11

Alex WongAlex WongSenior PhysiotherapistSenior Physiotherapist

Queen Elizabeth HospitalQueen Elizabeth Hospital19 September 200819 September 2008

Lumbar Spine andLumbar Spine and PPelvic elvic DysfunctionsDysfunctions

22

ContentsContents Classification of Lumbo-sacral DysClassification of Lumbo-sacral Dys

functionsfunctions Clinical Reasoning PracticeClinical Reasoning Practice Clinical Concerns Related to ReasClinical Concerns Related to Reas

oning oning Take Home MessageTake Home Message

33

Vague Diagnosis of LBPVague Diagnosis of LBP 80% no structural diagnosis80% no structural diagnosis Limited evidence to support classificatLimited evidence to support classificat

ionion Vague complaints to relate pathologyVague complaints to relate pathology Poor understanding biomechanicsPoor understanding biomechanics Complicated treatment outcomesComplicated treatment outcomes

impairment, disability, capabilityimpairment, disability, capabilitypsychosocial……….psychosocial……….

44

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

PurposePurpose Direct Specific and Effective Direct Specific and Effective Treatments to Homogenous Treatments to Homogenous Sub-groupSub-group

Ford et al, 2007

55

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Treatment BasedTreatment Based Specific exerciseSpecific exercise – extension / flexion – extension / flexion / lateral shift syndrome/ lateral shift syndromeMobilization Mobilization – lumbar / sacroiliac mobi– lumbar / sacroiliac mobilizationlizationImmobilizationImmobilization – immobilization syndr – immobilization syndromeomeTractionTraction – traction / lateral shift syndro – traction / lateral shift syndrome me

George & Delitto, 2005

66

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

McKenzie ApproachMcKenzie ApproachPostural Postural – symptoms after static – symptoms after static positionpositionDysfunctional Dysfunctional – symptoms at end – symptoms at end range range DerangementDerangement – symptoms – symptoms through rangethrough range

MeKenzie

77

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007Physical Therapy Reviews 2007 632 papers retrieved from data base632 papers retrieved from data base 77 papers reviewed full document77 papers reviewed full document 55% uni-dimensional55% uni-dimensional 6% multi-dimensional6% multi-dimensional

Ford et al, 2007

88

Classification ofClassification of Lumbo-sacral Dysfunctions Lumbo-sacral Dysfunctions

Physical Therapy Reviews 2007Physical Therapy Reviews 2007Classification DimensionsClassification Dimensions Patho-anatomy (47%)Patho-anatomy (47%) Signs and Symptoms (58%)Signs and Symptoms (58%) Psychological (51%)Psychological (51%) Social (14%)Social (14%)

No clear guideline to classifyNo clear guideline to classifyFord et al, 2007

99

Clinical ReasoningClinical Reasoning

PracticePractice

1010

Hypothesis-Oriented Algorithm for Hypothesis-Oriented Algorithm for Clinicians II (HOAC II)Clinicians II (HOAC II)

Physical Therapy, Vol 83, No.5, 2003Physical Therapy, Vol 83, No.5, 2003A Guide for Patient ManagementA Guide for Patient Management A framework for science-based cliniA framework for science-based clini

cal practicecal practice Focus on remediation of functional Focus on remediation of functional

deficits deficits How changes in impairments relateHow changes in impairments relate

d to these deficits d to these deficits

Rothstein, 2003

1111

Clinical Reasoning ProcessClinical Reasoning ProcessGenerate Patient Identified and Generate Patient Identified and

Non-identified Problem Lists (S/E)Non-identified Problem Lists (S/E)

Formulate Exam. Strategy Formulate Exam. Strategy

Conduct Examination and Analyze (O/E)Conduct Examination and Analyze (O/E)

Generate Working HypothesesGenerate Working Hypotheses

InterventionInterventionRe-assessment

Rothstein, 2003

1212

Clinical ReasoningClinical Reasoning Generate Patient Identified and Non-iGenerate Patient Identified and Non-i

dentified Problem Lists (S/E)dentified Problem Lists (S/E) Patient’s concernsPatient’s concerns Problems led to seek PTProblems led to seek PT Layman informationLayman informationeg. eg. inability to downstairs (PIP)inability to downstairs (PIP)

contracture after knee amp. (NPIP)contracture after knee amp. (NPIP)

