Piotr Bargiel , Norbert Czapla , Piotr Prowans , Daniel Kotrych , Paweł Ziętek , Dariusz Lusina , Paweł Łęgosz and Jan Petriczko

Thermography in the diagnosis of carpal tunnel syndrome

De Gruyter | Published online: January 27, 2021

Abstract

Introduction

Carpal tunnel syndrome (CTS) is a condition caused by chronic compression of the median nerve. The diagnosis is made mainly on the basis of clinical image and confirmed with electrodiagnostic testing (electromyography and nerve conduction study); however, these methods do not always aid in reaching the diagnosis of CTS. Moreover, they are invasive examinations, unpleasant for the patient and have to be performed by a qualified physician.

Aim

An evaluation of the usefulness of dynamic thermography in the diagnosis of CTS.

Material and methods

Forty patients were included in the study group. CTS was diagnosed based on clinical examination and electromyography. Forty healthy volunteers were included in the control group. Each of the participants was examined thrice with dynamic thermography. The patient’s hands were first cooled down and then a thermal camera measured their return to normal temperature. The measurement was repeated on the dorsal and volar aspects of each hand.

Results

The results obtained in the study show that a relief of symptoms after carpal tunnel release does not correlate with thermal image. Moreover, the return to normal hand temperature was faster in the control group. In patients with unilateral CTS, no difference was observed in thermographic images of the affected and healthy hands.

Conclusions

  1. Dynamic thermography can be useful in confirming CTS diagnosis.

  2. Dynamic thermography does not allow for objective assessment of patient’s complaints in the postoperative period.

  3. This method has currently limited clinical application. Due to complexity, it presently serves mainly scientific purposes.

1 Introduction

Carpal tunnel syndrome (CTS) is caused by chronic compression of the median nerve within the carpal tunnel. It is one of the most common peripheral mononeuropathies and the most common upper extremity neuropathy. Prevalence in general population is estimated at 0.1–1%. Risk factors include female gender and physical labour. Ten percent of patients have bilateral CTS [1,2,3].

The diagnosis is based on clinical image. Patients complain about nocturnal pain and paresthesia, which wake them up during the night and as the disease progresses, the symptoms increase in severity and begin to appear during the day. In advanced cases of CTS, motor disorders occur in the form of grip precision and strength loss. It makes handling small items (such as a pen or keys) more difficult. Thenar muscle atrophy is observed on examination. Due to decreased or abundant sensitivity, some patients develop wounds on fingertips from repetitive trauma [4,5,6,7].

Clinical presentation is not always obvious. In some cases, one group of symptoms can dominate for years. There are patients with considerable motor deficits without pain or sensitivity impairment and patients with positive electrophysiological results who, despite being in severe pain for years, have no muscle atrophy. This varying clinical image could be a result of overlap syndromes, multifocal compression on the median nerve (“double crush” syndrome) or substitution of lost median nerve functions by the ulnar nerve [8].

Electrodiagnostic testing plays a key role in diagnosing peripheral nerve disorders. Nerve conduction study (NCS) and electromyography (EMG) are mostly used when CTS is suspected. NCS directly measures the sensory and motor fibre conduction speed and amplitude, while with EMG it is possible to register and assess the function of thenar muscles (it has a lower sensitivity than NCS). Many clinicians consider these electrodiagnostic examinations as gold standard to diagnose CTS; however, it has been proved that approximately 18% of patients with clinical signs of median nerve compression have unimpaired nerve conduction in a classic NCS examination. Both NCS and EMG are invasive, unpleasant for the patient and a qualified physician must perform them. Moreover, according to many authors, they are not more sensitive than physical examination combined with medical history [8,9,10,11].

In search of new objective CTS diagnostic tests, researchers have recently taken interest in thermography.

Infrared thermography (IRT, IR) records a map of surface temperature of an examined area. Skin temperature indirectly reflects blood supply to a given area, which changes in response to various stimuli. Such measurements are easy, non-invasive, inexpensive and quick. These features make IRT a promising diagnostic test [12,13,14] (Tables 1 and 2).

