Managing premenstrual syndrome through movement: Effects of clinical pilates on physical fitness, symptoms, and kinesiophobia: A randomised controlled trial

Authors

Abstract

Aim Premenstrual Syndrome (PMS) is a common condition affecting women’s physical and emotional health during the menstrual cycle. Although regular exercise has been shown to manage PMS, studies focusing on clinical Pilates remain limited. This study aimed to investigate the effects of a clinical Pilates- based exercise program on physical fitness, PMS symptoms, and kinesiophobia in women with PMS.
Materials and Methods Forty women with PMS were randomly assigned to either the experimental group or the control group. Both groups followed general wellness advice for 8 weeks, while the experimental group participated in supervised clinical Pilates sessions twice a week. Outcome measures included anthropometric assessments for body composition, the sit-and-reach test for flexibility, the 6-Minute Walk Test for functional capacity, McGill’s core endurance tests, Premenstrual Syndrome Scale (PMSS) for symptom severity, and Tampa Scale for Kinesiophobia (TSK). Outcome measures were assessed at baseline and after 8 weeks.
Results Statistically significant improvements were found only in the experimental group for body composition, functional capacity, core endurance, PMSS score, and kinesiophobia (p < 0.05). Flexibility improved in both groups, but the improvement was significantly greater in the experimental group (p<0.05).
Discussion Clinical Pilates appears to be an effective, safe, and adaptable non-pharmacological approach for managing PMS. It enhances both physical and psychological well-being, making it a valuable addition to personalized rehabilitation programs for women with PMS.

Keywords

Introduction

Premenstrual Syndrome (PMS) is a common condition in reproductive-age women, marked by physical, emotional, and behavioral symptoms during the luteal phase that subside with menstruation [1]. Symptoms such as fatigue, irritability, breast tenderness, bloating, and mood changes can impair daily life, relationships, and work performance [2]. With a global prevalence of nearly 48%, effective non-pharmacological strategies are needed [1].
Exercise is a promising approach, improving both physical and psychological aspects of PMS. Regular activity, particularly aerobic and resistance training, helps reduce pain, anxiety, and depression while enhancing quality of life [1]. Pilates has gained attention for combining strength, flexibility, and mindfulness, targeting core muscles, postural stability, and body awareness, with benefits for emotional regulation and stress tolerance [3]. PMS is also associated with reduced physical fitness and pain-related avoidance of activity, potentially fostering kinesiophobia—the fear of movement—that aggravates inactivity and diminishes quality of life. Despite its clinical relevance, the phenomenon of kinesiophobia in PMS has received scant research attention, and the paucity of evidence represents a critical gap to be addressed in future studies [4]. Clinical Pilates may counter this by improving functional capacity, muscular control, and movement confidence, with evidence showing benefits for menstrual pain and psychological well-being [3, 5].
Despite promising findings, few studies have examined the effects of clinical Pilates on physical fitness, PMS symptoms, and kinesiophobia. Therefore, this study aims to evaluate the impact of a clinical Pilates-based exercise program on these key health dimensions in women with PMS.

