Pes Equinus Varus (Striker Foot) Why this Occur by Adults!

Research Article

Pes Equinus Varus (Striker Foot) Why this Occur by Adults!

  • Jan Van De Rakt 1*
  • Steve McCarthy-Grunwald 2

*Corresponding Author: Jan Van De Rakt, Physical Therapist NDT teacher IBITA, Course Leader and teacher on the Dutch Institute for Allied Health Sciences. Nursing Home “Waelwick” in Ewijk the Netherlands.

Citation: Jan Van de Rakt, Steve McCarthy-Grunwald, (2024), Pes Equinus Varus (Striker Foot) Why this Occur by Adults! J. General Medicine and Clinical Practice, 7(7); DOI:10.31579/2639-4162/161

Copyright: © 2024, Jan Van De Rakt. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 13 March 2024 | Accepted: 22 March 2024 | Published: 01 April 2024

Keywords: pes equinus varus;plantar flexion; diagonals; striker-foot

Abstract

Introduction.                                                                                                                                                                     

Till today the “fairy tale” exist, that the pes equinus varus (striker Foot) can occur through the pressure of blankets on the feet of the person that lying is in bed, often with the remark that the blankets were put in, so tight that the feet were not movable anymore. This is an “insult” for all the nurses and let see that many people working in the care, see not what people must do, lying on their back in bed when the try to move or lift even one leg. That fact and the effects of an neurological disease are the most common reason for the arise of the striker foot 

Method.           

In the literature search, we search for reasons for the occurrence and regrettable the remarks about blankets still exist, but other reasons are also mention so that an better view can occur. Still the heaviness of lifting an leg, lying on your back is still not an part of this thinking and thus also not an part of the treatment of the striker foot. 

Results.                                                                                                                                                                           

The treatment is still not effective as we see, what the reasons are for the occurrences and often (to) late in the treatment program and secondary “care” on the pressure score prevention. The tone and the pathological synergy that people need to stabilize there leg, to move the other will end with plantar flexion and the only treatment option is, to take care of an relaxation that place the foot back in the right position. 

Conclusion/Discussion. 

Pes equinus varus by adults isn’t the debt of blankets but is the normal reaction of people with an neurological disease to search stability to move on his own. Most striker foot we see by that group of patients but by others we see it sometime also occur and then it is important to search for the cause.  By chronic stroke survivors that wear a certain AFO is an clear mobility loss of the ankle mobility present after an period. Pes equinus varus (striker foot).                                                                                                                                                                                                                                                                   

Introduction

Till today we read in all literature and books for people that studied medicine that the pes equinus varus can occur through a too long and heavy load of the blankets on the feet. [1,2, 3, 4] The citation of their list of causes is mentioned in the appendix 1 and 2 in which the finger is pointed to the nursing that they have put the blankets so tight that the feet are forced in an maximal plantar flexor and that should than be the cause of the occurrence of the pes equines varus (striker foot).                                                                                                                                        

It is time that we invest and think what the reason could be, that this deformation can occur and by who.

The most common cause has an direct relation with brain/ spinal cord damage [3,4,5,6,7,8,9] and. of course trauma/ dystrophic disorders that interfere with the muscle/ joint performance of the ankle. Then there is an disbalance between the plantar flexor and the dorsal flexor and is the dorsal flexor group not capable to hold the movement range of the foot optimal. 

The second observation is that this striker foot occur mostly by people that lies in bed] [1.2.3.4.5.6]. The prevalence of this phenomena in sitting or even standing attitude is clear lesser, thus is it important to invest what the impact is of lying in bed and the performance to hold the movement range in the ankle.

Third item is that some stroke patients seem to develop an striker foot in the chronic stage [5,10], despite the are capable to walk and receive treatment, but often an operation or Botox treatment is necessary to restore the mobility of the ankle. Further is the mobility of the ankle an item, that can fixate the ankle in an position that looks like an striker foot but now hold the joint in an fixed position with consequences and as last item the influence of medicines as par example statins [28.29.30].

But the most common cause is an neurological disease (see appendix 3,4,5) in combination with lying in bed. This combination is for the development of the striker foot the clearest cause and then is the severity of the neurological disease an factor that makes this combination possible. 