Table 1

Skin temperature change in the study group (volar and dorsal side) on days −1, 1 and 14 after 3 min cold exposure expressed as area under the curve

Study group
No Dorsal aspect (d) Volar aspect (V)
Right (R) Left (L) Right (R) Left (L)
Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2]
1 5738.7954 7661.8318 5247.0674 5830.4074 7809.6044 5044.512 5733.7871 7407.9383 5139.8895 5588.9585 7955.766 4949.2093
2 6788.1167 6406.5961 5278.8475 6001.192 6048.0365 5677.8629 6696.8626 6618.3152 6134.609 6148.8008 7393.307 6040.4161
3 7047.3592 6509.9462 6942.9268 6964.1448 6306.3424 6891.9942 7077.0337 6199.914 6981.5185 7094.2211 6912.317 6540.6793
4 7172.5313 7559.0131 7628.7504 7416.5034 7743.7833 7604.5627 7005.7044 7346.557 7493.6902 7381.5325 7581.901 7526.9028
5 7407.8042 7601.5353 7517.0499 7430.2092 7605.3407 7595.3287 7709.701 7397.9859 7515.4516 7735.8987 7873.257 7565.0939
6 6817.0816 7593.8763 7474.5757 6558.6345 7540.5374 7370.4258 6687.5851 7295.9813 6926.9493 6494.2285 7620.692 7109.7913
7 8015.8948 6642.3724 7418.5549 8067.7989 7265.3256 7310.884 7934.782 6723.329 7081.0221 7946.9858 7759.517 7324.1033
8 7309.7887 7367.0289 4256.9423 6955.7899 7163.2455 4254.8952 6534.5163 7515.998 4194.0041 6346.3395 7142.091 4337.0405
9 7582.8238 6414.475 6377.498 7258.309 6216.576 5503.479 6910.09 6295.712 5788.669 6437.497 7375.88 5323.079
10 7466.418 7371.716 6050.844 7289.279 6507.579 5578.934 6941.636 7108.365 5826.119 6324.852 7215.417 5412.285
11 5566.186 5214.194 7282.395 5348.346 4986.756 7250.772 5536.749 5125.916 7612.315 5254.351 6564.692 7540.743
12 7333.067 7260.516 7506.669 7447.416 7341.889 7426.07 7426.768 7736.378 7506.669 7626.45 6309.18 7552.422
13 5784.216 6162.626 7575.474 6053.251 5746.267 7581.58 6743.047 6050.695 7499.184 6991.285 5785.055 7293.785
14 7711.548 6727.103 7468.428 7621.656 6704.846 7495.8 7666.691 6510.624 7646.282 7675.845 7615.244 7687.339
15 6903.785 7140.782 7581.512 6908.295 7040.08 7675.327 7107.863 7051.307 7629.842 7255.583 6771.736 7769.634
16 7760.978 0 0 7660.777 0 0 7579.234 7522.356 0 7632.886 7931.145 0
17 7720.041 7547.857 7649.1 7807.966 7597.292 7653.915 7435.501 7735.052 7708.1 7581.559 7378.262 7799.344
18 6552.423 5099.829 0 6583.997 4957.659 0 5284.565 5811.949 0 5579.183 6486.184 0
19 7378.214 7450.177 6580.865 7493.246 7627.63 6927.553 6337.277 7625.306 6572.66 6579.345 7543.51 6909.17
20 6925.756 7307.599 7673.456 6658.792 6635.398 7319.403 7591.466 6981.113 7636.585 6018.125 7854.768 7572.801
21 7377.338 7467.43 7931.33 7212.892 7619.24 7897.262 6986.53 6553.641 7629.767 7159.964 7601.74 7608.069
22 6823.587 7226.326 7692.785 6554.609 7292.132 7522.476 7097.08 7210.87 7736.019 7088.723 7770.488 7575.838
23 7188.357 5547.25 8012.986 7049.089 5376.11 7894.202 7118.68 5604.277 7858.293 6936.609 7138.907 7633.78
24 7384.856 7384.335 8043.201 7368.208 7416.252 8101.438 7368.408 7385.482 8052.101 7433.914 7325.788 8068.624
25 7641.064 7615.568 8147.866 7619.311 8019.349 8167.685 7561.372 7561.845 8023.069 7609.731 7192.348 8051.5709
26 7363.349 0 7491.52 7365.141 0 7581.078 7217.851 0 7649.151 7358.705 6068.448 7719.987
27 7465.357 7229.305 7940.297 7385.472 7322.485 7896.825 7453.162 7255.292 7536.237 7450.363 6928.541 7611.418
28 7453.065 7723.253 7597.0091 7583.082 7777.943 7660.194 6325.129 7698.297 7341.56 6549.858 7325.788 7342.615
29 6189.559 7204.995 7194.602 6348.549 7094.84 7054.25 6312.377 7321.995 6186.51 6041.102 5812.128 5834.426
30 7292.017 7177.755 7637.219 7352.46 7318.195 7731.399 6794.774 7168.356 7498.795 6947.294 7592.575 7562.134
31 7536.452 0 6345.166 6345.166 0 6102.38 7163.624 0 6445.802 7217.876 6748.843 6327.314
32 7443.36 7578.313 7383.942 7383.942 7691.162 7571.457 7481.491 7562.951 7472.296 7558.933 7940.122 7614.151
33 7584.729 6402.215 6326.16 6326.16 6266.061 5480.812 6925.2831 6424.963 5771.308 6470.631 7479.213 5372.737
34 7245.426 7352.746 4117.947 4117.947 7099.679 4322.886 6658.887 7597.089 4210.107 6492.073 7073.213 4488.695
35 6734.632 5518.511 6959.144 6959.144 5773.442 6953.582 6343.529 5743.148 7357.987 6001.186 7445.154 7240.555
36 6926.741 7615.272 7182.663 7182.663 7598.465 7139.323 6628.539 7448.668 7266.991 7091.038 7361.571 7425.18
37 6928.644 7549.101 7618.502 7618.502 7602.188 7586.2975 7028.173 7303.756 7498.523 7421.219 6441.04 7516.028
38 6607.199 6165.755 6805.185 6805.185 6474.394 6896.919 5455.211 6185.663 6499.905 6386.031 7575.476 6100.129
39 5617.811 5752.141 6222.673 6222.673 6836.857 6986.948 5754.189 5461.753 5198.507 5922.529 7862.005 6047.83
40 5505.797 5750.37 5240.434 5240.434 6015.909 6184.999 5572.637 5892.825 5199.465 5368.412 7594.724 6065.676
Table 2