Materials and Methods

Study Design
This prospective randomized controlled trial included 40 women aged 18–40 years with a clinical diagnosis of PMS, recruited from a university hospital outpatient clinic between April and October 2024. Exclusion criteria were menopause or perimenopause, pregnancy, regular exercise (other than clinical Pilates) within the past year, or comorbid conditions affecting assessments.
Participants were randomly assigned to an experimental (EG; n=20) or control group (CG; n=20) using a computer- generated sequence prepared by an independent researcher, with allocation concealment ensured through sequentially numbered, opaque, sealed envelopes. All outcome assessments were performed by an assessor who was blinded to group allocation. All assessments were performed face-to-face by the same physiotherapist one week before menstruation and repeated after 8 weeks; the physiotherapist also supervised all exercise sessions. The CG received general education on PMS symptoms, physical activity, and wellness-oriented nutritional guidance [6]. In addition to this program, participants in the EG underwent a supervised clinical Pilates-based exercise intervention twice a week for eight weeks. The sessions were conducted by a physiotherapist certified in Pilates. The exercise protocol was developed by the researcher by current evidence-based guidelines [7].
Outcome Measures
Body composition: Waist and hip circumferences were measured with a non-elastic tape; waist-to-hip ratio was calculated [8]. Functional capacity: The 6-Minute Walk Test (6MWT) followed ATS guidelines, with distance recorded in meters. Participants were instructed to walk briskly at a self-selected pace—without running—for six minutes along a 30-meter level corridor [9].
Flexibility: Sit-and-reach test, where participants reached forward while seated with extended knees; the average of three trials was recorded in centimeters [10].
Core muscle endurance: Evaluated with McGill’s test battery (trunk flexion, lateral bridge, Biering-Sorensen, plank). Participants held each position isometrically, and the best duration from two trials was recorded in seconds [11].
Premenstrual Syndrome Scale: Assessed with the Premenstrual Syndrome Scale (PMSS), a 44-item questionnaire scored on a 5-point scale (range 44–220); higher scores reflect greater severity. It covers nine domains, including mood, anxiety, fatigue, irritability, appetite, sleep, and pain, and PMS is indicated when total or subscale scores exceed 50% of maximum [12].
Tampa scale for kinesiophobia: Assessed with the 17-item Tampa Scale for Kinesiophobia (TSK), scored on a 4-point scale (range 17–68); higher scores indicate greater fear of movement, with values above 37 reflecting high kinesiophobia [13].
Interventions
Both groups were provided with a structured wellness program developed in collaboration with a dietitian and physiotherapist. The program comprised relaxation-oriented breathing exercises, moderate physical activity such as brisk walking and yoga-based stretching, and nutritional recommendations emphasizing reduced caffeine and sugar intake alongside increased consumption of milk, water, and micronutrient-rich foods. These strategies were intended to promote physical health and psychological well-being, in line with evidence from previous research [6].
In addition to the general wellness recommendations provided to both groups, participants in the EG received a supervised clinical Pilates-based exercise program. The intervention lasted for 8 weeks and consisted of 16 face-to-face sessions (2 sessions per week), each lasting approximately 50 minutes. The program began immediately after the end of the participants’ menstrual cycle and was delivered by a physiotherapist certified in Pilates.
The researcher developed the exercise protocol based on current guidelines [7] and progressively tailored according to the participants’ fitness levels and needs. The program was implemented over eight weeks in four progressive phases. In Weeks 1–2 (mat-based phase), foundational exercises emphasized core control, spinal articulation, and lumbo-pelvic stabilization (e.g., Pelvic Curl, Chest Lift, Swimming). In Weeks 3–4, participants were introduced to reformer-based exercises targeting core activation and lower limb strengthening (e.g., Footwork, Frog, AB Openings). Weeks 5–6 focused on upper body and scapular stabilization, postural control, and coordination through reformer progressions (e.g., Modified Rowing, Side Splits, Up Stretch). Finally, Weeks 7–8 integrated advanced functional movements combining breath control, flexibility, and whole-body coordination (e.g., Hundred, Scooter, Shoulder Push). Each session began with education on Pilates principles (alignment, breathing, core engagement), followed by postural correction and neuromuscular control exercises targeting the lumbo-pelvic and cervico-thoracic regions. Exercise repetitions and complexity were progressively increased under supervision to ensure safety, adherence, and individualized progression.
Statistical Analysis And Sample Size
Statistical analyses were performed using SPSS v26. Normality was tested with the Shapiro–Wilk. Categorical variables were compared with Chi-square tests; within-group differences with Paired t-tests or Wilcoxon tests; and between-group differences with Independent t-tests or Mann–Whitney U tests, as appropriate. Significance was set at p < 0.05. Effect sizes (Cohen’s d) were calculated, with 0.2, 0.5, and 0.8 indicating small, medium, and large effects.
The sample size was calculated using G*Power 3.1 (Universität Kiel, Germany) based on PMSS outcomes from a previous Pilates study in women with PMS [14]. That study reported a large between-group effect size (Cohen’s d = -1.98). Assuming a similar effect, with 80% power and a 5% significance level, 12 participants per group were required. To account for an anticipated 20% dropout, 15 participants were included in each group.
Ethical Approval
This study was approved by the Ethics Committee of Istanbul Atlas University (Date: 2024-03-04, No: 03/25).

