Posts Tagged paretic hand

[Abstract+References] Effect of Mirror Therapy on Upper Limb Function: A Single Subject Study.


Objectives: Mirror therapy is a unique treatment with a touch of modality that is purported to improve the motor function of the affected limb in individuals with hemiplegia. Previous studies have focused on the neuro-physiological factors underlying the mechanism of the clinical effect of this technique. The present study aims to understand the mechanism using the rehabilitation method and neuro-occupation model as well as analyze the effects of mirror therapy on the upper limb function of subjects with spastic hemiplegic cerebral palsy.
Methods: Single subject design known as withdrawal design was used by a convenience sample of four subjects. The study involved three observational phases known as baseline, treatment, and withdrawal phases that took place during a 10 week period. The study contained a home-based mirror therapy protocol whereby the participants were instructed to do some exercises on a daily basis. The improvement of the hand function of the hemiplegic side was examined by Box and Block test along with two more activities including Threading Beads and Stacking Rings.
Results: The ability to perform the Box and Block test, Threading Beads, and Stacking Rings tended to remain steady in the baseline phase, whereas there was a noticeable improvement during the treatment phase and a decline in the withdrawal phase.
Discussion: From the perspective of visual feedback neuro-occupation model, it could be hypothesized that alterations to the sensory system caused by the mirror reflection of non affected hand may have led to the destabilization of the sensory cortices that changed the participants’ intention, meaning, and perception, thereby improving the subject’s motor control.