Rothstein, 2003

1313

Clinical ReasoningClinical Reasoning

Formulate Exam. StrategyFormulate Exam. Strategy Establish clinical hypothesis Establish clinical hypothesis Base on Base on pathoanatomic activitiespathoanatomic activities

(pathology, physiology, anatomy, m(pathology, physiology, anatomy, movement science and biomechanicovement science and biomechanics)s)

Change to clinical informationChange to clinical information

Rothstein, 2003

1414

Clinical ReasoningClinical Reasoning Conduct Examination and AnalyzeConduct Examination and Analyze Test the tentative reasons Test the tentative reasons Pathology extent and type not Pathology extent and type not

observable and measurable by observable and measurable by PT PT

Confirm or reject the hypothesesConfirm or reject the hypotheses

Rothstein, 2003

1515

Clinical ReasoningClinical Reasoning

Generate Working HypothesesGenerate Working Hypotheses Working base for interventionWorking base for intervention Causes of problems usually due Causes of problems usually due

to impairmentto impairmenteg. joint stiffness, muscle weakneg. joint stiffness, muscle weakness ess

Causes sometimes relate to patCauses sometimes relate to pathologyhologyeg. wound infectioneg. wound infection

Rothstein, 2003

1616

Clinical ReasoningClinical Reasoning InterventionIntervention

Mainly base on examination findings Mainly base on examination findings (O/E) (O/E)

Usually focus on impairment and funcUsually focus on impairment and functional limitationstional limitationseg. LBP PID (MRI confirmed)eg. LBP PID (MRI confirmed)intervention not designed to change tintervention not designed to change the pathology, but rather the impairmehe pathology, but rather the impairment and disability that the pathology cant and disability that the pathology caused used

Sometimes attempt to eliminate a patSometimes attempt to eliminate a pathology, eg. eliminate the sepsis for whology, eg. eliminate the sepsis for wound healingound healing

Rothstein, 2003

1717

Formulate Examination StrategyFormulate Examination Strategy (base on clinical presentations)(base on clinical presentations)

1818

Formulate Examination StrategyFormulate Examination Strategy (base on clinical presentations)(base on clinical presentations)

Case 1• C/O anterolateral thigh pain during walking• much more pain when up & downstairs (likely hip problem)

Case 2• C/O pain over posterior thigh when bending forward to lift• much relieved when squatting to lift (likely hamstrings/neurodynamic problem)

1919

Conduct Examination, O/E Conduct Examination, O/E (base on examination strategy)(base on examination strategy)

InterventionIntervention(base on examination, O/E, findings)(base on examination, O/E, findings)

2020

Clinical Concerns Clinical Concerns Related to ReasoningRelated to Reasoning

ininLumbo-sacral DysfunctionsLumbo-sacral Dysfunctions

2121

Pathological “Pathological “RedRed Flags” Flags”

Most clues are in history Most clues are in history

NotNot in physical in physical examinationsexaminations

Wilk, 2004Wilk, 2004

2222

Cauda Equina & Widespread NeurologiCauda Equina & Widespread Neurological Disorderscal Disorders

Clinical ConcernsClinical Concerns Bladder dysfunction (rapid & immediatBladder dysfunction (rapid & immediat

e)e) Saddle anaesthesia Saddle anaesthesia Sphincter disturbanceSphincter disturbance Progressive motor weaknessProgressive motor weakness Gait disturbance (spastic, clonus in stairGait disturbance (spastic, clonus in stair

s walking)s walking) UMNL tests positive (Hoffman’s, BabinsUMNL tests positive (Hoffman’s, Babins

ki & Clonus)ki & Clonus) Surgical intervention within 48 hrsSurgical intervention within 48 hrs Wilk, 2004Wilk, 2004

2323

Potential Tissue InjuredPotential Tissue InjuredClinical ConcernsClinical Concerns Vascular Tissues:Vascular Tissues:

inflammatory signs appear within hainflammatory signs appear within half hour after injurylf hour after injurye.g. ligament, muscle, capsule….e.g. ligament, muscle, capsule….

