rehabilitation of neurological patients

neurological rehabilitation

1. PRESENTED BY ABHILASHA CHAUDHARY REHABILITATION OF NEUROLOGICAL DISORDER PATIENTS

2. CONTENT Rehabilitation Definition of neuro rehabilitaiton Principles of rehabilitation Goals of rehabilitation Types of rehabilitation Approach of rehabilitation Neurorehabilitation team Factors affecting quality of life and coping

3. Bobath neurodevelopmetal treatment approach Positioning Sitting Mobility Transfer Physical therapy Range of motion exercise Other exercises

4. Treatment of pain and inflammation Heat therapy Cold therapy Electrical stimulation Traction Massage Acupuncture biofeedback

5. Sensory perceptual deficit Communication deficit Speech therapy Swallowing difficulty Bladder dysfunction and retraining Neurological disorder and its rehabilitation Stroke Head injury Spinal cord injury Parkinsonism Gullaine barre syndrome Nurses role in rehabilitation

6. Summary Conclusion

7. REHABILITATION Rehabilitation is a dynamic process through which a person is assisted to achieve optimal physical, emotional, psychological, social, and vocational potential and to maintain dignity, self-respect, and a quality of life that is as self- fulfilling and satisfying as possible.

8. NEUROREHABILITATION Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it.

9. PRINCIPLES OF REHABILITATION Rehabilitation should begin during the intial contact with the patient . Restoring the patient to independence or to regain his/ her preillness Maximizing independence within the limits of the disability.

10. Realize goals based on individual patient assessment and to guide the rehabilitation program Must be an active participation Activities of daily living are facilitated. Motivate the patient and helps him/her to attain social independence.

11. Goals of rehabilitation Physical independence Mobility

12. Social integration Occupational integration

13. Psychological support

14. Types of rehabilitation Medical rehabilitation : restoration of structure and function. Vocational rehabilitation: restoration of the capacity to earn a useful and decent livelihood

15. Types contd.. Social rehabilitation : restoration of family and social relationships Psychological rehabilitation : restoration of personal dignity and confidence

16. Approaches of rehabilitation Institution based : the services are delivered in an institution for the disabled.

17. Outreach based : professional travel to the community

18. Community based : where resources for rehabilitation are available in the community and services are delivered in community area.

19. Neurorehabilitation team Medical team Physiatrist Orthopaedic surgeon Neurologist Neurosurgeon Plastic surgeon Psychiatrist Paediatrician Obstetrician Geneticist Cardiologist Cardiac surgeon General surgeon Oncologist Ophthalmologist Paramedical members Physiotherapist Occupational therapist Creative movement therapist Recreation therapist Prosthetist Rehabilitation nurse

20. Neurorehabilitation team contd … Speech pathologist Psychologist Play and drama therapist Music therapist Social worker Vocational counsellor Non governmental organization Community Family members

21. FACTORS AFFECTING QUALITY OF LIFE AND COPING Nature of disease Severity of disease Freedom to live and work Economical stability Access to education Sexual dysfunction

22. Bobath Neurodevelopmental Treatment Approach

23. Patterns of muscle recovery in hemiplegia Flacidity - occurs from the time of injury to 2 to 3 days after(decreased or no tendon reflexes or resistance to passive movement) Spasticity- onset 2days to 5 wk(Hyperactive tendon reflexes and exaggerated response to minimal stimuli

24. Patterns contd.. Synergy – onset 2–3 wk (Simultaneous flexion of muscle groups in response to flexion of a single muscle (e.g., an attempt to flex the elbow results in contraction of the fingers , elbow, and shoulder) Near normal, slight incoordination may be present

25. Bobath Neurodevelopmental Treatment Approach Used for patients with hemiplegia caused by stroke, brain injury, and cerebral palsy. Major goal is normalization of muscle tone, posture, movement, and function

26. Principles ( positioning, turning, transferring) Reintegration of function of the two sides of the body. Proximal to distal positioning is recommended . Weight bearing is provided on the affected side to normalize tone. Tasks should begin from a symmetric midline position with equal weight bearing on the affected and unaffected sides. Movement toward the affected side i s encouraged.

