ensure an equal number of subjects in each group.39 The intervention sessions (2-6) for the experimental group participants consist will include a group discussion of the objectives for the week, 20-30 minutes of education and journaling (Attachment B), 45-60 minutes of PA consisting of various yoga poses followed by SMART goal setting and guided relaxation..

Other: Yoga

Journaling, meditation, education arm

ACTIVE COMPARATOR

Participants will be required to attend 1x/wk for 7 total sessions. The pre/post-testing will take approximately 45 minutes to one hour. Session 1 for all participants (control and experimental) will be comprised of an initial screening with a health history questionnaire regarding information about comorbidities, medications, and type of Multiple Sclerosis (MS) diagnosis, and completion of all outcome measurement tests as listed above. Following session one, subjects will be assigned to the control or experimental group utilizing the robust randomization application (RRApp) and the block randomization technique to ensure an equal number of subjects in each group.39 The control group will participate in a 45-60 minute session for weeks 2-6 consisting of goal setting to facilitate behavior change, education on MS, and meditation. Session 7 will conclude the study with reassessment of all outcome measurements as listed above.

Other: Control

Interventions

Yoga OTHER

Participants will be lead through a series of yoga poses by a licensed physical therapist with advanced training in yoga. Participants in this group will also receive education related to MS as well as SMART goal setting, journaling and guided meditation. Modifications will be offered as needed.

Journaling, meditations, education, yoga intervention Arm

Control OTHER

Participants in this group will receive education related to MS as well as SMART goal setting, journaling, and guided meditation.

Journaling, meditation, education arm

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Clinical diagnosis of Multiple Sclerosis.
• PDDS Category 0-6. Those patients that are classified as PDDS 5 or 6, must be able to ambulate into the clinic without the use of a wheelchair or scooter.
• Ability to participate in light to moderate physical activity for 45 minutes one time per week.

You may not qualify if:

• Participants experiencing a multiple sclerosis exacerbation at the time of the scheduled intervention
• Serious Cardiovascular Disease (Uncompensated CHF, Unmanaged hypertension)
• Advanced Musculoskeletal Disorder (ie. Unhealed Fracture, advanced stages of osteoporosis)
• PDDS Category 7-8

Sponsors & Collaborators

• Winston Salem State University: lead
• Appalachian State University: collaborator

Study Sites (1)

Winston Salem State University

Winston-Salem, North Carolina, 27110, United States

Location

Related Publications (39)

• Lassmann H. Neuropathology in multiple sclerosis: new concepts. Mult Scler. 1998 Jun;4(3):93-8. doi: 10.1177/135245859800400301.

  PMID: 9762654 BACKGROUND

• National Multiple Sclerosis Society. Who Gets MS? (Epidemiology). https://www.nationalmssociety.org/What-is-MS/Who-Gets-MS. Accessed June 9, 2019

  BACKGROUND

• Ghasemi N, Razavi S, Nikzad E. Multiple Sclerosis: Pathogenesis, Symptoms, Diagnoses and Cell-Based Therapy. Cell J. 2017 Apr-Jun;19(1):1-10. doi: 10.22074/cellj.2016.4867. Epub 2016 Dec 21.

  PMID: 28367411 BACKGROUND

• Bruck W, Lucchinetti C, Lassmann H. The pathology of primary progressive multiple sclerosis. Mult Scler. 2002 Apr;8(2):93-7. doi: 10.1191/1352458502ms785rr.

  PMID: 11990878 BACKGROUND

• Fasczewski KS, Rothberger SM, Gill DL. Why do they do it? Assessing self-report physical activity behavior and quality of life in individuals with multiple sclerosis. J Health Psychol. 2020 Jun;25(7):964-975. doi: 10.1177/1359105317739965. Epub 2017 Nov 27.

  PMID: 29172811 BACKGROUND

• Hurwitz BJ. The diagnosis of multiple sclerosis and the clinical subtypes. Ann Indian Acad Neurol. 2009 Oct;12(4):226-30. doi: 10.4103/0972-2327.58276.