Avascular Tissues:Avascular Tissues:inflammatory signs appear after few inflammatory signs appear after few hours following injury hours following injury

e.g. IV disc, meniscus…..e.g. IV disc, meniscus…..

2424

Facet Joint / Extension Syndrome Facet Joint / Extension Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Lumbar facet joints orientation (sLumbar facet joints orientation (s

agittal plan)agittal plan) Increasing stress due to: Increasing stress due to:

- decreasing IVD height- decreasing IVD height- short hip flexor muscles- short hip flexor muscles- decreased performance of - decreased performance of

abdominal and gluteal muabdominal and gluteal muscles scles - excessive use of hip flexor and - excessive use of hip flexor and

paraspinal muscles paraspinal muscles Harris-Hayes, et al, 2005

2525

Facet Joint / Extension Syndrome Facet Joint / Extension Syndrome Clinical ConcernsClinical Concerns Common with increasing ageCommon with increasing age Facet Joints block excessive eFacet Joints block excessive e

xtension, associate with OA chxtension, associate with OA changes (morning stiff)anges (morning stiff)

Aggravate in prolonged comprAggravate in prolonged compression usuallyession usually

Regular pattern presentationRegular pattern presentation Relieve in stretch patternRelieve in stretch pattern

(opposite to lig./mm strain)(opposite to lig./mm strain) Palpable local joint signPalpable local joint sign Positive finding in local diagnosPositive finding in local diagnos

tic injectiontic injectionHarris-Hayes, et al, 2005

2626

Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc

Applied Anatomy & PhysiologyApplied Anatomy & PhysiologyIntrinsic Discogenic DisorderIntrinsic Discogenic Disorder Avascular tissueAvascular tissue Pain nerves over periphery Pain nerves over periphery After injury, ingrowth of vascular After injury, ingrowth of vascular

granulation tissues & nervesgranulation tissues & nervesalong torn fissures, extend from externaalong torn fissures, extend from external layer of anulus fibrosus to nucleus pull layer of anulus fibrosus to nucleus pulposusposus

Painful disc from injury and repairPainful disc from injury and repairPeng, et al, 2006

2727

Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc

Applied Anatomy & PhysiologyApplied Anatomy & PhysiologyProlapsed Inter-vertebral DiscProlapsed Inter-vertebral Disc Fissures communicated, disc materialFissures communicated, disc material

s protrudeds protruded Axilla / shoulder regions protrusion Axilla / shoulder regions protrusion

ipsilateral / contralateral Lx listingipsilateral / contralateral Lx listing L5 nerve may be compressed by L4/5 L5 nerve may be compressed by L4/5

or L5/S1 discor L5/S1 discL5/S1 disc may compress L5 and /or L5/S1 disc may compress L5 and /or S1 nervesS1 nerves

Nerve compression irritation Nerve compression irritation Neural tissues ischaemic inflammationNeural tissues ischaemic inflammation

Peng, et al, 2006

2828

Clinical ConcernsClinical Concerns Nature of injury (F/Rot)Nature of injury (F/Rot) Delayed symptoms after injuryDelayed symptoms after injury Sensitive to vibrationSensitive to vibration Morning symptoms Morning symptoms Increase symptoms on changingIncrease symptoms on changing

intra-abdominal pressureintra-abdominal pressure Restricted mov’t of neuro-tissuesRestricted mov’t of neuro-tissues Lumbar listing (ipsilat. / contralat.)Lumbar listing (ipsilat. / contralat.) Diagnosed by MRI (match with sym)Diagnosed by MRI (match with sym)

Pathogenesis of Pathogenesis of Inter-vertebral DiscInter-vertebral Disc

Peng, et al, 2006

2929

Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeApplied Anatomy & PhysiologyApplied Anatomy & Physiology Weight-bearing synovial jointWeight-bearing synovial joint MovementMovement

A-P translation : ~3 to 7 mmA-P translation : ~3 to 7 mmA-P rotation : ~3 to 5 degreeA-P rotation : ~3 to 5 degree