Results

Forty-five women with PMS were assessed for eligibility; a total of five were excluded for not meeting the inclusion criteria or refusing to participate. Twenty participants for each group were included in the study, and a total of 40 completed the study with no drop-outs (Figure 1). The demographic and clinical characteristics of the participants are shown in Table 1. No significant difference was found between the two groups’ demographic and clinical data. Tables 2 and 3 summarize the effects of a clinical Pilates-based exercise program on each outcome. Groups were similar in terms of baseline values. Flexibility significantly improved in both groups at the end of the eight weeks (p < 0.05). The improvement in flexibility was greater in the experimental group compared with the control group (p < 0.001). At the end of the eight weeks, only the experimental group showed significant improvements in waist and hip circumferences, waist-to-hip ratio, 6MWT distance, trunk and core endurance measures (trunk flexion, lateral bridge tests, Biering-Sorensen, and prone bridge), as well as reductions in depressive mood, anxiety, fatigue, irritability, depressive thoughts, pain, appetite and sleep disturbances, swelling, total PMS score, and kinesiophobia score (p < 0.05). Between-group effect sizes were large for prone bridge (d = 1.886), lateral bridge test (L) (d = 1.539), waist circumference (d = 1.417), kinesiophobia score (d = 1.393), sit-and-reach (d = 1.358), trunk flexion (d = 1.306), total PMS score (d = 1.288), irritability (d = 1.234), Modified Biering-Sorensen (d = 1.035), lateral bridge (R) (d = 0.977), hip circumference (d = 0.958), fatigue (d = 0.945), swelling (d = 0.939), pain (d = 0.880), anxiety (d = 0.825), and depressive thoughts (d = 0.816). Medium effect sizes were found for depressive mood (d = 0.785), sleep changes (d = 0.757), and 6MWT distance (d = 0.739). Waist-to-hip ratio demonstrated a small effect size (d = 0.491), indicating more modest yet meaningful between-group differences.