  PMID: 20182569 BACKGROUND

• Motl RW, Snook EM. Physical activity, self-efficacy, and quality of life in multiple sclerosis. Ann Behav Med. 2008 Feb;35(1):111-5. doi: 10.1007/s12160-007-9006-7. Epub 2008 Feb 12.

  PMID: 18347911 BACKGROUND

• Fasczewski KS, Gill DL. A model of motivation for physical activity in individuals diagnosed with multiple sclerosis. Disabil Rehabil. 2019 Sep;41(18):2143-2150. doi: 10.1080/09638288.2018.1459883. Epub 2018 Apr 10.

  PMID: 29631465 BACKGROUND

• Fasczewski KS, Gill DL, Rothberger SM. Physical activity motivation and benefits in people with multiple sclerosis. Disabil Rehabil. 2018 Jun;40(13):1517-1523. doi: 10.1080/09638288.2017.1300946. Epub 2017 Mar 14.

  PMID: 28291956 BACKGROUND

• Wahbeh H, Elsas SM, Oken BS. Mind-body interventions: applications in neurology. Neurology. 2008 Jun 10;70(24):2321-8. doi: 10.1212/01.wnl.0000314667.16386.5e.

  PMID: 18541886 BACKGROUND

• Bolton RE, Fix GM, VanDeusen Lukas C, Elwy AR, Bokhour BG. Biopsychosocial benefits of movement-based complementary and integrative health therapies for patients with chronic conditions. Chronic Illn. 2020 Mar;16(1):41-54. doi: 10.1177/1742395318782377. Epub 2018 Jun 18. No abstract available.

  PMID: 29914264 BACKGROUND

• Kahraman T, Ozdogar AT, Yigit P, Hosgel I, Mehdiyev Z, Ertekin O, Ozakbas S. Feasibility of a 6-Month Yoga Program to Improve the Physical and Psychosocial Status of Persons with Multiple Sclerosis and their Family Members. Explore (NY). 2018 Jan-Feb;14(1):36-43. doi: 10.1016/j.explore.2017.07.006. Epub 2017 Oct 23.

  PMID: 29174060 BACKGROUND

• Rogers KA, MacDonald M. Therapeutic Yoga: Symptom Management for Multiple Sclerosis. J Altern Complement Med. 2015 Nov;21(11):655-9. doi: 10.1089/acm.2015.0015. Epub 2015 Aug 13.

  PMID: 26270955 BACKGROUND

• Subramaniam S, Bhatt T. Effect of Yoga practice on reducing cognitive-motor interference for improving dynamic balance control in healthy adults. Complement Ther Med. 2017 Feb;30:30-35. doi: 10.1016/j.ctim.2016.10.012. Epub 2016 Oct 26.

  PMID: 28137524 BACKGROUND

• Cohen ET, Kietrys D, Fogerite SG, Silva M, Logan K, Barone DA, Parrott JS. Feasibility and Impact of an 8-Week Integrative Yoga Program in People with Moderate Multiple Sclerosis-Related Disability: A Pilot Study. Int J MS Care. 2017 Jan-Feb;19(1):30-39. doi: 10.7224/1537-2073.2015-046.

  PMID: 28243184 BACKGROUND

• King L, Horak F. On the mini-BESTest: scoring and the reporting of total scores. Phys Ther. 2013 Apr;93(4):571-5. doi: 10.2522/ptj.2013.93.4.571. No abstract available.

  PMID: 23547173 BACKGROUND

• Ross E, Purtill H, Uszynski M, Hayes S, Casey B, Browne C, Coote S. Cohort Study Comparing the Berg Balance Scale and the Mini-BESTest in People Who Have Multiple Sclerosis and Are Ambulatory. Phys Ther. 2016 Sep;96(9):1448-55. doi: 10.2522/ptj.20150416. Epub 2016 Feb 25.

  PMID: 26916925 BACKGROUND

• Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther. 2013 Feb;93(2):158-67. doi: 10.2522/ptj.20120171. Epub 2012 Sep 27.