Male: likely fused in late 40 Male: likely fused in late 40 Female in late 60Female in late 60

DonTigny, 1990 DeMann, 1997

3030

Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeApplied Anatomy & PhysiologyApplied Anatomy & Physiology Stable with form and force closureStable with form and force closure

Form closure: closely fit joint surface (sulcuForm closure: closely fit joint surface (sulcus)s)Force closure: muscles, ligaments & thoracoForce closure: muscles, ligaments & thoracolumbar fascialumbar fascia

No direct prime mover muscle No direct prime mover muscle Strong dorsal / ventral SI Strong dorsal / ventral SI

& sacrotuberous ligaments& sacrotuberous ligaments Anterior dysfunction more likelyAnterior dysfunction more likely One of common metastasis areaOne of common metastasis area

DonTigny, 1990 DeMann, 1997

3131

Inter-rater Reliability of SIJ TestsInter-rater Reliability of SIJ Tests(Oldreive,1995)(Oldreive,1995)

Test % of AgreementIliac crest standing level 35

Iliac crest level in sitting 41

PSIS level in standing 35

PSIS level in sitting 35

ASIS level in sitting 43

ASIS level in standing 38

Standing flexion test 43

Sitting flexion 50

Side-lying iliac approximation 76

Supine/long sitting test 40

3232

Reliability SIJ TestsReliability SIJ Tests(Freburger JK & Riddle DL,1999)(Freburger JK & Riddle DL,1999)

♦ 4 Tests:Gillet,stand flexion,sit flexion,supine to sit test

♦ Results:– Sensitivity:8-44%– Specificity:64-93%– Negative predictive value:28-38%– Positive predictive value:61-79%

3333

Reliability of SIJ TestsReliability of SIJ Tests(Cibulka MT & Koldehoff R, 1999)(Cibulka MT & Koldehoff R, 1999)

♦ 4 clinical tests used together:stand flexion test,PSIS palpation,supine long sitting leg length test,prone knee flexion test

♦ at least ¾ test should positive for positive♦ Result

– Sensitivity :82%– Specificity: 86%– Negative predictive value: 84%– Positive predictive value: 86%

3434

Sacral Iliac Joint SyndromeSacral Iliac Joint SyndromeClinical ConcernsClinical Concerns Age / Sex Age / Sex History of Trauma / child-birthHistory of Trauma / child-birth Buttock pain / tender over PSISButtock pain / tender over PSIS Symptoms likely not below kneeSymptoms likely not below knee Symptoms when rolling at nightSymptoms when rolling at night Occ cross SLR / Step forward painOcc cross SLR / Step forward pain Muscle imbalanceMuscle imbalance

Priformis, Priformis, Hamstring, iliopsoasHamstring, iliopsoas, , Gluteus maximusGluteus maximus

Cluster of tests to confirmCluster of tests to confirmDonTigny, 1990 DeMann, 1997

3535

Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Applied Anatomy & PhysiologyApplied Anatomy & Physiology Vascular Vascular (Intermittent Claudication)(Intermittent Claudication) : :

- arterial insufficient of distal aorta,- arterial insufficient of distal aorta, iliac or femoral arteries iliac or femoral arteries- ischemic symptoms- ischemic symptoms

Spinal Spinal (Spinal Stenosis):(Spinal Stenosis): - IVF occlusion- IVF occlusion- mechanical constriction and irrita- mechanical constriction and irritation of spinal nervestion of spinal nerves- impinging spinal nerves usually i- impinging spinal nerves usually in dynamic extension pattern n dynamic extension pattern Gray, 1999

3636

Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Clinical ConcernsClinical ConcernsVascular:Vascular: Heavy smoker, > age 40 maleHeavy smoker, > age 40 male Diabetes, obesity, coronary heart disease Diabetes, obesity, coronary heart disease Common in calf, cramp, decrease dorsaliCommon in calf, cramp, decrease dorsali

s pedis pulses pedis pulse Symptoms appear after similar distance wSymptoms appear after similar distance w

alk, fast symptoms relieve with rest, alk, fast symptoms relieve with rest, even even slow walking or standingslow walking or standing