Discussion

This study aimed to evaluate the effects of a clinical Pilates program on physical fitness, PMS symptoms, and kinesiophobia in women with PMS. Significant improvements were found in the EG for body composition, functional capacity, core endurance, PMSS, and kinesiophobia, while flexibility improved in both groups, with greater gains in the EG.
Body composition is an important factor in PMS, with hormonal and neurochemical changes contributing to increased risk of overweight and abdominal fat accumulation [15]. As abdominal adiposity, reflected by increased waist circumference and waist- to-hip ratio, is strongly linked to heightened cardiovascular and metabolic risk, addressing these parameters is critical for both symptom management and long-term health outcomes [16]. These findings suggest that PMS is not merely a psychological or hormonal condition but may also encompass significant metabolic components. In this context, exercise interventions have garnered increasing attention. Although aerobic training is widely accepted as effective for improving body composition, Pilates-based exercise programs have also demonstrated promising outcomes [17]. Although some studies have reported no significant effects of Pilates on body composition, often due to differences in training frequency, duration, or intensity, our study demonstrated significant reductions in waist and hip circumferences and waist-to-hip ratio only in the EG. These improvements may stem from Pilates’ focus on core activation, dynamic stabilization, and controlled breathing, which can influence abdominal fat distribution. Overall, the results highlight the potential of Pilates as a targeted approach to improve body composition and reduce cardiovascular risk in women with PMS.
Physical fitness is a multidimensional concept that includes cardiovascular endurance, muscular strength, flexibility, and motor control, and plays an essential role in the management of PMS. Hormonal fluctuations throughout the menstrual cycle can negatively affect these parameters, leading to fatigue, musculoskeletal pain, and decreased physical activity, which in turn diminishes functional capacity and overall quality of life in women with PMS [1]. Functional capacity reflects the ability to perform daily tasks efficiently, and its impairment is associated with difficulties in women experiencing PMS symptoms [5]. Exercise interventions that aim to improve physical fitness have shown promise in alleviating PMS-related limitations. Among these, clinical Pilates has gained attention for its structured, low- to moderate-intensity approach that combines controlled breathing, core activation, and neuromuscular coordination. Previous studies have demonstrated that Pilates- based programs significantly enhance strength, flexibility, and functional capacity [18]. Following the 8-week intervention, a statistically significant increase in walking distance was observed in the EG, while only minimal changes were detected in the CG. These results underscore the positive impact of clinical Pilates on functional capacity in women with PMS. The observed improvements in the EG may be attributed to multiple factors, including enhanced respiratory efficiency via diaphragmatic breathing, increased vascularization and oxygenation of skeletal muscle, and improved confidence in movement due to reduced kinesiophobia. Conversely, the limited improvement observed in the CG may be explained by the lack of structured physical activity and a potential decline in motivation due to the absence of regular supervision. This aligns with existing evidence suggesting that consistent and guided participation in exercise programs is necessary to achieve meaningful gains in functional capacity.
Flexibility is a fundamental component of physical fitness, playing a critical role in maintaining functional movement and musculoskeletal health [19]. In women with PMS, hormonal fluctuations—especially declines in estrogen and progesterone—can cause muscle stiffness and reduced joint mobility, leading to bloating, tenderness, and joint or muscle pain [19]. These biological effects often result in decreased flexibility, which may further limit exercise capacity, impair respiratory efficiency, and reduce overall quality of life [19]. The relationship between menstrual cycle phases and muscle flexibility remains controversial. While some studies suggest increased flexibility during the ovulatory phase due to elevated estrogen levels, others report no significant variations across menstrual phases [20]. Despite some inconsistency, evidence supports exercise in reducing flexibility loss during the menstrual cycle. Pilates programs specifically improve muscle extensibility and joint range through postural alignment, stretching, breathing, and neuromuscular activation [3]. Previous studies have demonstrated significant improvements in flexibility following Pilates interventions in different populations [7]. The authors concluded that Pilates enhances flexibility by integrating core strengthening with proprioceptive awareness and dynamic stretch techniques, offering a comprehensive approach to mobility improvement. In the present study, flexibility was assessed using the sit-and-reach test. Statistically significant improvements were observed in both the experimental and the CGs at the end of the eight weeks. However, the improvement in flexibility was greater in the EG compared with the CG. The improvement in the EG may be attributed to the program’s emphasis on core stabilization, postural correction, and controlled muscular elongation, which likely facilitated better functional mobility in participants with PMS. Interestingly, although the CG did not receive any structured exercise training, a significant within-group improvement in flexibility was still observed. This unexpected finding may be explained by the concept of phenotypic flexibility—defined as the body’s adaptive response to environmental changes such as improved diet and increased low-level activity—which has been linked to physiological gains, including enhanced muscle elasticity [21]. Thus, while lifestyle advice may explain flexibility gains in the CG, the greater improvements in the EG highlight Pilates’ effectiveness in enhancing musculoskeletal function in women with PMS.