  PMID: 23023812 BACKGROUND

• Feys P, Lamers I, Francis G, Benedict R, Phillips G, LaRocca N, Hudson LD, Rudick R; Multiple Sclerosis Outcome Assessments Consortium. The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Mult Scler. 2017 Apr;23(5):711-720. doi: 10.1177/1352458517690824. Epub 2017 Feb 16.

  PMID: 28206826 BACKGROUND

• Yozbatiran N, Baskurt F, Baskurt Z, Ozakbas S, Idiman E. Motor assessment of upper extremity function and its relation with fatigue, cognitive function and quality of life in multiple sclerosis patients. J Neurol Sci. 2006 Jul 15;246(1-2):117-22. doi: 10.1016/j.jns.2006.02.018. Epub 2006 May 5.

  PMID: 16678208 BACKGROUND

• Fischer JS, Rudick RA, Cutter GR, Reingold SC. The Multiple Sclerosis Functional Composite Measure (MSFC): an integrated approach to MS clinical outcome assessment. National MS Society Clinical Outcomes Assessment Task Force. Mult Scler. 1999 Aug;5(4):244-50. doi: 10.1177/135245859900500409.

  PMID: 10467383 BACKGROUND

• Motl RW, Cohen JA, Benedict R, Phillips G, LaRocca N, Hudson LD, Rudick R; Multiple Sclerosis Outcome Assessments Consortium. Validity of the timed 25-foot walk as an ambulatory performance outcome measure for multiple sclerosis. Mult Scler. 2017 Apr;23(5):704-710. doi: 10.1177/1352458517690823. Epub 2017 Feb 16.

  PMID: 28206828 BACKGROUND

• Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport. 1992 Mar;63(1):60-6. doi: 10.1080/02701367.1992.10607557.

  PMID: 1574662 BACKGROUND

• Gill DL, Chang Y, Murphy KM et al. Quality of Life Assessment for Physical Activity and Health Promotion. Applied Research in Quality of Life. 2011 June; 6(2):181-200

  BACKGROUND

• Gill DL, Reifsteck EJ, Adams MM, Shang Y. Quality of Life Assessment for Physical Activity and Health Promotion: Further Psychometrics and Comparison of Measures. Measurement in Physical Education & Exercise Science 2015 Oct;19(4):159-166.

  BACKGROUND

• Learmonth YC, Motl RW, Sandroff BM, Pula JH, Cadavid D. Validation of patient determined disease steps (PDDS) scale scores in persons with multiple sclerosis. BMC Neurol. 2013 Apr 25;13:37. doi: 10.1186/1471-2377-13-37.

  PMID: 23617555 BACKGROUND

• Hohol MJ, Orav EJ, Weiner HL. Disease steps in multiple sclerosis: a simple approach to evaluate disease progression. Neurology. 1995 Feb;45(2):251-5. doi: 10.1212/wnl.45.2.251.

  PMID: 7854521 BACKGROUND

• Learmonth YC, Dlugonski D, Pilutti LA, Sandroff BM, Klaren R, Motl RW. Psychometric properties of the Fatigue Severity Scale and the Modified Fatigue Impact Scale. J Neurol Sci. 2013 Aug 15;331(1-2):102-7. doi: 10.1016/j.jns.2013.05.023. Epub 2013 Jun 20.

  PMID: 23791482 BACKGROUND

• Amtmann D, Bamer AM, Noonan V, Lang N, Kim J, Cook KF. Comparison of the psychometric properties of two fatigue scales in multiple sclerosis. Rehabil Psychol. 2012 May;57(2):159-66. doi: 10.1037/a0027890.

  PMID: 22686554 BACKGROUND

• Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193-213. doi: 10.1016/0165-1781(89)90047-4.

  PMID: 2748771 BACKGROUND

• Trojan DA, Arnold D, Collet JP, Shapiro S, Bar-Or A, Robinson A, Le Cruguel JP, Ducruet T, Narayanan S, Arcelin K, Wong AN, Tartaglia MC, Lapierre Y, Caramanos Z, Da Costa D. Fatigue in multiple sclerosis: association with disease-related, behavioural and psychosocial factors. Mult Scler. 2007 Sep;13(8):985-95. doi: 10.1177/1352458507077175. Epub 2007 Apr 27.