Worse in slope walking Worse in slope walking Gray, 1999

3737

Vascular Vs Spinal ClaudicationVascular Vs Spinal Claudication Clinical ConcernsClinical ConcernsSpinal:Spinal: Symptoms aggravated by walking aSymptoms aggravated by walking a

nd change of body positionsnd change of body positions Slow relieve by sitting or squattingSlow relieve by sitting or squatting Worse even in prolonged standingWorse even in prolonged standing Various walking toleranceVarious walking tolerance Neuropathy symptomsNeuropathy symptoms Gelderen Bicycle testGelderen Bicycle test

Gray, 1999

3838

Applied Anatomy & PhysiologyStructural Defect (Spondylolisthesis) Grade (I – III), likely at L4/L5 and L5/

S1 Review the flexion / extension

x-ray view Lumbar curvature kink Usually associated with abdominus

weakness / hamstring tightness

Lumbar Dynamic StabilityLumbar Dynamic Stability

3939

Applied Anatomy & PhysiologyNeuromuscular Defect Global Muscles

larger torque producing musclesbalance external loadsspine: erector spinae

Intrinsic Musclessmall local musclescontrol joint position & mov’t planesspine: multifidus; transversus abdominus

Lumbar Dynamic StabilityLumbar Dynamic Stability

4040

Neuromuscular Control

Lumbar Dynamic StabilityLumbar Dynamic Stability

Active StructuresPassive Structures

Panjabi, 1992Panjabi, 1992

Neutral ZoneNeutral Zone

• A region of no or little resistance to motion in the middle of an IV joint’s ROM

• Min. Passive Tissue StiffnessGay et al, 2006

4141

Lumbar Dynamic StabilityLumbar Dynamic StabilityNeutral ZoneNeutral Zone

• A feature of natural ROM• Exists mainly in flexion / extension• Facet joint contribute much on NZ

stability• Small change in torque gives

moderate change in position

• Require complex control of IV joints by spinal muscles

• Increase with increasing disc degeneration or injuries

• Decrease with addition of muscle forces / spinal instrumentation

Gay et al, 2006

4242

Clinical ConcernsChronic LBP Studies demonstrated delay on

set or poor motor control of the intrinsic muscles

Multifidus max contracts at upright standing in normal subjects, while max. in 25 forward stooping in LBP patients

Lumbar Dynamic StabilityLumbar Dynamic Stability

Hides, 1994; Lee et al, 2006

4343

Clinical Concerns Decrease the cross section are

a of multifidus over the injured / defect segment

Clinically ‘catching pain’ in different range of motionesp. forward flexion

Intrinsic muscles minimize unnecessary rotational stress over the disc

Lumbar Dynamic StabilityLumbar Dynamic Stability

Hides, 1994; Lee et Al, 2006

4444

Thoracolumbar Junction SyndromeThoracolumbar Junction Syndrome

Applied Anatomy & PhysiologyApplied Anatomy & Physiology Transition zone between two regioTransition zone between two regio

ns of facet orientationns of facet orientation Thoracic – coronal planeThoracic – coronal plane

Lumbar – sagittal planLumbar – sagittal plan T12 - Superior facet inclined as TxT12 - Superior facet inclined as Tx

Inferior facet inclined as Inferior facet inclined as Lx Lx

T12 as an intermediate vertebrae T12 as an intermediate vertebrae during trunk rotationduring trunk rotation

Sebastian, 2006

4545

Thoracolumbar Junction Syndrome Thoracolumbar Junction Syndrome

Clinical ConcernsClinical Concerns Symptoms at upper Lx and gluteal reSymptoms at upper Lx and gluteal re

gions gions Considerable Considerable rotational stressrotational stress in TL a in TL a

nd LS junctions nd LS junctions Associated with impact injuryAssociated with impact injury

(slipped / fell with buttock landed)(slipped / fell with buttock landed) One of the common osteoporotic siteOne of the common osteoporotic site