Core muscle endurance refers to the trunk’s capacity to sustain contractions and stabilize the spine. In women with PMS, fatigue, pain, and low energy can compromise this ability, making daily tasks more difficult. Exercise interventions, particularly aerobic and resistance training, can counteract these effects by enhancing performance and reducing fatigue. Pilates, with its focus on controlled movement, breath synchronization, and activation of deep stabilizing muscles, offers a unique platform for improving core endurance, which in turn may help alleviate PMS-related physical limitations [2]. Moderate-quality evidence from a systematic review of 16 randomized controlled trials supports the efficacy of Pilates in improving muscular endurance among healthy populations [22]. In our study, significant improvements were observed in all measures within the EG, with statistically significant differences compared to the CG post-intervention. These findings suggest that Pilates improves muscular endurance by combining neuromuscular activation, posture correction, and progressive loading, with an emphasis on deep core activation (e.g., transversus abdominis, multifidus) that enhances trunk control and reduces energy expenditure.
PMS severity arises from intertwined physiological, hormonal, and psychological factors, where emotional, somatic, and cognitive symptoms reinforce one another. Interventions like Pilates, which target both mind and body, may therefore provide comprehensive symptom relief [1]. A meta-analysis found that Pilates training significantly reduced depressive symptoms and anxiety [23]. In our study, improved sleep-related PMSS subdomain scores, along with reductions in anxiety and depressive thoughts, may reflect similar mechanisms, including enhanced parasympathetic regulation and muscular relaxation promoted by controlled breathing and core-focused movements intrinsic to Pilates. Beyond mental health and sleep, PMS-related physical symptoms such as pain, fatigue, and appetite changes improved significantly in the EG, likely due to Pilates’ effects on neuromuscular coordination, endorphin release, and circulation, which help reduce inflammation and discomfort. Shele et al. [24] noted that regular exercise may modulate estrogen and progesterone levels, helping alleviate PMS symptoms, similar to effects seen in hormonal disorders like PCOS. Despite variability across studies, the consistent PMSS improvements in our Pilates group highlight its robust, low-risk, and accessible role in PMS management, with core engagement, breath control, and structured movement supporting both physiological and psychological regulation.
PMS involves not only physical symptoms like pain and fatigue but also emotional disturbances that reduce daily functioning and quality of life. Kinesiophobia, though less studied in this population, may worsen these effects as fear of pain leads to activity avoidance, deconditioning, and increased discomfort [25]. While kinesiophobia is extensively investigated in chronic musculoskeletal conditions, its intersection with PMS symptoms is still emerging in the literature. De Arruda et al. [25] noted that menstrual hormonal fluctuations heighten pain sensitivity and may sensitize pain pathways, explaining why many women experience increased pain and fear of movement. Similarly, a systematic review by Suarez et al. [4] reported that kinesiophobia is strongly associated with pain, sleep disturbances, and disability, and moderately linked to reduced quality of life. Our study provides novel evidence supporting the effectiveness of clinical Pilates-based exercise in reducing kinesiophobia among women with PMS. A statistically significant reduction in TSK score was observed in the EG compared to the CG. This is consistent with findings in chronic pain populations, where Pilates reduced fear of movement and improved well-being, likely through core stabilization, controlled breathing, and postural alignment that ease tension and support safer movement [18]. These physiological changes, along with psychological benefits such as improved self-efficacy, reduced anxiety, and mood stabilization, can make movement feel less threatening and encourage regular participation in physical activity. Importantly, reductions in kinesiophobia may have broader implications for treatment adherence: women who no longer fear pain during movement are more likely to sustain exercise behaviors, which is critical for long-term symptom management in PMS. The significant improvements in pain- related PMSS scores likely contributed to reduced kinesiophobia, while gains in flexibility and muscular endurance in the Pilates group may have further strengthened movement confidence. Collectively, these findings highlight kinesiophobia as a novel but clinically meaningful target in PMS, with the potential to improve both short-term outcomes and long-term adherence to exercise-based interventions.