27. Principles contd.. Straightening of the trunk and neck is encouraged to promote symmetry and normalization of tone and posture. Hemiplegic patients should be positioned in opposition to the spastic patterns of flexion and adduction in the upper extremity and extension in the lower extremity

28. POSITIONING Importance of Positioning prevent development of musculoskeletal deformities Contracture Ankylosis (stiffness and rigidty of joints) Pressure ulcers decreased vascular supply Thrombosis Edema

29. PRINCIPLES FOR POSITIONING OF PATIENT IN BED The unconscious patient should be repositioned every few (e.g., 2 hours) hours If spasticity is present, frequent repositioning is necessary. Splintin g and casting to inhibit tone may be ordered and applied by a physical therapist.

30. Principles of positioning contd.. Any restrictions of position are posted in patient file(paper or electronic site). A sufficient number of pillows are available to maintain body alignment. Trochanter rolls and other positioning devices are useful

31. Principles of positioning contd.. If an arm is weak or paralyzed, it is positioned to approximate the joint space in the glenoid cavity. The affected arm is not pulled. A pillow or small wedge in the axillary region helps prevent adduction of the shoulder.

32. Principles of positioning contd.. Special resting hand splints may be ordered to prevent contracture; remove periodically to assess the skin for pressure ulcers Reduce edema by elevating the hand higher than the elbow or by using elastic glove .

33. Principles of positioning contd.. Foot drop- high-top sneakers or special splints, may be ordered. Heels are kept off the bed to prevent pressure ulcers from developing. Pillow placed crosswise to elevate the lower legs or heel guards may be applied

34. Wrist support splint Foot drop boot Trochanter

35. Side-Lying Position Favourable for unconscious patient head of the bed elevated 10 to 30 degrees . head should be placed in a neutral position. soft collar or towel roll is useful to maintain the neutral position head turned slightly to facilitate drainage of oral secretions and to maintain a patent airway.

36. SITTING The conscious patient may sit on the side of the bed, using the over bed table and pillows for support. For the weak, debilitated patient who cannot hold up the head or neck, a high-back chair that extends to the top of the head is most effective

37. Some patients have a neck brace; apply it for sitting. Pillows or rolls support the arms in the desired position. The feet are positioned flat on the floor . The pressure on the bottom of the feet assists in stretching the heel cord.

38. Neck brace High back chair

39. MOBILITY: TRANSFER AND AMBULATION Transfer Types Two-person lift: physical transfer by at least two staff members; no active patient participation Mechanical lift: transfer using a lifting device that is operated by staff members; no active patient participation

40. 2 person lift

41. Mechanical lifts

42. Contact guard: provision of verbal cues and minimal physical support during the activity, such as holding the arm or waist during ambulation. Supervision: provision of verbal cues only, as necessary

43. PRINCIPLES OF TRANSFER Transfer toward the unaffected side. Patients should wear properly fitted , flat shoes. Never tug on the paretic arm by pulling on the upper arm or shoulder. If balance is unsteady, stand on the affected side, ready to grasp the belt around the patient’s waist.

44. If the patient’s knees buckle and additional assistance is required, stand in front of the patient and push with your knee against the patient’s unaffected knee to lock the knee in position and prevent buckling. A walker or four-point cane may be used for support.

45. 00

46. Transfer Activity: From Lying in Bed to a Sitting Position Hemiplegic Patients . Move toward or roll onto the side of the bed on which you intend to sit. Slip the unaffected leg under the affected leg at an angle so that the unaffected leg becomes a transfer cradle for the affected limb. Place the affected arm on the abdomen or lap.

47. Transfer Activity: From Lying in Bed to a Sitting contd.. Push off the mattress with the unaffected elbow, raising your upper body, while turning your hips toward the side of the bed on which you intend to sit. Swing the unaffected leg over the side of the bed, and use the unaffected hand to push up. Once in the sitting position, lean on the unaffected hand to maintain an erect position.

48. Transfer Activity: From Lying in Bed to a Sitting contd.. Paraplegic or Incomplete Quadriplegic Patients. Most transfer activities for quadriplegic and some incomplete quadriplegic patients require direct assistance from facility personnel.

49. Transfer Activity: From a Sitting Position on the Bed to a Chair Place the chair at a slight angle as close as possible to the bed on the unaffected side . With feet close together, lean forward slightly, put the unaffected hand on the mattress edge, and push off to a standing position, bearing weight on the unaffected side.