Sebastian, 2006

4646

Neurodynamic Dysfunction Neurodynamic Dysfunction Applied Anatomy & PhysiologyApplied Anatomy & Physiology Neuro- connective tissues involvemeNeuro- connective tissues involveme

ntnt Dynamic mechanical irritationDynamic mechanical irritation Circulation deficiency (extra / intraneuCirculation deficiency (extra / intraneu

ral circulatory systemral circulatory system Occasionally associated with neurogeOccasionally associated with neuroge

nic signsnic signs Common adhesion sites at C6, T6 anCommon adhesion sites at C6, T6 an

d L4 (approximate points)d L4 (approximate points) SLR, Slump, ULTTsSLR, Slump, ULTTs

Bulter, 1992; Ko et al, 2006

4747

Neurodynamic Dysfunction Neurodynamic Dysfunction Clinical ConcernsClinical Concerns Relative dynamic mov’t of neuro-connectiRelative dynamic mov’t of neuro-connecti

ve tissues deficiency:ve tissues deficiency:- total length insufficiency, adhesion to se- total length insufficiency, adhesion to sensitive structures, poor excursion / glidinnsitive structures, poor excursion / gliding movementsg movements

Distal symptoms dominatedDistal symptoms dominated Morning severityMorning severity Associated with spine post-op complicatiAssociated with spine post-op complicati

onon Aware latency effect after neurodynamic Aware latency effect after neurodynamic

treatmenttreatment- prefer for stable symptoms- prefer for stable symptoms Bulter, 1992; Ko et al, 2006

4848

Piriformis Syndrome Piriformis Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Sacral plexus L5, S1,2Sacral plexus L5, S1,2 Mainly hip external rotatorMainly hip external rotator Entrapment of sciatic nerve Entrapment of sciatic nerve Comparable to sciaticaComparable to sciatica Buttock pain with muscle Buttock pain with muscle

trigger pointstrigger points

Kuncewicz, et al, 2006

4949

Piriformis Syndrome Piriformis Syndrome Clinical ConcernsClinical Concerns Symptoms similar to sciaticaSymptoms similar to sciatica After fall / leg twisting injury, pyAfter fall / leg twisting injury, py

omyositis, fibrosis after deep iomyositis, fibrosis after deep injectionnjection

Tight hip external rotatorTight hip external rotator Supine lying with different hip rSupine lying with different hip r

otation when compared on bototation when compared on both sidesh sides

Buttock pain on stretching the Buttock pain on stretching the musclemuscle

Fair tolerance on SLSFair tolerance on SLSKuncewicz, et al, 2006

5050

Thoracic Outlet Syndrome Thoracic Outlet Syndrome Applied Anatomy & PhysiologyApplied Anatomy & Physiology Non-specific labelNon-specific label Vascular: obstruction of subclaviaVascular: obstruction of subclavia

n artery / veinn artery / veindue to: stenosis, cervical rib, throdue to: stenosis, cervical rib, thrombosis mbosis

Neurogenic: brachial plexus comNeurogenic: brachial plexus compression pression due to: scared / tight scalene mudue to: scared / tight scalene musclesscles

Sanders et al, 2007

5151

Thoracic Outlet Syndrome Thoracic Outlet Syndrome

5252

Thoracic Outlet Syndrome Thoracic Outlet Syndrome Clinical ConcernsClinical Concerns ~ 90% neurogenic ~ 90% neurogenic Adson Test minimum clinical valuAdson Test minimum clinical valu

ee Neck rotation, head tilting elicit syNeck rotation, head tilting elicit sy

mptoms over contralateral armmptoms over contralateral arm Abducting arm to 90Abducting arm to 90in external roin external ro

tation leads to symptoms within 6tation leads to symptoms within 60 sec0 sec

Symptoms with carrying low weigSymptoms with carrying low weightht

Symptoms during sleeping Symptoms during sleeping Sanders et al, 2007

5353

Take Home MessageTake Home Message Make use of anatomy, physiology, pathMake use of anatomy, physiology, path

ology, movement sciences and biomecology, movement sciences and biomechanics knowledge to analyze hanics knowledge to analyze pathoanpathoanatomic activitiesatomic activities

Integrate into clinical contextIntegrate into clinical context Test your Test your clinical hypothesesclinical hypotheses Looking for Looking for physical problemsphysical problems to treat to treat Confirm with patient’s responseConfirm with patient’s response

5454

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