Limitations

Limitations include the lack of follow-up on CG adherence and the absence of objective or subjective measures of physical activity, despite its relevance to outcomes like endurance, pain, kinesiophobia, and body composition. Additionally, body composition assessment was limited to waist and hip measures without detailed parameters such as basal metabolic rate or body fat percentage.

Conclusion

Limitations include the lack of follow-up on CG adherence and the absence of objective or subjective measures of physical activity, despite its relevance to outcomes like endurance, pain, kinesiophobia, and body composition. Additionally, body composition assessment was limited to waist and hip measures without detailed parameters such as basal metabolic rate or body fat percentage.

References

1. Sanchez BN, Kraemer WJ, Maresh CM. Premenstrual syndrome and exercise: a narrative review. Women (Basel). 2023;3(2):348-64.
   PubMed Google Scholar
2. Yesildere Saglam H, Orsal O. Effect of exercise on premenstrual symptoms: a systematic review. Complement Ther Med. 2020;48(1):102272.
   PubMed Google Scholar
3. Li F, Dev RDO, Soh KG, Wang C, Yuan Y. Effects of Pilates on body posture: a systematic review. Arch Rehabil Res Clin Transl. 2024;6(3):100345.
   PubMed Google Scholar
4. Luque-Suarez A, Martinez-Calderon J, Falla D. Role of kinesiophobia on pain, disability, and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. Br J Sports Med. 2019;53(9):554-9.
   PubMed Google Scholar
5. Zulisa E, Zahirah E, Sirait LI, Rahayu ES, Inayati IN. The effect of Pilates exercise on reducing menstrual pain in adolescents: literature study. Bull Insp Dev Achiev Midwifery. 2024;1(1):10-21.
   PubMed Google Scholar
6. American College of Obstetricians and Gynecologists. Management of premenstrual disorders: ACOG clinical practice guideline no. 7. Obstet Gynecol. 2023;141(6):e1-17.
   PubMed Google Scholar
7. Wood S. Pilates for rehabilitation. Champaign, IL: Human Kinetics; 2019.
   PubMed Google Scholar
8. Dalton M, Cameron AJ, Zimmet PZ, et al. Waist circumference, waist-hip ratio, and body mass index and their correlation with cardiovascular disease risk factors in Australian adults. J Intern Med. 2003;254(6):555-63.
   PubMed Google Scholar
9. American Thoracic Society. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111-7.
   PubMed Google Scholar
10. Liemohn W, Sharpe GL, Wasserman JF. Criterion-related validity of the sit- and-reach test. J Strength Cond Res. 1994;8(2):91-4.
    PubMed Google Scholar
11. McGill SM, Childs A, Liebenson C. Endurance times for low back stabilization exercises: clinical targets for testing and training from a normal database. Arch Phys Med Rehabil. 1999;80(8):941-4.
    PubMed Google Scholar
12. Gençdoğan B. Premenstrual sendrom için yeni bir ölçek [A new scale for premenstrual syndrome]. Turk Psikiyatri Derg. 2006;8(2):81-7.
    PubMed Google Scholar
13. Miller RP, Kori SH, Todd DD. The Tampa Scale: a measure of kinesiophobia. Clin J Pain. 1991;7(1):51-2.
    PubMed Google Scholar
14. Citil ET, Kaya N. Effect of Pilates exercises on premenstrual syndrome symptoms: a quasi-experimental study. Complement Ther Med. 2021;57(1):102623.
    PubMed Google Scholar
15. Itriyeva K. The effects of obesity on the menstrual cycle. Curr Probl Pediatr Adolesc Health Care. 2022;52(8):101241.
    PubMed Google Scholar
16. Singh P, Covassin N, Marlatt K, Gadde KM, Heymsfield SB. Obesity, body composition, and sex hormones: implications for cardiovascular risk. Compr Physiol. 2022;12(1):2949-93.
    PubMed Google Scholar
17. Pereira MJ, Dias G, Mendes R, et al. Efficacy of Pilates in functional body composition: a systematic review. Appl Sci. 2022;12(15):7523.
    PubMed Google Scholar
18. Manzak Dursun AS, Ozyilmaz S, Ucgun H, Elmadag NM. The effect of Pilates-based exercise applied with hybrid telerehabilitation method in children with adolescent idiopathic scoliosis: a randomized clinical trial. Eur J Pediatr. 2024;183(2):759-67.
    PubMed Google Scholar
19. Nagahori H, Shida N. Relationship between muscle flexibility and characteristics of muscle contraction in healthy women during different menstrual phases. Phys Ther Res. 2022;25(2):68-74.
    PubMed Google Scholar
20. Miyazaki M, Maeda S. Changes in hamstring flexibility and muscle strength during the menstrual cycle in healthy young females. J Phys Ther Sci. 2022;34(2):92-8.
    PubMed Google Scholar
21. van Ommen B, van der Greef J, Ordovas JM, Daniel H. Phenotypic flexibility as key factor in the human nutrition and health relationship. Genes Nutr. 2014;9(5):423.
    PubMed Google Scholar
22. Cruz-Ferreira A, Fernandes J, Laranjo L, Bernardo LM, Silva A. A systematic review of the effects of Pilates method of exercise in healthy people. Arch Phys Med Rehabil. 2011;92(12):2071-81.
    PubMed Google Scholar
23. Fleming KM, Herring MP. The effects of Pilates on mental health outcomes: a meta-analysis of controlled trials. Complement Ther Med. 2018;37:80-5.
    PubMed Google Scholar
24. Shele G, Genkil J, Speelman D. A systematic review of the effects of exercise on hormones in women with polycystic ovary syndrome. J Funct Morphol Kinesiol. 2020;5(2):35.
    PubMed Google Scholar
25. de Arruda GT, Driusso P, Rodrigues JC, et al. Are menstrual symptoms associated with central sensitization inventory? A cross-sectional study. Eur J Pain. 2022;26(8):1759-67.
    PubMed Google Scholar

Declarations

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article