50. Transfer Activity: From a Sitting Position on the Bed to a Chair contd.. Once balance has been maintained and is steady enough for momentary release of support, move the strong hand to the farthest arm rest of the chair. Keep the body weight well forward; pivot on the unaffected foot, and slowly lower to a sitting position

51. PHYSICAL THERAPY

52. RANGE OG MOTION EXERCISES Types Passive exercises Active exercises Active assistive exercises Resisted exercise Manual resisted exercises Mechanical resisted exercises Isometric or muscle strengthening exercises

53. PRINCIPLES OF EXERCISE Patient is rested, comfortable, and pain free to gain cooperation. Position in proper body alignment, and drape, as necessary, to avoid undue exposure . Maintain good posture to ensure efficient body movement Face the patient to observe facial reaction to the exercises.

54. • Movements are slow, smooth, and rhythmical. • Move the body part to the point of Pain ,resistance and stop. • If the patient becomes excessively fatigued, discontinue the exercises.

55. Passive exercises Smooth rhythmical and accurate anatomical movements performed by the therapist within the pain limited range.

56. Active exercise Exercises which are performed by the patient himself without any assistance and resistance by the external force except the gravity.

57. Active exercise

58. Active assited exercise Range of motion to a body joint is accomplished by the patient with the assistance of another person

59. Active assited exercise

60. Resisted exercise The activities, which are performed by opposing the mechanical or manual resistance is called resisted exercise. Types Manual resisted exercises Mechanical resisted exercises

61. Resisted exercises contd.. Manual resisted exercises Resistance can be applied by the patient himself or by any other person. Mechanical resisted exercises Mechanical devices are used to oppose the active movement of a person e.g weights, pulleys

62. Manual resisted exercises

63. Mechanical resisted exercises

64. Isometric or muscle strengthening exercises: exercises are accomplished by alternately tightening and relaxing the muscle without joint movement

65. Isometric or muscle strengthening exercises

66. Muscle strengthening exercises Strengthen muscles enough to perform a given function As muscle strength increases, resistance is gradually increased

67. Tilt table(for orthostatic hypotension)

68. Mat exercise

69. Mirror feedback therapy with parallel bars

70. Co ordination exercise Frenkel’s exercise

71. Task oriented exercise Involves repeating meaningful movement that works more than on joint and muscles.

72. Treatment of pain and inflammation Heat therapy Mechanism of action Increases bloodflow and the extensiblity of connective tissue Decreases joint stiffness, pain, and muscle spasm Reduces inflammation, oedema and exudates resolve

73. Indication Sprains Myositis Arthralgia Neuralgia Muscle spasm Strains

74. TYPES OF APPLICATION Hot pack (containers filled with silicate gel) Infra red ray(Applied with lamp )

75. Paraffin baath (Wax heated at 49 degree centigrade)

76. Hydrotherapy( warm water 96 to 100)

77. D iathermy( use of high-frequency electromagnetic current )

78. Cold therapy

79. Electrical stimulation Denervated skeletal muscle and innervated muscle that cannot be contracted voluntarily can be stimulated electrically to help alleviate or prevent disuse atrophy and muscle spasticity.

80. Transcutaneous electrical nerve stimulation(TENS) use of electric current to stimulate the nerves Uses Chronic low back pain Neuralgia Contusion

81. Traction Used for extrinsic muscle spasm and to keep bony surfaces aligned while fracture heal. E.g cervical traction, lumbar traction

82. Massage

83. Acupuncture

84. Biofeedback Electromyogram Galvanic skin response

85. SENSORY-PERCEPTUAL DEFICITS Perception is a complex intellectual process of recognizing, interpreting, and integrating sensory stimuli into meaningful information from the internal and external environments. The parietal lobe is particularly important in perception.

86. SENSORY-PERCEPTUAL DEFICITS Perception of illness Body image Spatial relationship Agnosia Apraxia

87. COMMUNICATION DEFICITS Results from injury to the cortex of the left hemisphere in the posterior frontal or anterior temporal lobes Aphasia -is the loss of ability to use language and to communicate thoughts verbally or in writing.