Skin temperature change in the control group (volar and dorsal side) on days −1, 1 and 14 after 3 min cold exposure expressed as area under the curve

Control group
No Dorsal aspect (d) Volar aspect (V)
Right (R) Left (L) Right (R) Left (L)
Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2] Day −1 [cm2] Day 1 [cm2] Day 14 [cm2]
1 7931.789 8018.725 7992.002 7944.69 8021.499 8001.998 7837.452 7958.452 7902.098 7818.496 7955.766 7880.987
2 7420.906 7807.555 7549.036 7157.381 7746.42 7730.55 6942.505 7507.791 7332.101 6824.457 7393.307 7540.394
3 7375.576 7242.062 7417.303 7275.891 7331.754 7442.08 7019.673 6717.26 7004.259 6846.933 6912.317 7107.129
4 7496.062 7470.305 7660.607 7506.423 7573.31 7646.501 7499.088 7363.305 7381.77 7420.631 7581.901 7322.57
5 7838.856 7801.766 7576.021 7928.603 7777.979 7605.85 7762.567 7867.767 7272.483 7799.8 7873.257 7269.62
6 7841.396 7797.629 7802.432 7831.478 7830.348 7830.986 7895.997 7592.659 7792.098 7955.076 7620.692 7823.987
7 7939.365 7956.175 8003.475 7902.297 7933.434 7974.1 8078.802 7840.773 7901.058 7968.235 7759.517 7858.535
8 7785.669 7395.189 5898.385 7814.308 7497.196 5924.191 7509.795 7032.656 5761.783 7491.527 7142.091 5779.267
9 7847.208 7481.591 6979.941 7851.236 7499.11 7029.309 7729.167 7280.531 6881.055 7716.017 7375.88 7043.586
10 8122.939 7690.557 7379.837 8006.076 7628.331 7241.683 7707.437 7308.749 7069.012 7691.005 7215.417 7027.306
11 5484.605 6107.246 5430.307 5578.629 6284.529 6148.846 5498.959 6392.72 6350.993 5658.332 6564.692 6441.04
12 7614.6 6932.045 6589.296 7349.413 6972.879 6887.417 7304.864 6614.023 6122.468 6625.497 6309.19 6307.162
13 5475.814 5996.919 5927.656 5434.092 6087.442 5353.154 5020.157 5820.822 5845.526 4909.604 5785.055 4855.228
14 7521.972 7581.084 7577.265 7556.966 7598.959 7548.5 7507.015 7598.077 7578.142 7461.083 7615.244 7592.575
15 7256.8412 7289.844 0 7198.52 7216.869 6171.461 6818.311 6876.332 6605.62 6775.314 6771.736 6455.032
16 7938.222 8006.154 0 7936.055 8003.07 0 7784.173 7977.427 0 7806.163 7931.145 0
17 7347.619 7810.582 7524.392 7047.287 7680.187 7691.494 6962.052 7474.044 7382.423 6835.164 7378.262 7476.944
18 5426.226 6037.146 5431.891 5520.76 6188.335 6262.346 5367.018 6289.378 6502.053 5541.145 6486.184 6518.376
19 7484.808 7475.43 7647.502 7493.637 7551.137 7526.288 7444.353 7392.796 7385.374 7386.396 7543.51 7359.638
