Loading

Journal of Sleep Medicine and Disorders

Effects of Hypoglossal Nerve Stimulation on Tongue Strength and Endurance: Prospective Study

Research Article | Open Access

  • 1. Departement of Pneumology, Cliniques universitaires Saint-Luc, University of catholique de Louvain, Belgium
  • 2. Departement of Pneumology, Cliniques universitaires Saint-Luc, University of catholique de Louvain, Belgium
  • 3. Department of Pneumology and Center for Sleep Medicine, Universitaires of Clinique Saint Luc, University Catholique de Louvain, Belgium
  • 4. Departement of Otholaryngology, Cliniques universitaires Saint-Luc, University of catholique de Louvain, Belgium
  • 5. Departement of Pneumology, Cliniques universitaires Saint-Luc, University of catholique de Louvain, Belgium
+ Show More - Show Less
Corresponding Authors
Corresponding author Gimbada Benny Mwenge, Department of Pneumology and Center for Sleep Medicine, Universitaires of Clinique Saint Luc, AV Hippocrate 10, 1200 Brussels, Belgium
Abstract

Background:

Neuromuscular changes in patients with OSA might occur when treated with the application of unilateral THN.

Objectives:

Our aim was to assess whether nightly long-term stimulation of the hypoglossal nerve (N. XII) or CPAP treatment could modify tongue strength and/or endurance and whether there is a difference in tongue strength and/or endurance between OSA patients compared to an age and sex-matched healthy control group.

Materials and methods:

We prospectively measured tongue strength and/or endurance by The Iowa Oral Performance Instrument in OSA patients previous to any treatment and after 3 months of neurostimulation. We collected data of 28 male OSA patients (including 9 subjects treated with neurostimulation, and 19 subjects treated with CPAP) and 20 healthy controls. In the CPAP and healthy control groups, patients were divided each time into 2 subgroups according to their BMI.

Results:

We did not find any influence of nightly stimulation of the hypoglossal nerve or of CPAP on tongue strength and endurance. We observed no influence of the BMI on tongue strength and endurance; obesity doesn’t play a negative role in muscle capacity.

Conclusion:

Although it can be theorized that a lack of supportive strength in the pharyngeal musculature is strongly contributive to the pathophysiology of OSAS, these difference could not be measured in awake patients.

Keywords

Tongue strength and endurance, OSA, Iopi, Neurostimulatio 

citation

Tuyls S, Smetcoren1 C, Desuter G, Rodenstein D, Mwenge GB. (2023) Effects of Hypoglossal Nerve Stimulation on Tongue Strength and Endurance: Prospective Study. J Sleep Med Disord 8(1): 1129.

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of respiratory arrest despite continuous breathing efforts. This condition occurs during sleep and is mainly due to obstruction of the upper respiratory tract with a decrease in oropharyngeal neuromuscular activity in the face of persisting negative inspiratory pressures [1]. Very recently, it was suggested that stimulating the hypoglossal nerve (N.XII) would reshape the tongue enough to enlarge and stiffen the oropharyngeal tract, eventually achieving complete or partial resolution of obstructive sleep apnea (OSA) [2]. The application of unilateral targeted hypoglossal neurostimulation (THN) in patients with untreated severe obstructive sleep apnea for a 12-month period led to clinically and statistically significant improvements in apneas and hypopneas falls in oxygen saturation and sleep fragmentation, i.e. the main pathophysiological events in OSAS. A residual effect after one year of hypoglossal nerve neurostimulation using the THN system was also found: the improvement obtained in the apnea/ hypopnea index (AHI), micro-arousal index (MAI) and oxygen desaturation index (ODI) remained unchanged on the first night without stimulation [3-10]. Mechanisms explaining these changes have been proposed, but there are few that have been clearly demonstrated in studies and so far they remain hypothetical and mainly based on our general knowledge of muscle physiology. Stimulation could influence the type of muscle fibers in tongue musculature, resulting in improvement in force or endurance for a given neural output. Another mechanism involved might be that continuous nocturnal stimulation modifies the control of the interaction between agonist and antagonist muscles within the tongue, facilitating the maintenance of a patent pharynx in sleep. This second mechanisms would induced little or no change in tongue strength and endurance.