88. INTERVENTION Stimulate conversation and ask open-ended questions. Allow patients time to search for the words to express themselves. Disregard choice of incorrect words . Assure patients that their speech will gradually improve with time.

89. Provide a loose-leaf notebook with pictures of common objects so that the patient can point to the picture when unable to say the word. Tell the patient that speech skills can be relearned, given time. Anticipate the patient’s needs

90. SPEECH THERAPY Auditory training Lip reading Sign board

91. Muscle exercise E.gMasako Maneuver (Place the tip of your tongue between your front teeth or gums and swallow)

92. SWALLOWING DEFICITS Swallowing is a complex process of ingesting solid or liquid food while protecting the airway. four phases of swallowing: Oral preparatory phase: food is taken into the mouth and chewed, forming a bolus.

93. Oral phase: the bolus of food is centered and moved to the posterior oropharynx . Pharyngeal phase: the swallowing reflex carries the bolus through the pharynx . Esophageal phase: peristalsis carries the bolus to the stomach.

94. Intervention Feed or eat in the upright, sitting position at a 90-degree angle. Tilt the head forward and tuck the chin in to prevent food from moving into the posterior oropharynx before it has been chewed Encourage taking small bites and thorough chewing . For patients with hemiplegia or hemiparesis , place food on the unaffected side .

95. If “pocketing” of food is a problem, have the patient sweep the mouth with his or her finger after each bite to clear the food.

96. The speech therapist can be helpful by suggesting an adaptive cup and special techniques to ensure swallowing . If oral feeding is contraindicated, a feeding tube or gastrostomy tube can be considered

97. If cognitive deficits are present, the patient may have poor impulse control and may stuff the mouth hurriedly with food (manage the behavior and controlling distractions from the focus of eating. This patient requires mealtime supervision and verbal and nonverbal cues )

98. BLADDER DYSFUNCTION AND RETRAINING Bladder control is an integrated function of the brainstem, spinal, and cerebral level . Alterations in urinary elimination patterns can be classified generally into urinary incontinence (UI) and urinary retention

99. Urinary incontinence can be associated with various problems, such as a diminished level of consciousness; cerebral injury, especially to the frontal lobe; or spinal cord injury.

100. Four major categories Urge incontinence : the involuntary loss of urine associated with an abrupt and strong desire to void (urgency). Stress incontinence : the involuntary loss of urine during coughing, sneezing, laughing , or other physical activities that increase abdominal pressure.

101. Overflow incontinence : the involuntary loss of urine associated with overdistension of the bladder. Functional incontinence : urine loss caused by factors outside the lower urinary tract; this category includes UI

102. Urinary retention is often associated with spinal cord–injured patients.

103. BEHAVIOURAL TRAINING Bladder Training. Bladder training, also called bladder retraining, includes several variations. Three primary components of education, scheduled voiding, and positive reinforcement . The patient needs to be educated to understand the physiology,pathophysiology , technique, and desired outcome.

104. A bladder retraining program assists the patient to learn to resist or inhibit the sensation of urgency, postpone voiding, and urinate according to a timetable rather than the urge to void. The initial goal interval may be 2 to 3 hours , although it is not followed during sleep

105. Prompted Voiding . Prompted voiding is a technique used primarily with dependent or cognitively impaired people. Monitoring : the person is checked by caregivers on a regular basis. Prompting : the person is asked (prompted) to try to use the bathroom to void. Praising: the person is praised for maintaining continence and attempting to use the toilet

106. Pelvic Muscle Exercises . also called Kegel exercises, comprise a behavioral technique that requires repetitive active exercise of the pubococcygeus muscle to improve urethral resistance and urinary control by strengthening the periurethral and pelvic muscles in women.

107. contracted to a count of 10 and then relaxed to a count of 10. About 50 to 100 of these exercises must be done daily to be effective. It takes about 4 to 6 weeks to notice improvement.

108. Bladder-Triggering Techniques A few bladder-triggering techniques facilitate bladder emptying. They include suprapubic stimulation, Valsalva’s maneuver , and Credé’s maneuver . Suprapubic stimulation

109. suprapubic stimulation activates the sacral-lumbar dermatomes by manually tapping the suprapubic area, pulling pubic hairs, or stroking the medial thighs. Valsalva’s maneuveris straining against a closed epiglottis while contracting the abdominal muscles and bearing down on the bladder. The straining is sustained or the breath held until the urine flow ceases..