  PMID: 17468448 BACKGROUND

• Beadnall HN, Kuppanda KE, O'Connell A, Hardy TA, Reddel SW, Barnett MH. Tablet-based screening improves continence management in multiple sclerosis. Ann Clin Transl Neurol. 2015 Jun;2(6):679-87. doi: 10.1002/acn3.205. Epub 2015 May 1.

  PMID: 26125042 BACKGROUND

• Ritvo P, Fischer J, Miller D, et al. Multiple sclerosis quality of life inventory: a user's manual. National Multiple Sclerosis Society: New York, United States of America, 1997. p. 1-35.

  BACKGROUND

• Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985 Sep;10(3):141-6.

  PMID: 4053261 BACKGROUND

• Amireault S, Godin G. The Godin-Shephard leisure-time physical activity questionnaire: validity evidence supporting its use for classifying healthy adults into active and insufficiently active categories. Percept Mot Skills. 2015 Apr;120(2):604-22. doi: 10.2466/03.27.PMS.120v19x7. Epub 2015 Mar 23.

  PMID: 25799030 BACKGROUND

• Godin G. The Godin-Shephard Leisure-Time Physical Activity Questionnaire. Health Fit J Cananda. 2011;4(1):18-22.

  BACKGROUND

• Jacobs DR Jr, Ainsworth BE, Hartman TJ, Leon AS. A simultaneous evaluation of 10 commonly used physical activity questionnaires. Med Sci Sports Exerc. 1993 Jan;25(1):81-91. doi: 10.1249/00005768-199301000-00012.

  PMID: 8423759 BACKGROUND

• Motl RW, McAuley E. Physical activity and health-related quality of life over time in adults with multiple sclerosis. Rehabil Psychol. 2014 Nov;59(4):415-421. doi: 10.1037/a0037739. Epub 2014 Aug 25.

  PMID: 25150806 BACKGROUND

• Tu C, Benn EKT. RRApp, a robust randomization app, for clinical and translational research. J Clin Transl Sci. 2017 Dec;1(6):323-327. doi: 10.1017/cts.2017.310. Epub 2018 Feb 19.

  PMID: 29707253 BACKGROUND

MeSH Terms

Conditions

Multiple Sclerosis

Interventions

Yoga

Condition Hierarchy (Ancestors)

Demyelinating Autoimmune Diseases, CNS; Autoimmune Diseases of the Nervous System; Nervous System Diseases; Demyelinating Diseases; Autoimmune Diseases; Immune System Diseases

Intervention Hierarchy (Ancestors)

Mind-Body Therapies; Complementary Therapies; Therapeutics; Spiritual Therapies; Exercise Movement Techniques; Physical Therapy Modalities

Study Officials

• LaVerene Garner, DPT

  Winston Salem State University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Masking Details: Researchers and participants will not be blinded due to the nature of the intervention. Participants will know whether or not they are performing yoga or just receiving the control group intervention. Additionally, the PI is leading the intervention and will therefore know who is in the control vs the experimental. Investigators will attempt to blind clinicians and students completing pre and post intervention testing to who was in the control vs experimental, however, this may not be possible.
• Purpose: TREATMENT
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: PT, DPT; Visiting Clinical Assistant Professor;

Study Record Dates

• First Submitted: August 29, 2019
• First Posted: October 2, 2019
• Study Start: January 1, 2020
• Primary Completion: December 31, 2020
• Study Completion: December 31, 2020
• Last Updated: October 8, 2020

Record last verified: 2020-10

Data Sharing

• IPD Sharing: Will share
• Shared Documents: STUDY PROTOCOL, SAP, ICF
• Time Frame: Data will become available as collected and will be available through the conclusion of the study (potentially two years)
• Access Criteria: CITI training and IRB approval

Locations

US (1)