However, little is known about the effects of chronic stimulation of the hypoglossal nerve (N.XII) on tongue musculature strength and endurance. To assess the extent of neuromuscular changes in patients with OSA treated with the application of unilateral THN, we compared patients with OSA versus healthy control subjects, measuring tongue strength and endurance before and after 3 months of treatment. To take into account the eventual effect on tongue musculature of an improvement in OSA per se, we also studied a group of patients treated with the classical therapy, i.e. continuous positive airway pressure (CPAP). As body weight could increase the volume of the tongue. The eventual influence of body weight was also considered.

MATERIALS AND METHODS

Study Design

Patients treated with unilateral hypoglossal stimulation participated in an open label, single center, single arm safety and efficacy study in patients with untreated moderate to severe OSA. The Belgian Federal Medicines and Medical Devices Agency (Agence Federale de Medicaments et Produits de Sante) and the Ethics Committee of the Université Catholique de Louvain approved respectively the device and protocol CEHF 2013/039.

2013/039.This study was performed according to “Helsinki’s declaration” and to 7th May 2004 Belgian law regarding scientific experimentations on human beings.

Endpoints

The primary endpoints were to assess whether nightly long-term stimulation of the hypoglossal nerve (N. XII) or CPAP treatment could modify tongue strength and/or endurance in OSA patients and whether there is a difference in tongue strength and/or endurance between OSA patients compared to an age and sex-matched healthy control group. The secondary endpoint was to assess, whether BMI influences tongue strength and/or endurance.

Patient Selection

The study includes male individuals between the age of 25 and 70 years old. The use of muscle relaxant drugs was an exclusion criterion for all patients. All subjects gave written consent before the start of the study.

Group I

This cohort included OSA patients treated with the application of unilateral THN (ImThera stimulator) [2]. The patients had either used CPAP at one point in the past and had stopped treatment or refused to use CPAP altogether.

Group II

The second cohort of OSA patients was treated with standard treatment (CPAP). We selected patients suffering from OSAS confirmed by polysomnography, who were eligible for CPAP treatment reimbursement according to the Belgian Social Security rules, which require an apnea-hypopnea index of at least 20 events per hour of sleep. The cohort was divided in two groups according the BMI: above 30 kg/km2 and below 30 kg/m2.

Group III

In this cohort only healthy individual without OSA were included. The cohort was divided in two groups according the BMI: above 30 kg/km2 and below 30 kg/m2.

Polysomnography

Full night polysomnography (PSG) included the recording of three channels of EEG, two EOG, one chin EMG channel and one lead ECG. Snoring was obtained from a microphone glued to the patient’s neck. Airflow was assessed with a nasal cannula for nasal flow, and with an oronasal thermocouple for oral flow and as a backup nasal signal. Two inductive uncalibrated elastic bands monitored thoracic and abdominal respiratory movements. Body position was estimated from a sensor placed above the sternum, and oxygen saturation and pulse rate were obtained from a finger sensor of a pulse oximeter. Periodic legs movements were computed from two piezoelectric sensors placed on the right and left ankles (Medatec BrainNet, Brussels, Belgium). The polysomnographies were analyzed by hand according to Rechtschaffen and Kales, with stages 3 and 4 nonREM sleep merged. Micro arousals were scored according to the American Academy of Sleep Medicine, and reported as the number of micro-arousals per hour of sleep or micro arousal index (MAI). Apneas and hypopneas were identified according to the American Academy of Sleep Medicine rules, with hypopneas defined as a >30% decrease in the flow signals lasting at least 10 seconds and inducing a >4% oxygen saturation fall or a micro arousal. The number of apneas and hypopneas per hour of sleep is given as the apnea-hypopnea index. The percentage of apneas and hypopneas in the supine position is also reported. The oxygen desaturation index (ODI) was defined as the number of falls in oxygen saturation >4% per hour of sleep.

Device for measurement of strength and endurance

The Iowa Oral Performance Instrument (IOPI; Model 2.1, IOPI Medical LLC, Carnation, WA) is a portable device that measures the amount of pressure exerted on a small air-filled bulb. Pressures (expressed in kPa) are obtained digitally on a LCD panel on the instrument. A series of LED lights representing percentages in 10% increments of a manually set pressure acts in combination with the build-in timer as a tool for measuring endurance. The IOPI has a high inter- and intra-individual reliability [11-15]. We remark that the instrument doesn’t allow assessing one half of the tongue but that it is designed to assess the strength of the tongue as a whole.