1. Forsyth K, Mann LS, Kielhofner G. Scholarship of practice: Making occupation-focused, theory-driven, evidence-based practice a reality. British Journal of Occupational Therapy. 2005; 68(6):260-8. doi: 10.1177/030802260506800604 [DOI]
2. Deconinck FJ, Smorenburg AR, Benham A, Ledebt A, Feltham MG, Savelsbergh GJ. Reflections on mirror therapy: A systematic review of the effect of mirror visual feedback on the brain. Neurorehabil Neural Repair. 2015; 29(4):349-61. doi: 10.1177/1545968314546134 [DOI]
3. Thieme H, Mehrholz J, Pohl M, Behrens J, Dohle C. Mirror therapy for improving motor function after stroke. Cochrane Database of Systematic Reviews. 2012(3):CD008449. doi: 10.1002/14651858.cd008449.pub2 [DOI]
4. Gordon AL, Di Maggio A. Rehabilitation for children after acquired brain injury: Current and emerging approaches. Pediatric Neurology. 2012; 46(6):339-44. doi: 10.1016/j.pediatrneurol.2012.02.029 [DOI]
5. Feltham MG, Ledebt A, Deconinck FJ, Savelsbergh GJ. Mirror visual feedback induces lower neuromuscular activity in children with spastic hemiparetic cerebral palsy. Research in Developmental Disabilities. 2010; 31(6):1525-35. doi: 10.1016/j.ridd.2010.06.004 [DOI]
6. Royeen CB. Chaotic occupational therapy: Collective wisdom for a complex profession. American Journal of Occupational Therapy. 2003; 57(6):609-24. doi: 10.5014/ajot.57.6.609 [DOI]
7. Lazzarini I. Neuro-occupation: The nonlinear dynamics of intention, meaning and perception. British Journal of Occupational Therapy. 2004; 67(8):342-52. doi: 10.1177/030802260406700803 [DOI]
8. Derakhshanrad SA, Piven E, Zeynalzadeh Ghoochani B. Adaption to stroke: A nonlinear thinking approach in occupational therapy. Occupational Therapy in Health Care. 2017; 31(3):255-69. doi: 10.1080/07380577.2017.1335922 [DOI]
9. Lazzarini I. A nonlinear approach to cognition: a web of ability and disability. In: Katz N, Baum MC, editors. Cognition and Occupation Across the Life Span: Models for Intervention in Occupational Therapy. Bethesda: American Occupational Therapy Association; 2004.
10. Derakhshanrad SA, Piven E, Zeynalzadeh Ghoochani B. Comparing the cognitive process of circular causality in two subjects with strokes through qualitative analysis. Nonlinear Dynamics, Psychology, and Life Sciences. 2017; 21(4):555-567. PMID: 28923161 [PubMed]
11. Parham LD, Mailloux Z. Sensory integration. In: Case-Smith J, O’Brien J, editors. Occupational Therapy for Children. Berlin: Elsevier; 2005.
12. Piven E, Derakhshanrad SA. A case study demonstrating reduction of aggressive client behaviors using the Neuro-Occupation model: Addressing professional burnout through nonlinear thinking. Occupational Therapy in Mental Health. 2017; 33(2):179-94. doi: 10.1080/0164212X.2017.1278734 [DOI]
13. Loukas KM. Occupational placemaking: Facilitating self-organization through use of a sensory room. Mental Health Special Interest Section Quarterly. 2011; 34(2):1-4.
14. Williams KL. Understanding the role of sensory processing in occupation: An updated discourse with cognitive neuroscience. Journal of Occupational Science. 2017; 24(3):302-13. doi: 10.1080/14427591.2016.1209425 [DOI]
15. Carter RE, Lubinsky J, Domholdt E. Rehabilitation research: Principles and applications. Berlin: Elsevier; 2011.
16. Morgan. DL, Morgan. RK. Single-case research methods for the behavioral and health sciences. Thousand Oaks, California: SAGE; 2009.
17. Creswell JW. Research design: Qualitative, quantitative, and mixed methods approaches. Thousand Oaks, California: SAGE; 2013.
18. Eliasson AC, Krumlinde-Sundholm L, Rösblad B, Beckung E, Arner M, Öhrvall AM, et al. The Manual Ability Classification System (MACS) for children with cerebral palsy: Scale development and evidence of validity and reliability. Developmental Medicine and Child Neurology. 2006; 48(7):549-54. doi: 10.1017/S0012162206001162 [DOI]
19. Bohannon RW, Smith MB. Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Physical Therapy. 1987; 67(2):206-7. PMID: 3809245 [PubMed]
20. Park EJ, Baek SH, Park S. Systematic review of the effects of mirror therapy in children with cerebral palsy. Journal of Physical Therapy Science. 2016; 28(11):3227-31. doi: 10.1589/jpts.28.3227 [DOI]
21. Gygax MJ, Schneider P, Newman CJ. Mirror therapy in children with hemiplegia: A pilot study. Developmental Medicine & Child Neurology. 2011; 53(5):473-6. doi: 10.1111/j.1469-8749.2011.03924.x [DOI]
22. Grunt S, Newman CJ, Saxer S, Steinlin M, Weisstanner C, Kaelin-Lang A. The mirror illusion increases motor cortex excitability in children with and without hemiparesis. Neurorehabilitation and Neural Repair. 2017; 31(3):280-9. doi: 10.1177/1545968316680483 [DOI]
23. Smorenburg AR, Ledebt A, Deconinck FJ, Savelsbergh GJ. Practicing a matching movement with a mirror in individuals with spastic hemiplegia. Research in Developmental Disabilities. 2013; 34(9):2507-13. doi: 10.1016/j.ridd.2013.05.001 [DOI]
24. Bruchez R, Jequier Gygax M, Roches S, Fluss J, Jacquier D, Ballabeni P, et al. Mirror therapy in children with hemiparesis: a randomized observer‐blinded trial. Developmental Medicine & Child Neurology. 2016; 58(9):970-8. doi: 10.1111/dmcn.13117 [DOI]

via Effect of Mirror Therapy on Upper Limb Function: A Single Subject Study – Iranian Rehabilitation Journal


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[Poster] Exploration of the Factors That Influence Spontaneous Bimanual Arm Use After Stroke: Implications for Clinical Rehabilitation


After a stroke, returning to activities of daily living requires the use of the two hands together for bimanual tasks, such as cutting bread, buttoning a shirt etc. Here, we sought to first, identify spontaneous volitional arm use patterns adopted for two distinct bimanual tasks, and, next, determine if and to what extent the degree of impairment, side of stroke, task demands, self-reported confidence, and single-limb (paretic and non-paretic) measures of functional performance can predict the observed task use patterns.