Method

Literature and website- search as mentioned in the appendix give the clear overview what the cause could be of the developmental of an striker foot by adults. And regrettable the blankets are still mentioned but the most common cause has an direct relation with loss of the possibility of the active movement in the ankle and then especially of the dorsal flexion.

Almost everyone see an direct relation by neurological -and spinal cord diseases and of course are trauma of the ankle joint, nerve damage or/ and dystrophic disturbances certainly also causes. But the relation between lying in bed and the developmental of an striker foot is most clear for neurological diseases than the relation between distal trauma and lying in bed -supine. This relationship is invested but till today nobody see the connection and change the treatment. Because the differences what to do by people that may be develop an striker foot is so different and regrettable can am wrong treatment lead to an development of an striker foot. Par example by people with dementia is the prevention often more focused on the prevention of decubitus and so will there the striker foot develop fast.

Relation lying supine - neurological disease and developmental of an pes equinus varus. 

Lying on your back in bed looks like the easy attitude that exist, but to alter this attitude we need an lot of muscle pattern to do this. [11,12] And what is “easy”, when you are young and healthy but often are people older or disable. To move in the bed most people will lift the buttocks without bending the knee, but this (bending knee) we see occur by elderly and that is an sign that movements in bed on the back are getting difficult. When there is an neurological disease this movement will be much more difficult and that has an great influence. [13,14,15,16]. 

Par example what we need to lift one leg from the bed-surface in the air [17.18]!  Before the lift start the other leg will push into the bed- surface and create an anchor for the other leg to go in the air. By people with neurological disease there will be an decrease of selectivity and an increase of tone and an pathological synergy, that must be use to lift the other leg in the air. People after an stroke will search what they can, that start from the first moment that this person realize what he has experienced. That means that he will search what he can move and that will be his not-affected leg and when the affected leg give no stability than will this lead to an turn or even an fall out bed. But this is an example in which the affected leg cannot give the anchor (the affected leg has no or little tone) but what we most often see, is that there is an anchor but with less selectivity.

We see than that people use the pathological extension movement synergy and that means that the hip isn’t capable to control the rotations but use the adductor muscles to make enough extension and that gives an extension synergy with adduction /end rotation/extension in the hip and knee and an plantar flexion with inversion in the foot.

Compare an normal movement with that of lesser selectivity:

  • Control of the extension through the m. gluteus maximum and that is translate through an push of the heel in the matrass and of course the control of the rotations.
  • We see no plantar flexion at all because the push is done through the extensor of the hip. The greatest pressure is under the heel. When this selectivity is lesser than we feel no or lesser gluteal activity, an lesser pressure under the heel and an plantar flexion. Photo 1 give an image of an lift with load and an normal reaction and photo 2 and three give an image when the selectivity is decreasing.                                                                                                                                                                    

                                                                                                                         Photo 1                                         Photo 2   

Photo 1. Lift of one leg with load and before that lift, the push of the heel is there and is adapting and controlling during the whole movement. See the rotation in the foot and the straight pressure on the heel. 

Photo 2 let us see when the selectivity is lesser and now, we see no good control about the rotation and clear the plantar flexion in the foot. 

Photo 3 give an picture when the selectivity is poor that even the foot isn’t on the bed anymore and the foot stand in an maximal plantar flexion.

Thus, by all neurological diseases with decreasing selectivity will lifting an leg give an plantar flexion and that can lead to an higher tone in the calf muscles and when that is “long” present [18], will this give changes in the muscles/ other tissues [18,19] in and around the muscle and the striker foot – pes equinus varus is there. 

Treatment must therefore focus on the duration of the plantar activation.   

Because when this is an push and the foot is than relaxing in an good position that can this shortening in the muscles (sarcomeres) and other tissues not have such an impact but that asked for good measurement, to realize this demand [19.20.24.33].                                                                                       

Here is the great problem to prevent the striker foot when people lie in bed on their back, because when they move an leg, the other will push against the striker-foot prevention and after that movement the tone must decrease in the calf muscle and the foot go back in the right position, almost in 0-5 degree dorsal flexion. And here is the problem, because that means that this approach asked for an pillow, orthosis even an striker foot device that take care that after the push the foot is going back in the correct position and that the tone decrease. 

Photo 4. One of the many devices that are there to prevent the stroker foot but is this the right one? And is the danger to develop an pressure score not too great. This device pull the foot back after the push but is the control and stability enough? Every person asked for an individual measurement and approach! 