Measurement of strength and endurance

Tongue strength was performed 3 times. The highest pressure obtained across the three trials is considered as the participant’s Maximal Isometric Pressure (MIP).

Endurance measures were performed after the MIP measuring tasks and a resting period of 8 minutes was assured between the two series of measurements.

Anterior and posterior bulb positioning during strength and endurance measures: In this study both anterior and posterior tongue body were assessed.

Swallowing anterior pressure: considering the fact that MIP does not represents a swallowing–related physiological value but rather a maximal effort that is never performed during a regular swallow, anterior tongue pressure was also be recorded while swallowing a coffee spoon of viscosity standardized pudding.

In total 5 measures are taken into consideration: 1) MIP anterior or “MIPant” measured in kPa, 2) MIP posterior or “MIPpost” measured in kPa, 3) Swallowing anterior pressure or “Swalant” measured in kPa, 4) Endurance anterior or “Endant” measured in seconds, 5) Endurance posterior or “Endpost” measured in seconds (Figure 1).

AHI:apnea/hypopnea index; ODI:oxygen desaturation index; MIPant:maximal isometric pressure measured on the anterior part of the tongue;  MIPpost: maximal isometric pressure measured on the posterior part of the tongue; Endant: endurance measured on the anterior part of the tongue;  Endpost: endurance measured on the posterior part of the tongue.

Figure 1: AHI:apnea/hypopnea index; ODI:oxygen desaturation index; MIPant:maximal isometric pressure measured on the anterior part of the tongue; MIPpost: maximal isometric pressure measured on the posterior part of the tongue; Endant: endurance measured on the anterior part of the tongue; Endpost: endurance measured on the posterior part of the tongue.

These 5 measurements were acquired once for individuals in group III and once before treatment and once after 3 months of treatment for patients in group I and II.

Statistical analysis

Data are presented as mean ± SD. Statistical differences between the baseline and the follow-up visits were assessed using Wilcoxon test. All statistical analyses were performed using SPSS Statistics 23.

 

RESULTS

Patients

We collected data of 28 male OSA patients (including 9 subjects treated with neurostimulation, and 19 subjects treated with CPAP) and 20 healthy controls. In the CPAP and healthy control groups, patients were divided each time into 2 subgroups according to their BMI. Distribution of age and BMI is shown in [Table 1].

Main outcomes

In comparing OSA patients treated with CPAP or THN and healthy controls at baseline, we could not see any significant differences in tongue strength and endurance. The results are shown in [Table 1]. We observed a tendency towards higher values for tongue strength and endurance in the CPAP group, but this was not statistically significant. The data as presented above were comparable for the healthy controls and OSA patients with a BMI < 30 kg/m2. We observed no influence of the BMI on tongue strength and endurance. The differences between the two BMI groups were not statistically significant.

We did not find any influence of nightly stimulation of the hypoglossal nerve on tongue strength and endurance. The results are shown in [Tables 1,2]. We also could not find any influence of nighty stimulation of the hypoglossal nerve on tongue endurance.A comparison was also performed before and after the therapy and revealed no differences between the groups. The application of CPAP itself did not seem to have an influence on tongue strength and endurance. The results are shown in [Table 1,2].

DISCUSSION

New findings

The main goal of this study was to assess whether nightly stimulation of the hypoglossal nerve (N. XII) could modify tongue strength and/or endurance in OSA patients.DISCUSSION New findings The main goal of this study was to assess whether nightly stimulation of the hypoglossal nerve (N. XII) could modify tongue strength and/or endurance in OSA patients.

First, we have observed that anterior and posterior tongue strength and endurance between patients suffering from OSAS and an age and sex-matched healthy control group was not different. Although it can be theorized that a lack of supportive strength in the pharyngeal musculature is strongly contributive to the pathophysiology of OSAS, these difference could not be measured in awake patients.

Secondly, our findings seem to show that obesity doesn’t play a negative role in muscle capacity, since we have found a comparative strength and endurance despite BMI differences, and therefore the correlation between BMI and OSA is probably due to an increase in tongue volume and narrowing of the pharynx, rather than a weakening of the muscle strength and endurance. To our knowledge, the influence of obesity in tongue strength and endurance has never been described before. Previous studies have shown that there is increased tongue volume and deposition of fat at the base of tongue in patients with OSA compared to controls, implicating that increased tongue fat explains the relationship between obesity and obstructive sleep apnea [16-18].