Fifty pre-morbidly right-handed stroke survivors (Upper Extremity Fugl-Meyer, UEFM 42±10, 25 right-hemiparesis, RHP) performed 2 bimanual tasks (letter-envelope and photo-album) without explicit instructions. Arm use patterns were classified by: 1) whether one or both arms were used, and 2) the nature of paretic arm use. Logistic regression and receiver-operator characteristics (AUC) were used to examine the influence of impairment (UEFM, more severe < 41, less severe ≥ 41), side of lesion, task demand, self-reported confidence (CAHM), and single-limb functional performances (paretic and non-paretic log-transformed distal component time-scores of Wolf Motor Function test, ln-WMFT) on bimanual arm use. Those more severely impaired and LHP were less likely to choose a bimanual strategy for either task (β = 14.64, p<0.001). For the photo-album task, probability of bimanual use was greater for RHP than LHP group, especially in less impaired; whereas, for the letter-envelope task, probability of use for RHP > LHP only in the more impaired (β = -1.45, p< 0.001). LHP, but not RHP, who reported greater confidence in the use of the paretic arm were more likely to use a bimanual strategy (ρ > 0.34, p<0.05). Finally, paretic arm ln-WMFT was a fair predictor of use patterns for both LHP (AUC = 0.79) and RHP (AUC = 0.80) groups, while the non-paretic arm time-score was a good predictor of use patterns only for the RHP (AUC = 0.85), but not the LHP group (AUC = 0.55).

Taken together, spontaneous bimanual arm use is modified by impairment, task demands, confidence in paretic arm, and non-paretic arm function, but the effect depends on the side of stroke. Thus, consideration of side of lesion is important when developing interventions to improve bimanual arm use.


via Abstract WP152: Exploration of the Factors That Influence Spontaneous Bimanual Arm Use After Stroke: Implications for Clinical Rehabilitation | Stroke

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[ARTICLE] Study of Repetitive Movements Induced Oscillatory Activities in Healthy Subjects and Chronic Stroke Patients – Full Text


Repetitive movements at a constant rate require the integration of internal time counting and motor neural networks. Previous studies have proved that humans can follow short durations automatically (automatic timing) but require more cognitive efforts to track or estimate long durations. In this study, we studied sensorimotor oscillatory activities in healthy subjects and chronic stroke patients when subjects were performing repetitive finger movements. We found the movement-modulated changes in alpha and beta oscillatory activities were decreased with the increase of movement rates in finger lifting of healthy subjects and the non-paretic hands in stroke patients, whereas no difference was found in the paretic-hand movements at different movement rates in stroke patients. The significant difference in oscillatory activities between movements of non-paretic hands and paretic hands could imply the requirement of higher cognitive efforts to perform fast repetitive movements in paretic hands. The sensorimotor oscillatory response in fast repetitive movements could be a possible indicator to probe the recovery of motor function in stroke patients.


Timing in the brain has its important role in many aspects, such as speech perception, speech production, reading, attention, memory, cognitive processing, decision-making, and motor coordination1. Especially, internal time counting is crucial for motor control in our daily life activities. The processing of time estimation for movements has been studied in many literatures2. Morillon et al. postulated the time estimation in human motor system as a dual system, which can track a short duration automatically (automatic timing) but requires more cognitive demands to track a long duration by a so-called default mode network (DMN)3. Poppel E. studied the capability of time estimation in a stimulus reproduction task from 0.5 s to 7 s, and found movements become temporally irregular for inter-movement interval (IMI) above 3 s which indicated precisely control of movements with IMIs longer than 3 s is not possible4. Though these literatures have shown great difference between movements in short and long durations in healthy subjects, nevertheless, the study of brain responses induced by rapid movements in patients with motor neurological disorder was seldom reported.