110. Valsalva’s maneuver

111. Credé’s maneuver placing the hands flat just below the umbilical area and pressing firmly down and inward toward the pelvic arch . The purpose of this maneuver is to express urine from the bladder

112. Catheters and Catheterizations Intermitten catheterization Suprapubic catheterization indwelling catheterization

113. SUPRAPUBIC CATHETERIZATION

114. Bowel elimination and defecation The act of bowel evacuation is called defecation. The anus, the terminal end of the large bowel, is controlled by two sphincters: the involuntary proximal anal sphincter (smooth muscle) and the voluntary distal anal sphincter (striated muscle).

115. Defecation is a coordinated reflex involving sacral segments S-3, S-4, and S-5 , which is initiated by stimulated stretch receptors located in the anus that initiate peristaltic waves.

116. Types of Altered Bowel Function Patterns Constipation Diarrhea Incontinence

117. Constipation: fluid restriction, prolonged immobility, nothing by mouth status as a result of swallowing deficits or unconsciousness, decreased bulk in diet, drugs known to decrease peristalsis (e.g., codeine), spinal nerve compression, paralytic ileus , lack of sensation, lack of privacy, interruption of usual bowel routine, and failure to respond to defecation stimuli Diarrhea : intolerance to tube feeding, antibiotic therapy, and fecal impaction .

118. I ncontinence : altered consciousness, cognitive deficits (e.g., social disinhibition , lack of impulse control, inability to recognize and respond to defecation impulses), impaired communication, and neurogenic bowel without sensation or control (related to spinal cord injury above T-11 or involving sacral reflex arc S-2 to S-4)

119. INTERVENTION Make sure the lower bowel is empty; an enema may be necessary before beginning the training program. Establish a time of day for a bowel movement based on the patient’s previous pattern; adhere to this designated time of day rigidly. Encourage a diet high in roughage (whole-grain bread and cereal, fresh fruits, and vegetables ).

120. Unless contraindicated by a fluid restriction, increase fluid intake to 2000 to 2500 mL /d. Insert a suppository on the first day. If it does not work, you may wait until the next day.

121. The patient should be seated on the commode or taken into the bathroom to defecate. Administer medications and collaborate with patient and health team members to adjust regimen individualized to the patient

122. Neurological disorders and its rehabilitation

123. STROKE Stroke is when poor blood flow to the brain results in cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. They result in part of the brain not functioning properly

124. Rehabilitation for stroke Positioning Mobilization and stretching Weight bearing activities Chest physiotherapy Pain relief Speech therapy Bowel and bladder care

125. Research abstract Title - A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients Author : VAN Bladel A, Lambrecht G, Oostra KM, Vanderstraeten Year of publication: 2017,jan Objectives To determine both the immediate and long-term effect on acromiohumeral distance using the Actimove ® sling and Shoulderlift (V!GO, Belgium) and to determine the effect of slings on pain and passive range of motion of the shoulder in stroke patients with glenohumeral subluxation

126. Shoulder drift Actimove sling

127. METHODS: 28 stroke patients, with severe upper limb impairments, were randomly allocated to 3 groups ( Actimove , Shoulderlift , No sling). Patients wore their supportive device for 6 weeks and no sling in the control group . Immediate and post-interventional effect on acromiohumeral distance was measured using sonography . Pain (VAS), ROM (goniometry), spasticity (Modified Ashworth Scale), Fugl -Meyer Assessment and trunk stability (TIS) were also assessed before and after the intervention.

128. RESULTS: The level of immediate correction of both slings was different at baseline and after 6 weeks (0 weeks: Shoulderlift 63%, Actimove 36%; 6 weeks: Shoulderlift 28%, Actimove 24%). Comparing the level of subluxation over time shows a distinct decrease in subluxation but only for the control group (-37.59% or 3.30 mm) . Subluxation remained the same in the Actimove group (- 2.77 % or 0.27mm) but increased in the Shoulderlift group (+ 12.44% or 1.03 mm). After 6 weeks, the Actimove group reported more pain at rest (p = 0.036). ROM for abduction and external rotation decreased in 2 groups and remained un-altered in the Shoulderlift group

129. CONCLUSIONS: Results of immediate correction varied. Subluxation seemed to reduce in patients that did not wear a sling.