                                                                                              Photo 5. Look like an solution but is this an good one ?                                                                                  

Because when one foot move what’s happen with the other! Is the surface firm enough and stable to give stability that place the foot in the right position back and decrease the tone?   This asked for control, measurements and for regular inspection on pressure score. The device on photo 5 is also used by people with an neurological degenerative disease as Parkinson, dementia in the late stage but also people that lies in an vegetative stage with an high tone [20,21].                                                                                                                                                       

This people often cannot move, but the amount of pressure that they produce in the legs is often very high and the feet lies in an plantar /inversion position often for long hours. The orthosis that creates more stability, can also be transformed in an push-away orthosis and that create movement and tone decrease in the whole body and thus also in the feet. [22,23]                         

The orthosis create stability that has influence on the tone but when we create extra movements than will this shortening further decrease and also the change on the occurrence of the pes equinus varus. The treatment rhythmic when to go over to movement-treatment, is thus very important and must also be controlled on the risk of skin pressure.

Photo 6.  An person with the Parkinson disease in an stage that he has great difficulty to move in supine attitude and we see that his feet stand both in an plantar flexion position. Every time he lift his foot, the other will go in an increase plantar flexion to create an anchor for the leg in the air. In the morning his tone is so high that he cannot move on his own. We have given him an firm cushion under his feet on such an way that he is stimulated to push it away and that decrease the tone in his body. He started with increase pushing plantar flexion but this lowering the tone his whole body. After an 20 minutes his mobility in the ankles where almost normal and he was able to stand on his feet. That means that the striker foot was prevented but also that the start of the day was possible through and decrease of tone (rigidity) in his whole body. Thus, the prevention of the striker foot asked for an intervention that give an pressure against the foot sole. But which pressure/hardness is by every person different! 

Photo 7. Often is this the end-position that what we see on photo 7 and that means that also sitting in an chair isn’t nice. That amount of tension in the foot is an task for everyone to prevent it go the other way!!

The prevention of the striker foot is also an job, that is for every striker foot different, but the fact that people with less selectivity through an neurological disease must use an extension synergy is the reason that there the striker foot occur. Only an good support/pressure can catch the plantar flexion and bring the foot back in the good position and that support must be use for this person for prevention of his striker foot.

Photo 8. An example that will create pes equinus varus – striker foot, because the stability must be achieve through an plantar flexion as part of the extension of one or two legs to create stability. This is example, what fear for decubitus can do and that this will create that nasty foot that we see in photo 7. The prevention of pressure score, in this case the heel area and the striker foot are both important priority to hold the quality of life as high as possible. And that are both elements that are important for the quality of life. And both together is possible !

An solution that take care for the heel area and support the foot sole together is show in picture 1 

Picture 1. Prevention of an striker foot and also take care for to many pressure on the heel area.  In this example we treated an person after an severe stroke. His affected leg was hypo tone and need in the beginning support to prevent extreme exorotation in the hip joint [19.32]. The leg was unstable an lay in that extreme exhortation against the bed fence and that create an huge tone increasement in the knee flexors.                                                       

There wasn’t an stability for the not-affected leg and this create movement through the bed that harm the skin of both legs. To create stability this orthosis was make to prevent the extreme stretch on muscle and control the hip joint muscles and decrease the tone in the hamstrings of the affected leg, but also create an stability in which he now could move his not-affected leg better. Now occur an extension in the affected leg with plantar flexion in the ankle but the effect was tripart:                                                                                                                                                                                                                   1. The tone in the flexors of the knee goes down and

2. The pull of the foot sole was now followed with an relaxation and place the foot in good position and                                                                                          3. The skin was not so harmed. of course, asked this for an good multidisciplinary team that take care through the night with all the changes of positions that are necessary to prevent further damages.

Treatment in supine position in bed. 

Treatment asked thus for an whole approach with the possibility to change the orthosis from stability support to an push-away orthosis. Because that will create movement and thus a tone decrease and ankle movements, but as in picture 1, it stabilize an person after an stroke and makes movement with his not-affected leg/side better possible, sometimes even possible. 

Relation walking AFO (Ankle Foot Orthosis) - neurological disease and developmental of an pes equines varus. 