20 7809.787 7750.991 7578.268 7884.112 7692.559 7567.222 7769.421 7822.063 7251.109 7747.183 7854.768 7287.472
21 7838.235 7819.318 7817.969 7838.25 7809.712 7774.923 7880.007 7587.374 7640.158 7659.061 7601.74 7714.518
22 7933.339 7914.865 8006.161 7916.831 7931.969 7957.458 8106.917 7829.728 7907.318 7986.147 7770.488 7871.523
23 7791.83 7408.545 8536.373 7808.404 7457.339 5828.149 7520.686 7102.784 5671.876 7466.99 7138.907 5686.76
24 7836.506 7447.504 6963.893 7791.804 7434.288 6945.826 7718.714 7251.486 6889.445 7733.469 7325.788 6995.476
25 8127.782 7681.88 7438.169 8095.436 7627.691 7347.806 7709.021 7287.42 7024.735 7681.524 7192.348 6954.057
26 7424.791 6589.296 6703.144 7033.306 6652.372 6710.664 6982.44 6296.018 6505.96 6307.162 6068.448 6200.716
27 7334 7250.992 7461.055 7421.676 7362.357 7411.68 7051.114 6795.498 7034.848 6856.861 6928.541 7088.462
28 7836.506 7447.504 6963.893 7791.804 7434.288 6945.826 7718.714 7251.486 6889.445 7733.469 7325.788 6995.476
29 5452.463 5983.178 5907.96 5353.154 6054.229 5218.644 4904.129 5845.526 5649.476 4869.233 5812.128 5166.471
30 7542.093 4577.265 7552.235 7548.5 7567.339 7516.741 7557.708 .837 7560.877 7495.211 7592.575 7528.427
31 7290.9382 7252.433 6430.989 7153.462 7154.4 6097.115 6801.685 6807.516 6574.856 6748.019 6748.843 6446.622
32 7983.932 7998.098 7930.323 7789.432 8009.213 8013.3344 7839.432 7900.321 7889.423 7870.321 7940.122 7789.212
33 7400.433 7840.211 7398.321 7148.321 7534.432 7723.212 6930.213 7309.213 7430.21 6789.432 7479.213 7254.423
34 7349.234 7238.245 7381.23 7361.321 7382.234 6990.321 7092.543 6982.342 7150.543 6892.12 7073.213 7321.34
35 7564.423 7423.44 7790.21 7440.221 7543.133 7612.309 7545.234 7289.453 7432.432 7632.12 7445.154 7333.905
36 7203.645 7749.725 7626.76 7020.433 7614.456 7658.371 7014.062 7503.886 7374.112 6751.403 7361.571 7420.704
37 5430.307 6068.343 5415.025 5523.639 6148.846 6294.398 5415.601 6350.993 6472.183 5541.175 6441.04 6488.674
38 7516.488 7530.994 7674.995 7507.107 7589.853 7513.501 7444.353 7403.291 7425.145 7422.26 7572.476 7399.222
39 7804.203 7720.468 7577.005 7858.586 7680.731 7568.589 7803.775 7812.666 7276.477 7776.551 7862.005 7327.217
40 7817.696 7819.385 7817.696 7850.02 7776.581 7681.169 7894.325 7575.491 7727.383 7966.299 7594.724 7827.202

Few studies evaluating thermography in CTS have been published. Furthermore, no measurement standard is presently available [15].