Several imaging modalities have been developed to quantify motor response in human brain, including EEG, MEG, fMRI, TMS, etc.5,6. The EEG, which is the tool used most widely, has the advantages of low-cost, easy preparation, and its superiority of high temporal resolution to measure fast changes of neural oscillatory activities. Neural oscillatory activities in human brain can be either phase-locked or non-phase-locked reactive to external or internal stimuli. These oscillatory activities usually exist in specific frequency bands and spatial locations. Event-related non-phase-locked neural activities represent power changes, either enhanced or suppressed relative to baseline activities. The power changes in event-related activities can be caused by the decrease or increase in synchrony of the underlying activated neuronal populations. Pfurtscheller et al.7 studied the Mu-rhythm changes in discrete voluntary finger movements, and found oscillatory activities were suppressed, started about 1.5 s preceding movement onsets, followed by post-movement power rebound, occurred around 0.7 s~1 s after movement offsets7. The power suppression was referred to as event-related desynchronization (ERD), reflecting the motor planning and preparation of initialization a movement, whereas the post-movement power rebound was referred to as event-related synchronization (ERS), indicating the motor inhibition or idling of motor neural network. Other EEG techniques, such as temporal-spectral evolution (TSE)8, amplitude modulation (AM)9, autoregression model method (AR)10, etc., were also developed to quantify task-specific brain oscillatory activity. These signal processing tools enable researchers to quantify the neural activities under different experimental manipulations and provide evidences for diagnosing clinical neurological diseases11,12,13.

The difference of brain oscillatory activities between healthy and stroke patients has been investigated in some studies. Rossiter et al. studied the movement-related beta desynchronization (MRBD) in healthy and middle cerebral artery (MCA) stroke patients14. They found reduced MRBD when patients were performing visually-cued grip task with their affected hand, compared to the MRBD obtained from healthy subjects. Giaquinto et al. followed up the changes of resting EEG in different frequency bands over six months in MCA stroke patients15, and they observed the amplitudes of movement-related Mu – rhythm improved significantly in the first three months and reached stable states in six months after stroke. Tecchio et al. studied the rhythmic brain activity at resting states in mono-hemispheric MCA stoke patients16. They found both the values of spectral power in affected and unaffected hemispheres were increased over Rolandic areas. Stepien et al. studied alpha ERD in stroke patients with cortical and subcortical lesions in performing a visually-cued button press task17. They found suppressed ERD in affected hemisphere when moving paretic hand, while no suppression in alpha ERD was found in the affected hemisphere when moving non-paretic hand. These studies measured oscillatory activities of sensorimotor Mu rhythm in visual selection task or slow self-paced voluntary movement (IMI ≥ 7 s). Oscillatory activity induced by fast repetitive movement in stroke patient was not studied. Since fast simple movement has been reported to have strong coupled connections among motor-related cortices18, study of cortical oscillatory activity in rapid simple movements could be crucial for the understanding of motor function in stroke patients.

Fast repetitive movement with short IMI recruits several motor-related areas in human brain, including primary motor cortex (M1), premotor cortex, supplementary motor cortex, cingulate cortex, basal ganglia, and thalamus19. Studies in healthy subjects have shown clear difference between the oscillatory activities induced by slow and fast repetitive movements. Wu et al. recorded the post-movement beta rebound (PMBD) in healthy subjects and observed that the PMBD was suppressed with the decrease of IMI in repetitive finger-lifting movements19. Erbil and Ungan19 investigated EEG alpha and beta oscillatory activities in repetitive extension-flexion finger movements over rolandic regions. Sustained suppression in Mu rhythm was observed during continuous movements which indicated that continuous movements are conducted through neural processing distinct from discrete movements. Bortoletto and Cunnington measured the fMRI responses of repetitive movements, and compared the results with another two finger movements with highly cognitive demands, one was a complicated sequencing task and the other was a timing task20. They found neural activities in lateral prefrontal regions were participated differently in the three tasks, owing to the different levels of cognitive efforts involved in the three tasks. In this study, we aimed to study the oscillatory activities induced by simple repetitive movements in healthy subjects and chronic stroke patients. The difference of oscillatory activities between stroke patients and healthy subjects might be a potential feature to evaluate the recovery of motor function in stroke patients.[…]

Continue —> Study of Repetitive Movements Induced Oscillatory Activities in Healthy Subjects and Chronic Stroke Patients | Scientific Reports

Figure 1

Figure 1: Demonstration of signal processing for quantifying event-related oscillatory response in subject H1.