Third, we observed that the application of unilateral targeted hypoglossal neurostimulation (N. XII) (THN) in patients with untreated OSA for a 3-month period did not lead to statistically significant changes in tongue strength and endurance. Neither anterior nor posterior parameters seemed to be influenced by the treatment. The question immediately rises on how this can be explained while previous studies [2], have showed the efficacity of the THN principle in the treatment of OSA. An explication can be found in the complex physiology of the pharyngeal apparatus. The tongue is a hydrostat, like an elephant trump, where the final result of muscle contraction depends on the coordinated action not of one but of all muscles acting together on the hydrostat [6]. The tonic stimulation implicit in the ImThera THN concept, may modify the neural pattern of stimulation of the whole of the tongue muscles, either by modifying the agonist-antagonist balance of forces, or by modifying the motor units that are activated, or even because the cortical areas dealing with tongue representation and activation may have modified their circuitry and functioning. Indeed, hypoglossal nerve dysfunction in obstructive sleep apnea was assessed in patients with OSA versus control subjects by measuring motor unit potential (MUP) on electromyography [4]. It has been observed that the MUPs of the patients with OSAS were longer in duration and had a larger sizeindex compared with control subjects and thus support previous data [18-21], and the hypothesis that indicate that neurogenic changes occur in patients with OSA. This said, they seem not to affect, in any way, the whole organ strength or endurance. The final result is that the tongue activation can now result in effective pharyngeal lumen re-opening, whereas this was not the case before stimulation. Improvement in AHI, MAI and ODI found after long-term stimulation might therefore be the result of all these contributing factors without increasing or decreasing tongue strength and endurance. The hypotheses presented above are speculative at this point, but have been shown toexist in animals or humans and underline that OSA has both an anatomic and neural component in its pathogenesis and that neural stimulation cannot only result in muscle hypertrophy, but can perhaps induce changes in muscular activation [7]. Although we did not find clear changes in the variables in patients treated with CPAP or chronical stimulation of the hypoglossal nerve, this does not mean that tongue strength and endurance can’t play an important role in the pathophysiology of OSAS. Because the dilator muscles of the upper airway play a critical role in maintaining an open airway during sleep, pharyngeal muscle training has been advocated by many researchers with exercisessuch as singing, didgeridoo and instrument playing and has been explored to treat OSA [8, 9].

Strengths of the study: A particular strength of this study is that it includes a comparison between a treatment that stimulates tongue musculature (i.e. THN), and another one that results in a decrease in tongue muscle’s tone (i.e. CPAP). This should have brought to light any difference in muscle consequences, had one existed. This study emphasizes the coexistence of multiple mechanisms existing in the pathogenesis of obstructive sleep apnea syndrome.

This study has several limitations. The study group is small and could explain why, for some endpoints, if a tendency was observed; it could not be statistically confirmed. We underline the need of performing these measurements in a large sized population to confirm our findings. The lack of female subjects poses a problem in extrapolating our findings to the general population. Finally, the decrease in the AHI and ODI was mild in the neurostimulated patients (although highly significant statistically, contrary to the tongue muscle parameters), which may in part explain the weakness of the change in the strength and endurance measures.

Clinical applicability of the study: IoPi enables simple and quick measurement of the tongue strength and endurance in patients with sleep apnea syndrome but is not applicable in neurostimulation treatment. This tool should be measured in oropharyngeal exercises where the whole tongue muscles are involved.

In conclusion, in this small study we could not find any influence of nightly stimulation of the hypoglossal nerve on tongue strength or endurance in awake patients. The long-term use of CPAP did not seem to modify these parameters either. In comparing OSA patients treated with CPAP and healthy controls, we could not find any significant differences at baseline in tongue strength and endurance. Finally, BMI seems to have no influence on tongue strength and endurance.

REFERENCES

1. Pham LV, Schwartz AR. The Pathogenesis of Obstructive Sleep Apnea. J Thorac Dis. 2015; 8: 1358-1372.

2. Mwenge GB, Rombaux P, Dury M, Lengee B, Rodenstein D. Targeted Hypoglossal Neurostimulation for Obstructive Sleep Apnoea: A 1-Year Pilot Study. Eur Respir J. 2013; 2: 360-367.