130. BRAIN INJURY A brain injury is any injury occurring in the brain of a living organism. Brain injuries can be classified along several dimensions

131. REHABILITATION OF BRAIN INJURY Positioning, transfer Supportive eating and standing Rehabilitation of motor control Bowel and bladder care Pain Training balance Aids to improve memory

132. SPINAL CORD INJURY A spinal cord injury (SCI) is damage to the spinal cord that causes changes in its function, either temporary or permanent. These changes translate into loss of muscle function, sensation, or autonomic function in parts of the body served by the spinal cord below the level of the lesion

133. REHABILITATION OF SPINAL CORD INJURY Safe transportation Traction Positioning Active and passive ROM Mat work Orthoses (spinal corsets, crutches) Gait trainning Mobility training

134. Title - Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence . Authors: Mahmoud H, Qannam H, Zbogar D Year of publication: 2017,jan Objectives -To describe functional status, length of stay (LOS) and time to rehabilitation admission trends . To identify independent predictors of motor function following rehabilitation

135. METHODS: From chart review of 312 traumatic and 106 nontraumatic adult patients with spinal cord injury (SCI) we extracted information on time from injury to rehabilitation admission, rehabilitation LOS, Functional Independence Measure (FIM) motor score (admission and discharge), American Spinal Injury Association Impairment Scale (AIS) grade and demographics..

136. RESULTS: Mean±s.d ., median days from injury to rehabilitation admission were 377±855, 150 days for traumatic SCI and 288±403, 176 days for nontraumatic SCI . For individuals with traumatic SCI, after accounting for admission FIM motor score, tetraplegia and time from injury to rehabilitation admission had a significant but small negative association with discharge FIM motor score.

137. Parkinsonism Parkinsonism is a clinical syndrome characterized by tremor, bradykinesia , rigidity, and postural instability.

138. REHABILITATION OF PARKINSONISM Reduction of rigidity and maintaining flexibility Balance training Coordination exercises Breathing and chest expansion exercises Improvement in psychological well being

139. GUILLAIN BARRE SYNDROME Guillain–Barré syndrome (GBS) is a rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system

140. GUILLAIN BARRE SYNDROME Chest physiotherapy Maintenance of range of motion of all joints Psychological support Prevention of postural hypotension Strengthening Gait training

141. Nurses role in rehabilitation Coordinates various aspects of patient care in hands on manner, identifying day to day problems and monitoring progress . Liaises between various team members of the rehabilitation team and looks after critical executive function like positioning, splinting, hygiene

142. Acts as spokes person for the patient to highlight their problems and needs to the team. Provide psychological support. Create awareness of the problem in the community .

143. SUMMARY

144. CONCLUSION Rehabilitation is a combination of methods that are focused in restoring the patient’s useful life.  Rehabilitation could help one body achieve the normal daily functions by different kinds of recovery techniques.

145. References Books Clement. Textbook on neurological and neurosurgical nursing.1sted. Newdelhi.Japee brothers medical publishers.p553-58 Sundar S. Textbook of rehabilitation.3 rd ed. Newdelhi . Jaypee brothers medical publisher.p.13-40 Narayanan S lakshmi . Textbook of therapeutic exercises.6 th ed. New delhi . . Jaypee brothers medical publisher.p.13-40. Hickey J. the clinical practice of neurological and neurosurgical nursing. 7thed. Wolters and kluwer.p . 224-56 Smeltzer Suzanne C, Barebrenda G, Hinkle Janice L, Cheever Kerry H. Textbook of medical surgical nursing, 12 th ed. Newdelhi : Lippincot wolter’s kluwer ; p.113-114(vol-1). 

146. Journals Mahmoud H, Qannam H, Zbogar D. Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence. Spinal cord.2015 jan . 4(1) VAN Bladel A, Lambrecht G, Oostra KM, Vanderstraeten. A randomized controlled trial on the immediate and long-term effects of arm slings on shoulder subluxation in stroke patients.eur j physrehab med.2017 jan.6(2). Internet https://en.wikipedia.org/wiki/Pain_management https://en.wikipedia.org/wiki/Rehabilitation

147. Stephen Hawking

148. THANK YOU