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[BOOK Chapter] Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study – Full Text

By Marta Rodríguez-Hernández, Carmen Fernández-Panadero, Olga López-Martín and Begoña Polonio-López
DOI: 10.5772/67532


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via Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study | InTechOpen


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Background: Hand dysfunction is a common problem of stroke patients and it is the main cause of impairment of the upper limb. Finding new method to improve hand performance will decrease the disability of chronic stroke patients. Aim of the study: to study the effect of bilateral hand training with weight on the non paretic hand on the hand performance and time of performance in chronic stroke patients.

Materials and Methods: Thirty left chronic stroke patients participated in this study. The patients were assigned randomly into two equal groups. Group one (G1) received unilateral hand training and group two (G2) received bilateral hand training with weight on non affected hand. Both groups assessed two times before starting training program and after two months of training by Fugl meyer assessment scale, Wolf motor function test and hand dynamometer for the motor performance, time of performance and hand grip respectively.

Results: the patients in G2 showed significant improvement in the hand performance (P<.0001) and significant decrease in the time of performance (P<.001) and also significant improvement of hand grip (P<.0001).

Conclusion: Bilateral hand movement with weight on the non affected hand has a significant effect on improving hand performance and decreasing the time of performance and increasing hand grip than unilateral hand movement.

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[ARTICLE] Effects of observation of hand movements reflected in a mirror on cortical activation in patients with stroke – Full Text PDF


[Purpose] The purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

[Subjects and Methods] The subjects of this study were 14 patients with stroke (6 females and 8 males). The subjects were assessed by measuring the alpha and beta waves of the EEG (QEEG-32 system CANS 3000). The mirror therapy intervention was delivered over the course of four weeks (a total of 20 sessions).

[Results] Relative alpha power showed statistically significant differences in the F3, F4, O1, and O2 channels in the situation comparison and higher for hand observation than for mirror observation. Relative beta power showed statistically significant differences in the F3, F4, C3, and C4 channels.

[Conclusion] This study analyzed activity of the brain in each area when patients with stroke observed movements reflected in a mirror, and future research on diverse tasks and stimuli to heighten activity of the brain should be carried out.


Dysfunction from upper extremity hemiparesis impairs performance of many activities of daily living (ADL)1) . Individuals affected by stroke will learn or relearn competencies necessary to perform ADL. Traditionally, the practice of skills provided in neurologic rehabilitation has focused on reducing motor impairment and minimizing physical disability2, 3) . Since 2000, various studies of upper extremity function recovery using interventions such as constraint-induced movement therapy, functional electric stimulation, robotic-assisted rehabilitation, and bilateral arm training have been carried out4) . Such interventions were effective in increasing upper extremity functions in patients with stroke and are continually utilized in the clinical field5–7) .

However, most of the treatment protocols for the paretic upper extremity are labor intensive and require one on one manual interaction with therapists for several weeks, which makes the provision of intensive treatment for all patients difficult8) . Hence, alternative strategies and therapies are needed to reduce the long-term disability and functional impairment from upper extremity hemiparesis9) .

Mirror therapy may be a suitable alternative because it is simple; inexpensive; and, most importantly, patient-directed treatment that may improve upper extremity function8, 10) . Emerging methods in mirror therapy aim to restore motor control through a change in brain function, i.e. motor relearning11, 12) . Voluntary movements of the paretic upper extremity and hand by referring to a mirror activate the bilateral cortex and cause reorganization for other areas around the damaged brain to replace its function, thereby affecting recovery in motor function13) .

Although such methods are promising, they have failed to restore functional motor control for many patients who have experienced stroke. It is important to explore new methods that may facilitate the recovery of brain function and the restoration of more normal motor control14) . Many studies have addressed the neurophysiological effects of mirror therapy. The EEG study gave diverse stimulations to the thumb with or without a mirror to examine which area of the cortex was activated. They observed common activation areas in the primary motor cortex (M1), cingulate, and prefrontal cortex15) . And the study with healthy adults used mirror therapy with functional MRI (fMRI) and showed no difference between the dominant and non-dominant hand. Excitability of M1 ipsilateral to a unilateral hand movement was facilitated by viewing a mirror reflection of the moving hand16) . This finding provides neurophysiological evidence supporting the application of mirror therapy in stroke rehabilitation. Even though, previous studies concerned healthy subjects and had no interventions, a diversity of studies have shown upper extremity functional improvement through mirror therapy8) .