3. Rodenstein D, Rombaux Ph, Lengele B, Dury M, Mwenge GB. Residual Effect of THN Hypoglossal Stimulation in Obstructive Sleep Apnea: A Disease-Modifying Therapy. Am J Respir Crit Care Med. 2013; 11: 1276-1278.

4. Saboisky JP, Butler JE, Luu BL, Gandevia SC, David WS, Malhotra A, et al. Neurogenic Changes in the Upper Airway of Patients with Obstructive Sleep Apnea. Am J Respir Crit Care Med. 2012; 3: 322- 329.

5. Bergler W, Maleck W, Baker-Schreyer A, Ungemach J, Petroianu G, Hörmann K. Mallampati Score: Prediction of difficult intubation in otolaryngologic laser surgery by Mallampati Score. Anaesthesist. 1997; 5: 437-440.

6. Gilbert RJ, Napadow VJ, Gaige TA, Wedeen VJ. Anatomical Basis of Lingual Hydrostatic Deformation. J Exp Biol. 2007; 23: 4069-4082.

7. Duchateau J, Semmler, JG, Enoka RM. Training Adaptations in the Behavior of Human Motor Units. J Appl Physiol. 2006; 6: 1766-1775.

8. Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome. Am J Respir Crit Care Med. 2009; 179: 962-966.

9. Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O. Didgeridoo Playing as Alternative Treatment for Obstructive Sleep Apnoea Syndrome: Randomised Controlled Trial. BMJ. 2006; 332: 266-270.

10. Miki H, Hida W, Shindoh C, Kikuchi Y, Chonan T, Taguchi O, et al. Effects of Electrical Stimulation of the Genioglossus on Upper Airway Resistance in Anesthetized Dogs. Am Rev Respir Dis. 1989; 140: 1279-1284.

11. Guilleminault C, Powell N, Bowman B, Stoohs R. The Effect of Electrical Stimulation on Obstructive Sleep Apnea Syndrome. Chest. 1995; 107: 67-73.

12. Schwartz AR, Bennett ML, Smith PL, De Backer W, Hedner J, Boudewyns A, et al. Therapeutic electrical stimulation of the hypoglossal nerve in obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2001; 127: 1216-1223.

13. Eisele DW, Smith PL, Alam DS, Schwartz AR. Direct hypoglossal nerve stimulation in obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 1997; 123: 57-61.

14. Eastwood PR, Barnes M, Walsh JH, Maddison KJ, Hee G, Schwartz AR et al. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Sleep. 2011; 34: 1479-1486.

15. Adams V, Mathisen B, Baines S, Lazarus C, Callister R. A systematic review and meta-analysis of measurements of tongue and hand strength and endurance using the Iowa Oral Performance Instrument (IOPI). Dysphagia. 2013; 28: 350-369.

16. Kezirian EJ, Goding GS Jr, Malhotra A, O’Donoghue FJ, Zammit G, Wheatley JR et al. Hypoglossal nerve stimulation improves obstructive sleep apnea: 12-month outcomes. J Sleep Res. 2014; 23: 77-83.

17. Schwartz AR, Smith PL, Oliven A. Electrical stimulation of the hypoglossal nerve: a potential therapy. J Appl Physiol. 2014; 116: 337-344.

18. Mayer P, Dematteis M, Pepin JL, Wuyam B, Veale D, Vila A, et al. Peripheral neuropathy in sleep apnea: a tissue marker of the severity of nocturnal desaturation. Am J Respir Crit Care Med. 1999; 159: 213- 219.

19. Lindman R, Stal PS. Abnormal palatopharyngeal muscle morphology in sleep-disordered breathing. J Neurol Sci. 2002; 195: 11-23.

20. Boyd JH, Petrof BJ, Hamid Q, Fraser R, Kimoff RJ. Upper airway muscle inflammation and denervation changes in obstructive sleep apnea. Am J Respir Crit Care Med. 2004; 170: 541-546.

21. Kim AM, Keenan BT, Jackson N, Chan EL, Staley B, Poptani H, et al. Tongue fat and its relationship to obstructive sleep apnea. Sleep. 2014; 37: 1639-1648

Tuyls S, Smetcoren1 C, Desuter G, Rodenstein D, Mwenge GB. (2023) Effects of Hypoglossal Nerve Stimulation on Tongue Strength and Endurance: Prospective Study. J Sleep Med Disord 8(1): 1129.

Received : 26 Apr 2023
Accepted : 27 Jun 2023
Published : 27 Jun 2023
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X