2 Aim

An evaluation of the usefulness of dynamic thermography in the diagnosis of CTS.

3 Material and methods

3.1 Material

Out of 84 patients who underwent carpal tunnel release in our department in years 2014–2016, 40 were included in the study group – 32 females and 8 males aged 32 to 68 (mean age 54 years). Diagnosis was based on clinical examination and EMG. Symptoms had to present for a minimum of one year, mean duration was 21 months. Ten patients had bilateral CTS. Right hand was affected in 29 cases, left hand in 11 patients. Thirty-two patients were right-handed, 8 patients left-handed.

Control group consisted of 40 healthy volunteers: 25 women and 15 men aged 27 to 63, mean age was 49 years. The right hand was dominant in 34 people, the left hand in 6. No member of the control group complained on any hand, cervical or thoracic spine disorders.

3.2 Methods

Study protocol was approved by the Pomeranian Medical University Ethics Committee (KB-0012/94/13). Patients included in the study had no significant comorbidities. Smokers and patients with carpal release or carpal tunnel injections were excluded from the study. Each patient was examined with dynamic thermography thrice. First examination was performed one day prior to the surgery, second a day after surgery and the third one 2 weeks after surgery.

All measurements were taken in a room with a steady temperature of 22°C and 65% humidity. Patient’s hands were placed on a table 20 cm away from the camera and fan, which acted as a cooling device. Hands were cooled down for 20 s. A FLIR T335 camera was used to obtain thermal images after the fan was stopped. Measurements were sampled every 5 s for 3 min. The dorsal aspect was assessed first, then after re-cooling, the volar side. To analyse the thermographic images, FLIR Research IR programme was used. Temperature values were sampled from the fingertips (on the volar side) and nails (on the dorsal side) of fingers I-III. Capillary circulation efficiency was measured as area under curve in a graph that showed temperature change in time.

4 Results

Patients from the study group had undergone carpal tunnel release. At 24 h postoperatively, 37 patients reported spontaneous pain mitigation (which previously woke them up), while 3 patients did not report any improvement. At 14 days postoperatively, symptoms subsided in 39 patients, while one reported an exacerbation of pain.

During dynamic thermography, it was observed that after the cold stimulus had been withdrawn, temperature rose during the first 2 min and then stopped. Therefore, only data gathered during these first 2 min were included in the statistical analysis (Figure 1).

Figure 1 A comparison of temperature change between the affected (operated) hand in the study group and both hands of control group.

Figure 1

A comparison of temperature change between the affected (operated) hand in the study group and both hands of control group.

5 Discussion

In patients with median nerve compression, it appears natural that apart from motor and sensory fibre damage, autonomic nerve fibres can also be affected. Clinical examination and electrophysiological testing both measure the extent of motor and sensory function loss. Some patients, however, complain about symptoms resembling Raynaud’s phenomenon. Trophic changes to the skin are rare, although possible [16,17]. Literature data show that even as many as 50% of patients with CTS may suffer from sympathetic dysfunction [18].

In the study group, 75% of patients reported symptoms related to the sympathetic system: sweating, dryness, pallor, rubor, swelling or cyanosis. Literature reveals many papers where the extent of sympathetic system damage in CTS is evaluated by plethysmography, capillaroscopy or Doppler ultrasound. Another method is sympathetic skin response (SSR), where the electric potential of the skin varies depending on surface temperature, which reflects the activity of sweat glands controlled by the sympathetic nervous system [19,20,21,22,23,24].

While analysing the results, a number of questions had been posed.

First, does the thermographic image of a healthy hand (control group) differ from the image of an affected hand prior to the surgery?