Thus, the purpose of this study was to examine what changes occur in brain waves when patients with stroke receive mirror therapy intervention.

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[ARTICLE] An Original Classification of Rehabilitation Hand Exoskeletons – Full Text PDF


The hand is an organ of grasping as well as sensation, communication, and fine dexterity. Since the 80’s, many researchers have been attempting to develop robotic devices aiming at replicating the functions of the human hand in the fields of industrial robotics, tele-manipulation, humanoid robotics, and upper limb prosthetics.

A special kind of robotic hand is the hand exoskeleton, that is directly attached to the human hand with the aim of providing assistance in motion/power generation. Hand exoskeletons are increasingly widespread in robot-based rehabilitation of patients suffering from different pathologies (in particular neurological diseases).

This paper reviews the state-of-the-art of hand exoskeletons developed for rehabilitation purposes and proposes a new systematic classification according to three key points related to the kinematic architecture: (i) mobility of a single finger exoskeleton, (ii) number of physical connections between the exoskeleton and the human finger phalanges, and (iii) way of integration of the exoskeleton mechanism with the human parts.

The discussion based upon the classification can be helpful to understand the reasons of adopting certain solutions for specific applications and the advantages and drawbacks of different designs, based on the work already done by other researchers.

The final purpose of the proposed classification is then to provide guidelines useful for the design of new hand exoskeletons on the basis of a systematic analysis. As an example, the solution designed, manufactured and clinically tested by the authors is reported.

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[ARTICLE] Perceived ability to perform daily hand activities after stroke and associated factors: a cross-sectional study – Full Text



Despite that disability of the upper extremity is common after stroke, there is limited knowledge how it influences self-perceived ability to perform daily hand activities. The aim of this study was to describe which daily hand activities that persons with mild to moderate impairments of the upper extremity after stroke perceive difficult to perform and to evaluate how several potential factors are associated with the self-perceived performance.


Seventy-five persons (72 % male) with mild to moderate impairments of the upper extremity after stroke (4 to 116 months) participated. Self-perceived ability to perform daily hand activities was rated with the ABILHAND Questionnaire. The perceived ability to perform daily hand activities and the potentially associated factors (age, gender, social and vocational situation, affected hand, upper extremity pain, spasticity, grip strength, somatosensation of the hand, manual dexterity, perceived participation and life satisfaction) were evaluated by linear regression models.


The activities that were perceived difficult or impossible for a majority of the participants were bimanual tasks that required fine manual dexterity of the more affected hand. The factor that had the strongest association with perceived ability to perform daily hand activities was dexterity (p < 0.001), which together with perceived participation (p = 0.002) explained 48 % of the variance in the final multivariate model.


Persons with mild to moderate impairments of the upper extremity after stroke perceive that bimanual activities requiring fine manual dexterity are the most difficult to perform. Dexterity and perceived participation are factors specifically important to consider in the rehabilitation of the upper extremity after stroke in order to improve the ability to use the hands in daily life.

Continue —> Perceived ability to perform daily hand activities after stroke and associated factors: a cross-sectional study | BMC Neurology | Full Text

Fig. 1 Study flowchart


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[VIDEO] Lydia’s Story – Constraint Induced Movement Therapy (CIMT) – YouTube

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[VIDEO] Upper Limb Neurological Examination – OSCE Guide (New Version) – YouTube

Δημοσιεύτηκε στις 16 Φεβ 2015
To see the written guide alongside the video head over to our website…

This video aims to give you an idea of what’s required in the Upper Limb Neurological Examination OSCE.

Always adhere to your medical schools / local hospital trusts guidelines when performing examinations or clinical procedures. Do NOT perform any examination or procedure on patients based purely upon the content of these videos. Geeky Medics accepts no liability for loss of any kind incurred as a result of reliance upon information provided in this video.

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