The striker foot developmental can also be speeded up though an walking aid that the foot hold in the same position. The increase tone and the loss of selectivity will also her take care for an situation that the tone in the calf muscle is high and that the plantar flexion is present through more than 12 hours on an day [18, 26].

By people with an neurological disease is always important to test what the tension is in the calf muscles, because investigation has showed that sometimes the tone place the talus too far in the malleolus cave and that this give the immobilization. [24,25]                             

Thus, control always this.Further it is important to control people on the side-effects of statins, because the reactions by some people on muscle and foot clearances is still not clear. [27.28,29,30] 

                                                                                                               Photo 9                             Photo 10  

Photo 9,10 and 11. The foot on photo 9 stand in inversion and plantar flexion and is so very difficult to get load on it and walk, therefore there are AFO to set the foot stable in the shoe and make walking stable and better possible. But the two types of AFO that are presented on photo 10 and 11 will give an stable situation but no movement to hold the length of the sarcomeres and the not-contractile elements of the muscle on the right length[31]. This AFO is often wear for an great part of the day and that can therefore create an shorten amount of sarcomeres and an reversible restriction [19] that will lead to an striker foot- pes equinus varus that will inhibit the possibilities of the walking pattern in later stages and create than problems. 

Photo 12.  An example of an AFO that will take care of the length of the calf muscle through the possibility of an hinge that allow the person to walk with great step length and so stretch the calf muscle and the not-contractile elements and this is important for the walking pattern but also to prevent an striker foot on an later stage that than must be treated with redressing casting or even an operation of the Achilles tendon.

Conclusion and Discussion 

The assumption that till today still exist that lying in bed on your back with the blankets on your feet can lead to the arise of the pes equinus varus- striker foot – is nonsense and it is on the time that the nurses were not identified as the element that this striker foot arise. All team members must be aware what the cause is, of the reason that the system need so much tension in the calf muscle and that is the need to move and that this movement asked for an stable anchor. Certainly, neurological diseases must use an extension synergy to create that stability and then is there an plantar flexion and when that is permanent present than will this lead to an shortening in the muscle and tissues around the muscle and we have an striker foot. Thus, to prevent this, there must be search for an possibility that the push can be reversed so that the length stay optimal.  Lifting one leg asked for an action on the other side with an extension synergy after an brain damage but also lying on your back asked for an perception of stability and when the damaged brain this perception not find will it create his own stability with all possibilities that this brain has. 

This we see by people with severe neurological damage, that will also give an striker foot but also an increase risk on pressure scores through the huge amount of tension. The simple action to create on certain spots no skin-contact can lead to an decreasing of the stability and thus more tone and more pressure on the skin elsewhere.

Thus, both elements are important because they benefit both when the tone is lower. The element of the striker foot in the later/chronic stage asked for further investigation why exactly this occurs. But the element, that no movement is allow in the ankle is by some AFO’s clear and we know what the reaction is in the sarcomeres and other not-contractile tissues can be when no movement occur. The treatment that many years is prescribe -stretching- is mostly ineffective [33,34] and will never be able to hold the length optimal thus must the treatment be change so that this is be effective and the base must be movement in the ankle but always with control of the foot position so that “easy” walking is possible.

Appendix 1. Mens en Gezondheid. https://mens-en-gezondheid.infonu.nl/aandoeningen/160572-spitsvoet-of... Spitsvoet of pes equinus, oorzaak en behandeling  

Citation;  Oorzaken Een spastische verlamming kan ook een spitsvoet veroorzaken. Een spastische verlamming kenmerkt zich door wel kracht in de spieren te hebben, maar hier geen controle over te hebben. Er ontstaan onwillekeurige bewegingen en trillingen van de ledematen. Oorzaak voor een spastische verlamming kan aangeboren zijn, maar kan ook op latere leeftijd ontstaan zijn door schade aan de hersenen of de zenuwen. Langdurige bedrust is weer een andere veroorzaker. Hierbij kan de verpleging soms tekort schieten. Het gevolg is dat dat pezen of spieren na verloop van tijd verkorten. Maar ook kan er een te grote werking aan de spieren of pezen ontstaan. Dit zien we wanneer de patiënt op de rug ligt en de voeten gestrekt houdt. De dekens drukken de voet als het ware omlaag waardoor deze stand aan blijft houden. Een overmatige aanspanning van de spieren of de pezen zien we bij bepaalde spierziekten. De kuitspier raakt dan teveel gespannen en er ontstaat een spitsvoet. Een verkorte achillespees kan ook de veroorzaker zijn. Kinderen die veel op hun tenen lopen kunnen later ook last krijgen van een spitsvoet. Dit komt omdat hun voet deze houding aanneemt door verkorting van de achillespees. Een spitsvoet kan op iedere leeftijd ontstaan. Ook bij Multiple Sclerose (MS) zien we vaker een spitsvoet optreden, evenals een holvoet. De oorzaak van MS in onbekend, het afweersysteem zou hier een mogelijke rol in spelen. Over het algemeen kenmerkt MS zich door klachten met het lopen, het zien en het voelen. Een spitsvoet komt helaas vaker voor bij MS.