There was a statistically significant difference in thermographic images of hands of patients from both groups. In CTS, blood flow is higher, because the return to original temperature occurs quicker. Based on this observation, it can be assumed that dynamic thermography can be used to determine if a patient is suffering from CTS. Similar conclusions were made by other authors. Papez and Palfy compared the results of static thermography with NCS in patients with CTS. Control group was examined first to create a thermographic model of a healthy hand and then, using an artificial neural network, this model was compared with a thermographic image of patients affected by CTS. The results of that study were statistically significant – authors concluded that thermography is a tool with high sensitivity and is useful in diagnosing severe cases of CTS. When patients with less exacerbated CTS were included into the study group, the sensitivity, however, was lowered. In our study, most patients were diagnosed with moderate CTS (stage II, according to NCS). Papez also observed during his study that the sensitivity of the examination was higher on the dorsal side of the hand. [25,26,27]. Similar conclusions were made by Zivcak et al. [28]. Some authors examined only the volar aspect of the hand [29,30,31]. In our study, both the volar and dorsal sides of the hand were evaluated, and the results show a significant difference in blood flow for both sides between the study and the control group.

Secondly, do thermographic images of the unaffected hand in CTS patients in three examinations (a day before the surgery, one day after the surgery and 14 days after the surgery) differ among each other? In unilateral CTS, thermographic images of the unaffected hands did not differ in consecutive examinations. Similarly, 3 examinations of control group volunteers did not show any differences. Such stable thermographic images confirm the reproducibility of the method.

Thirdly, does the relief of symptoms during the first day after surgical carpal tunnel release correlate with changes in thermographic images?

Immediate relief of nocturnal pain after carpal tunnel release is seen in most patients with CTS. In this study, a similar postoperative observation was made in nearly all patients. It did not, however, correlate with thermographic images captured in 24 hours and 14 days after the surgery. In literature, there is scarce information on changes in blood circulation in patients with CTS after surgical release. A similar study had been conducted by Z. Ming and J. Sivola in 2007. Static thermography had been used to evaluate capillary flow. The diagnosis of CTS was made purely on NCS, without taking the clinical image into consideration. The first thermographic image was captured prior to the surgery, the second 6 months after. In our study, carpal tunnel was diagnosed mainly on signs and symptoms with NCS results only to confirm the diagnosis. A lack of NCS result with a clear clinical image of CTS did not exclude a patient from the study. Ming et al. in their study showed that an improvement in circulation follows a carpal tunnel release within 6 months. Immediate relief of nocturnal symptoms is related to an increase of blood flow to the nerve itself, while full healing is achieved after 6 months due to reinnervation [29].

Lastly, does a thermal image of the affected and unaffected hand differ in the same patient with CTS?

A comparison of the affected and unaffected hand in the same patient with CTS did not reveal statistically significant differences in hand temperature. This may be a result of many overlapping factors. CTS is diagnosed with clinical image. NCS is an additional examination to confirm the already suspected diagnosis and to evaluate the extent of nerve damage. Healthy limbs in patients with CTS were described as those showing no clinical symptoms, not ones with a negative NCS result. Out of 40 study group patients, as few as 12 people had a bilateral NCS, and in that group, only 2 patients had CTS excluded. Literature data estimate the prevalence of bilateral CTS at 50%. Not all symptoms of early CTS could be noticed by a patient. Thus, it may be possible that among 23 healthy limbs, some may be in an early stage of the disease. Most researchers compared hands with confirmed CTS with healthy limbs from the control group. Few authors focused on looking upon both hands of the same patient. The majority assessed the temperature difference of two corresponding points on the volar and dorsal aspect and then compared the results to the control group [25,26,27,28].

6 Results

Our research shows that:

  1. Dynamic thermography can be useful in confirming CTS diagnosis.

  2. Dynamic thermography does not allow for objective assessment of patient’s complaints in the postoperative period.

  3. This method has currently limited clinical application. Due to complexity, it presently serves mainly scientific purposes.

    Conflict of interest: The authors declare no conflicts of interest. This study has not been presented previously. This study was financed by authors’ own resources

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Received: 2018-12-17
Revised: 2020-09-19
Accepted: 2020-10-07
Published Online: 2021-01-27

© 2021 Piotr Bargiel et al., published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.