Appendix 2.  OnmedaGeverifieerdhttps://www.onmeda.de/krankheiten/spitzfuss-id200621Spitzfuß: Ursachen, Behandlung und OP bei Pes equinus - Onmeda  

Citation; Zerebrale Kinderlähmung (infantile Zerebralparese, spastische Lähmung, spastisch = mit erhöhter der Muskelspannung verbunden): tritt durch ein Trauma während der Geburt auf und beinhaltet als häufigste Fehlbildung den Spitzfuß. Störungen des Nervensystems (neurologische Störungen): lähmend (paralytisch), zum Beispiel bei Halbseitenlähmung nach einem Schlaganfall oder verkrampft (spastisch), wie beispielsweise bei der Friedreich-Krankheit oder Myelodysplasie. Krankheiten, die den gesamten Organismus betreffen (sog. Systemerkrankungen): beispielsweise Bluterkrankheit (Hämophilie), bei der Einblutungen in die Wadenmuskulatur die Beschwerden auslösen. Störungen nach Verletzungen (posttraumatische Störungen): Verletzungen des Unterschenkels im Bereich des Sprunggelenks oder des ganzen Fußes, die zu einer verkürzten Achillessehne führen. Mechanische Ursachen: zum Beispiel längere Bettlägerigkeit, bei welcher der Fuß nicht abgestützt ist, oder Verbände, die den Fuß längere Zeit in Spitzfußstellung fixieren

Appendix 3.  Physiopediahttps://www.physio-pedia.com/Equinus_defo…Equinus Deformity-Physiopedia                                                                                       Citation: Equinus is frequently caused by tightness in the calf muscles (the soleus and/or gastrocnemius muscles) or the Achilles tendon. Some people may have this feature congenitally (existing at birth) or inherited it. Others develop this tightness as a result of wearing high-heeled shoes frequently, being in a cast or using crutches. Other contributing factors include diabetes or having a shorter leg than other. The patient may develop equinus if a bone or bone fragment restricts movement of the ankle (for instance, after an ankle injury). Rarely, calf muscular spasms can induce equinus and may be a symptom of an underlying neurologic condition. 

Appendix 4

Maynou C, Szymanski C, Thiounn A. The adult cavus foot. EFORT Open Rev. 2017 May 11;2(5):221-229. doi: 10.1302/2058-5241.2.160077. PMID: 28630759; PMCID: PMC5467681. Citation: However, in recent years, a mild variation of the cavovarus deformity has been increasingly observed to exist without an identifiable underlying deficit. In our experience, this primary pes cavus (idiopathic) is diagnosed by elimination in more than half the cases and most authors believe that it is the consequence of a latent neurological disorder. Thus, neurological disorders must be looked for in the family history and clinical and electrophysiologica evaluation of the patient is necessary to eliminate any very subtle neurological lesion.

Appendix 5.                        

Lawrence SJ, Botte MJ. Management of the adult, spastic, equinovarus foot deformity. Foot Ankle Int. 1994 Jun;15(6):340-6. doi: 10.1177/107110079401500610. PMID: 8075766.Citation; Management of the persistent, acquired, neurogenic equinovarus foot may be a confounding rehabilitative dilemma. Victims of cerebrovascular accidents and traumatic brain injury commonly develop this neurogenic deformity. The plantarflexed and inverted foot position results from an imbalance of forces about the hindfoot due to exaggerated muscle tone and hyperactive stretch reflexes. Significant functional impairment may ensue if a plantigrade foot position cannot be achieved and maintained.

References

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Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

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S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann