1
Q
Rest @ the end, NOT IN THE MIDDLE!!!
A
Rest when you ARE FINISHED!!!!
2
Q
CVA- 2 Types
A
Ischemic
- Blood flow obstructed
Hemorrhagic
- Ruptured blood vessel leaks blood INTO brain
3
Q
Vascular Syndromes:
Anterior Cerebral Artery (ACA)
2 BIG things to remember w/ LOSS
A
- C/L motor and sensory loss: LE>UE
- Sensory loss: LE>UE
4
Q
Vascular syndromes:
ACA
ALL things: get the jist
A
- C/L M & S loss: LE>UE
- Sensory loss: LE>UE
- Memory/Behavioral impairs d/t Frontal lobe involve (A.CEO)
- Urinary incont
- Probs w/ imitation, Bimanual tasks, aPraxia
5
Q
Vascular Syndromes:
Middle Cerebral Artery
What about MCA?
A
MOST AFFECTED ARTERY!!!
aka most common loc. for ischemic stroke
6
Q
Vascular Syndromes:
MCA
A
- C/L M & S loss involving UE and face
- UE>LE
- C/L homonymous hemianopsia
Dominant Side (Left stroke): Aphasia
NONdominant Side (Right stroke): Perceptual problems
- U/L neglect, depth perception, spatial relations, aGnosia, aPraxia
Depth perception Ex. step ups and knowing how much effort to use
7
Q
Vascular Syndromes:
Posterior Cerebral Artery
A
Think VISION!!!
memory
thalamic pain
8
Q
Vascular Syndromes:
PCA
A
- C/L Homonymous hemianopsia
- Memory deficits
- Visual aGnosia (recoGnizing)
- ProsopaGnosia** diff naming people on site/recoGnize faces
- Central poststroke (Thalamic) pain**
9
Q
Practice!
53yo male had stroke affected his ACA. Which presentation?
A
C/L hemiparesis of LE, urinary incont, aPraxia (planning prob), C/L hemisensory LE
10
Q
Homonymous Hemianopsia (MCA, PCA) vs Hemineglect (R stroke, MCA, perceptual prob)
A
Homonymous Hemianopsia
- Visual Field defect
- actively have pt look that way where cut is
Hemineglect
- perceptual deficit
- NOT paying attn to that side
see pics
11
Q
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
A
- incorrect perception of self & illness (this is where they dont realize they have deficits)
- incorrect perception of self in space–> may neglect ALL Input from affected side
- AGnosia (come back to this)
- APraxia (come back to this)
12
Q
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
AGnosia
A
INability to recoGNize an obj by sight, touch, hearing
13
Q
Spatial-Perceptual Dysfunction
R. stroke, MCA, NONdom side
aPraxia
Talk about 2 types also… Ideational vs Ideomotor
A
INability to carry out learned/purposeful, sequential mvmts on command
aPraxia-motor Planning prob
- Ideational: Lost ability to recognize & what obj used for–> EX. think Toothbrush is for writing
- Ideomotor: Lose ability to do purposeful tasks on command–> Ex. Dr. Cohens pt in waiting room “stand up.” Ex. Brush your teeth–> cannot, even tho they brushed their teeth earlier in day
14
Q
Practice!
PT commands pt to pick a pen amongst straws, unable to complete d/t inability to FIND pen. MOST APPROP dx?
A
Form Discrimination
aka cannot “discriminate” bw pens and straws
Figure-Ground Discrim–background makes diff to find figure
15
Q
Types of Aphasia:
In terms of Comprehension
A
- Pt does not comprehend speech==Wernicke’s==Fluent
- Pt does not comprehend speech==Global aphasia==NON-fluent
- Pt DOES comprehend speech==Broca’s==NON-fluent
16
Q
Fluent speech aphasia
A
Wernicke’s
- Pt does NOT comprehend (comprehension prob)
- receptive
17
Q
NON-fluent speech aphasias
A
Broca’s
- Pt comprehends
- BEN has Broca’s–> Broca’s, Expressive, Non-fluent; Broken syntax
Global aphasia (s/s both Wernicke’s/Broca’s)
- Pt DOES NOT comprehend speech
18
Q
Fluent (WernIcke’s/Sensory/Receptive) Aphasia
What artery and S/S?
A
INF MCA
- Lesion=> Auditory assoc. cortex L. Lat Temporal Lobe
- Speech flows smoothly w/ variety of grammatical constructs and preserved melody of speech
- Comprehension impaired
- Pt demos diff in comprehending lang and in following commands
remember Temporal lobe is hearing and COMPREHENDING what we hear!
19
Q
NON-fluent aphasia (Broca’s/Expressive aphasia)
What artery and S/S?
NOTE: Comprehension is OK
A
SUP MCA
- Premotor area of L. Frontal lobe
- FLOW of speech slow, hesitant, vocab limtd, syntax impaired
- COMPREHESION GOOD
- Speech production labored or lost completely
20
Q
Side Specific Sx’s
Right CVA
Think “baby in a Rocker
Impulsive makes decisions too quickly–> Baby in a Rocker
A
- LEFT side weak/paralysis
- Left neglect, spatial-perceptual probs
- IMPULSIVE!
- Short attn, STM loss
- Communication probs—weak facial mm’s
- Cog probs
Gait belt! NEVER leave pt alone! IMPULSIVE!
21
Q
Side Specific Sx’s
Left CVA
Think “OLD person”
CAUTIOUS in making judgements; act like OLD person
A
- RIGHT side weak/paralysis
- Aphasias–> Dmg’d Brocas (frontal) or Wernickes (temporal)
- Personality changes– Cautious (opp to R side), disorganized
- Diff w/ NEW info–> dec memory, diff generalizing or conceptualizing
MOTIVATE YOUR Pt!!! d/t slow, cautious, unmotivated
22
Q
Practice!
Pt w/ recent R sided CVA has perceptual deficits and poor awareness of impairments. Which strategies to use?
A
- more verbal cues/commands
- Supine pos–> L scapula should be protracted and shoulder slightly abd’d
- L S/L- L. hip should be extended and knee flexed and supported by pillows
Visual cues not good bc they hve perceptual problems!
23
Q
Positive and Negative Features of Upper Motor Neuron Syndrome
A
see chart
24
Q
Reflexes
DTRs vs Pathologic
A
DTRs
- Asymmetry
- UMN: HypERreflex
- LMN: HypOreflex
Pathologic
- Babinksi–> Clear UMN sign
25
Practice!
New pt w/ LEFT CVA. Initial exam, what s/s most likely present?
OLD lady! slow cautious, R motor and sensory loss, R weakness, language defs aphasias, personality changes, decd memory,
Clonus of gastroc mm R. lower limp (abnorm reflexes)
NOT rigidity! Spasticity in CVA present
26
Abnormal Synergy Patterns
**Just memorize which ones are more predominant in UE (flexion)/LE (extension)**
This way if you remember the more common ones, the LESS common are just the OPPOSITE!!! So only remember 1 for ea!
UE abnorm synergy: **FLEX more common**
LE abnorm synergy: **EXT more common**
27
Abnormal Synergy Patterns
**UE: more common and entails?**
| Inc tone, multi jts
Unable to move jt individually
no **isolated** mvmts
FLEXION synergy more common
- Scapular **retraction, elevation, hyperext**
- Shoulder **ABD, ER**
- Elbow **Flex**
- Forearm **SUP**
- Wrist and finger **Flex**
*AND THEN YOU KNOW THAT EXT IS OPP OF ALL OF THESE!*
28
Abnormal Synergy Patterns
**LE: More common and entails what?**
EXTENSION synergy more common
- Hip **EXT, ADD, IR**
- Knee **EXT**
- Ankle **PF, INversion**
- Toe **Ext**
*Now you know w/ Flexion LE synergy it is just the OPP*
| Circumducted gait bc LE "longer"
29
# Brunnstrom Stages of Recovery (Cohen)
Stage I: Flaccidity
- Flaccidity of involved limbs
- NO reflex OR voluntary mvmts
30
# Brunnstrom Stages of Recovery (Cohen)
Stage II: Beginning of MIN voluntary mvmt
- Min. voluntary mvmt or **assocd reactions**
- Mvmts in **partial or whole** synergy patterns
- Spasticity BEGINS to develop
**Assocd reactions-- contraction elsewhere in body causes contract where observing**
31
# Brunnstroms Stages of Recovery (Cohen)
Stage III: Voluntary control of mvmt synergy (splints, RIPs)
**Diff stage bc spasticity @ PEAK**
- Voluntary control of mvmt synergies
- Mvmt may NOT be full ROM
- **Spasticity @ peak--HypERtonia (severe)**
32
# Brunnstroms Stages of Recovery (Cohen)
Stage IV: Dec Tone
- SOME mvmts OUT of synergy
- Spasticity DEC, but observable
**- Indiv can: ** place hand behind body, elevate arm to forward horz pos (flex), PRO/SUP w/ elbow @ 90deg
33
# Brunnstrom Stages of Recovery (Cohen)
Stage V: Declining spasticity
- Declining spasticity****
- INC in complex mvmt; able to perform more diff mvmts OUT of synergy
- **Ind can:** abduct arm, flex arm and OH, Pro/Sup w/ elbow ext'd
34
# Brunnstroms Stages of Recovery (Cohen)
Stage VI: Indiv, isolated jt mvmts
- Indiv jt mvmt, coord'd mvmt (nearly norm)
- NO spasticity!
- **Ind can:** hand from lap to chin, hand from lap to opp knee (MAJOR PROGRESS d/t isolating elbow is diff)
35
# Brunnstroms Stages of Recovery (Cohen)
Stage VII: Normal motor function
Normal motor function
36
Brunnstrom's Stages of Recovery
See pics and note the INC in spasticity to DEC and moving from synergies to controlling synergies to isolated mvmts!
37
Practice!
PT eval'ing 86yo w/ R CVA due to MCA infarct 4 wks ago. Classic s/s MCA CVA. Reflex testing. What should PT expect?
L. sided hypERreflex and + Babinski (toes fan out)
38
# Positioning Strategies to Reduce Common Malalignments
UE or LE, what is the basic jist/point of positioning? What do we want to do/achieve?
Want to BREAK OUT of all synergies!
Put them in pos's OPP of synergies!
39
# Positioning Strategies to Reduce Common Malalignments
Supine position
Head, Neck, and if **more affected UE (remember FLEX synergy more common)**
| LE other card
HOW TO SET THEM UP:
Head/Neck: Neutral and symmetrical; support on pillow
Trunk: Aligned @ midline
**More affected UE (flexor syn common):** Scapular **protracted;** Shoulder **forwrd/slight abd'd;** arm supported on pillow; Elbow **ext'd w/ hand resting on pillow;** Wrist **neutral;** Fingers **ext'd;** Thumb **abd'd**
40
# Pos'ing Strategies to Reduce Common Malaligns
Supine position
Head, Neck--> you did prev card
If **more affected LE (remember EXT synergy more common)**
HOW TO SET THEM UP:
**More affected LE (EXT synergy more common)**
- Hip **forward (pelvis PROtracted);** Knee on small pillow or towel roll to **prevent hyperEXT;** NOTHING against soles of feet.
- *If persisten PF, **splint** can be used to pos. foot/ankle in **neutral pos.**
41
# Positioning Strategies to Reduce Common Malalignments
**S/L on MORE Affected Side**
Head/Neck, Trunk, **More affected UE (Flexion synergy common)**
Head/Neck: Neutral/Symmetrical
Trunk: Alignment in **midline**
More affected**UE (Flexion common):** Scapular **protracted;** Shoulder **forward;** Arm in **slight ABD/ER;** Elbow **Extd;** Forearm **sup;** Wrist **neutral** Fingers **extd;** Thumb **abd'd**
42
# Positioning Strategies to Reduce Common Malalignments
**S/L on MORE Affected Side**
Head/Neck, Trunk, **More affected LE (EXT synergy common)**
Head/neck--see prev
Trunk--see prev
**More affected LE (EXT synergy):** Hip **extd and knee flexed and supported by pillows.** ALTERNATIVE pos--> Slight hip and knee flexion w/ pelvic rotation
43
# Positioning Strategies to Reduce Common Malalignments
**S/L on LESS AFFECTED Side**
Head/Neck, Trunk, **More affected UE (Flexion synergy common)**
Head/Neck: Neutral and Symmetrical
Trunk: Aligned in MIDLINE; small pillow or towel can be placed under rib cage to **elongate the hemiplegic side.**
**More affected UE (flexion more common):** Scapular **protracted,** Shoulder **forward;** Arm on a supporting pillow w/ Elbow **Extd,** Wrist **neutral,** Fingers **extd,** Thumb **abd'd**
44
# Positioning Strategies to Reduce Common Malalignments
**Sitting in Armchair or W/C**
Head/Neck, Trunk, Pelvis, More affected **UE,** **Both LEs**
Head/neck: Neutral/Symmetrical; **head directly above pelvis**
Trunk: Spine **EXT**
Pelvis: Aligned in neutral w/ **WB on buttocks**
More affected **UE:** Shoulder **protracted and forwrd;** Elbow supported on arm trough or lapboard; Forearm/wrist **neutral,** Fingers **extd,** Thumb **abd'd (resting splint prn)**
BOTH **LEs:** Hips **flexed to 90/90,** pos'd in **neutral w/ respect to rotation.**
45
Practice!
82yo suffered R. stroke (L affected) a week ago. PT educating him on various pos strategies. MOST approp for **S/L on LEFT side (affected side?**
Head/Neck: neutral
L. scapular protracted
L arm in sligh ABD/ER
Elbow EXTd
Forearm sup'd
Wrist neutral
Fingers EXTd
Thumb ABD'd
46
Practice!
82yo suffered R. stroke (L affected) a week ago. PT educating him on various pos strategies. MOST approp for **S/L on LEFT side (affected side?**
Head/Neck: neutral
L. scapular protracted
L arm in sligh ABD/ER
Elbow EXTd
Forearm sup'd
Wrist neutral
Fingers EXTd
Thumb ABD'd
47
Pusher Syndrome aka
**Contraversive pushing**
- Push **ONTO WEAK side-->** using STRONG side to push to weak side
Tx's:
- Have pt push/lean onto you AWAY from weaker side
- Mirror tx
- Have strong side next to wall and ask them to lean onto wall
48
Stroke- Interventions using **N**euro**d**evelopmental **T**echniques (**NDT)**
Kickstand
Tactile cueing on quads w/ clasped hands
49
PNF
UE PNF Patterns
| Chart, but you KNOW THESE!!!
SEE PICS
50
PNF: **UE D1 Flex/Ext**
Flex think **Eating**
Ext think **Pushing away**
| **HEAD MUST FOLLOW ARM/HAND TO BE PNF!!!**
D1 **Flex:**
- Shoulder: Flex, Add, ER
- Forearm: Sup
- Wrist: Radially flexed
- "Eating"
D1 **Ext:**
- Shoulder: Ext, ABD, IR
- Forearm: PRO
- Wrist: Ulnarly ext'd
- "Pushing away"
51
PNF: UE **D2 Flex/Ext**
| HEAD **MUST** FOLLOW ARM/HAND TO BE PNF!!!
D2 **Flex:**
- Shoulder: Flex, Abd, ER
- Wrist: Radially Extd
- **Drawing a sword**
D2 **Ext:**
- Shoulder: Ext, ADD, IR
- Wrist: Ulnarly flexed
- **Putting sword BACK**
52
# Implementing PNF into HEP
Head/neck and Trunk **Chop**
| Think Chop DOWN: D1 Flex into D1 Ext
Lead arm (**weak arm)** BEGINS D1 flex and moves into D1 ext
*use Opp arm (strong) arm to assist (opp arm moving in D2 patterns--dont memorize this)
| Head, neck, and trunk must all go WITH WRIST/HAND
53
# Implementing PNF into HEP
Head/neck and Trunk **Lift**
| Think Lift UP: D2 Ext into D2 Flex
Lead arm (**weak arm)** BEGINS D2 EXT and moves into D2 FLEX
| Upper trunk, head and neck extend/rotate TOWARD lead hand--MUST FOLLOW
54
# UE PNF- **Thrust Pattern aka Boxing!**
Thrust Pattern
see pics
55
LE PNF Patterns- **Overview**
LE/**D1--** F**AdER**; E**ABIR**
LE/**D2--** F**ABIR**; E**AdER**
56
**D1 LE-Flex/Ext**
| D1 Flex: put pants on or socks, cross
D1 Ext: getting out of car
LE D1 **Flexion**
- Hip flex, add, ER
- Knee flex or ext
- Ankle DF, Inv
- Toe ext
- "Putting pants on or socks, cross"
LE D1 **Extension**
- Hip ext, abd, IR
- Knee flex or ext
- Ankle PF, EV
- Toe flex
- "Getting out of car"
57
D2: LE **Flex/Ext**
| D2 Flex: Moving over in seat- very AWK
SAME POS @ KNEE FOR ALL****
LE D2 **Flexion:**
- Hip flex, abd, IR
- Knee flex or ext
- Ankle DF, EVersion
- Toe flexion
LE D2 **Extension**
- Hip ext, add, ER
- Knee flex or ext (SAME @ KNEE FOR ALL)
- Ankle PF, INV
- Toe flexion
58
Practice!
Pt w/ PD exhibits forward stooped posture. Which PNF pattern MOST approp for posture?
B/L D2 Flexion
**Draw 2 swords!!!**
59
TBI's
**Coup and Contrecoup**
see pics
60
Glasgow Coma Scale **(EMV)**
LESS than _ == COMA
| Eye: 1-4; Motor: 1-6; Verbal: 1-5
< 8
61
Glasgow Coma Scale **(EMV)**
What is it/How scored?
Score interpretations?
Obj way to describe pts **Lvl of Consciousness**
- **E**ye: 1 (never)-4(spont.)
- **M**otor: 1(none)-6(obeys commands)
- **V**erbal: 1(none)-5(Oriented)
Scores:
- **3-8= SEVERELY ABNORMAL**
- 9-12= MOD abnorm
- 13-14= Mild abnorm
- 15= MILD TBI
62
Glasgow Coma Scale
**Eye Opening: 1-4**
4: Spontaneous
3: To sound
2: To pain
1: Never
63
Glasgow Coma Scale
**Motor Response: 1-6**
6: Obeys commands
5: Localizes pain
4: Normal flexion (w/drawal)
3: ABnormal flexion
2: Extension
1: None
64
Glasgow Coma Scale
**Verbal Response: 1-5**
5: Oriented
4: Confused conversation
3: Inapprop words
2: Incomprehensible sounds
1: None
65
TBI- Tone abnorms
**Decorticate posturing vs** D**e**c**e**r**e**brat**e** (all the E's)
Decorticate== FLEXION one in UEs
D**e**c**e**r**e**brat**e** (all the E's)== **E**XT one!
66
Practice!
Pt dx w/ TBI. Pt **opens eyes to speech, makes convo w/ inapprop words, w/drawals from touch and rolls eyes.** Lvl of severity?
Opens to speech= 3
inapprop words= 4
w/drawals= 4
**=11= Mildly abnorm**
67
Rancho Los Amigos: **Lvl of Cog Functioning**
| Lvl you HAVE TO KNOW
Lvl 4: Confused-Agitated-- Needs MAX ASSIST
68
RLA: Lvl of Cog Functioning
Break it down by Lvl, Response, Assist
| This will help you get it organized!!!
Lvl I: NO response: **TOTAL** assist
Lvl II: Generalized response: **TOTAL** assist
Lvl III: Localized response: **TOTAL** assist
**Lvl IV: Confused-Agitated: MAX assist** **(problem lvl)**
Lvl V: Confused-Inapprop: MAX assist **(angry stage)**
Lvl VI: Confused-Approp: MOD assist
Lvl VII: Automatic-Approp: MIN assist
Lvl VIII: Purpose-Approp: Stand-By assist
69
**Rancho Lvl IV**
| KNOW THIS ONE!!!!
**RLA IV**
**Confused-Agitated**
- Alert, INCd state of activity
- Aggressive or flight behavior
- **absent STM**
- UNable to cooperate w/ tx
**Set up the environment!!!--more on this**
70
**Rancho Lvl IV**
Set up Environment
| THE ONE TO KNOW!
Set up environment + other deets:
- Quiet room, Remove distractions, Remove objs that could be thrown or used aggressively
- Simple instructions w/ process time
- Watch frustration--know when to stop/change acts.
- Safe choices--**allows pt to feel they have control over situation**
Interventions?--next cards
71
Rancho Lvl IV: **Interventions**
- NOTE: give control to pt when SAFE and APPROP. Control given while maint. focus on therap. goals by **phrasing questions as, "would you rather play ball or go fora walk?** PREVENTS situations where the pt chooses an undesirable or unrealistic activity if asked "What would you like to do?" Or case where pt simply answers "NO" when asked "Would you like to...?"
**Motor probs:**
- Prepare **MULT**. acts
- Give pt **choices** (No y/n ?'s)
**Behavioral probs:**
- Be calm, Be consistent (SAME tx time, PT, loc)
- Provide orientation
- Know when to stop/change acts.
71
Rancho Lvl IV: **Interventions**
- NOTE: give control to pt when SAFE and APPROP. Control given while maint. focus on therap. goals by **phrasing questions as, "would you rather play ball or go fora walk?** PREVENTS situations where the pt chooses an undesirable or unrealistic activity if asked "What would you like to do?" Or case where pt simply answers "NO" when asked "Would you like to...?"
**Motor probs:**
- Prepare **MULT**. acts
- Give pt **choices** (No y/n ?'s)
**Behavioral probs:**
- Be calm, Be consistent (SAME tx time, PT, loc)
- Provide orientation
- Know when to stop/change acts.
72
Rancho Lvl V:
**Confused-INapprop, NON-AGITATED**
| Deets:
- Unable to learn **new info**
- Freq brief pds, NON-purposeful sustained attn
- **Consist approp resp to SIMPLE commands in structured environ**
- Demos INapprop use of objs **w/out ext. direction**
Interventions? next cards
73
Rancho Lvl V:
**Confused-INapprop, NON-AGITATED**
| Interventions:
- Quiet environment, HIGHLY structured **functional tasks,** Give control to pt when safe/approp
- Give **options**
- Use **cues/ext. direction**
- **Use Assistive devices**
- Tx plans-- include using daily planner
74
Rancho Lvl VI:
**Confused-Approp**
| Deets
- LITTLE carry-over for **new learning**
- MAX A for new learning w/ little or no carry over
- **Consistently follows SIMPLE directions**
- **Unaware of impairs, disabilities and safety risks (KNOW THIS ONE!)**
INTERVENTIONS? NEXT CARDS
75
Rancho Lvl VI:
**Confused-Approp**
| Interventions:
- HIGHLY structured **functional tasks**
- **DECREASE:** use of cues/ext direction, use of ADs (opp of RLA V: Confused-INapprop)
- **INC:** speed and complexity of tasks as able
76
Practice!
TBI pt. Confused-Agitated (RLA IV). Memory impairs (esp STM), unable to recall day/loc or acts performed in prev sessions. All approp recommendations?
- Establish daily routine, orient pt place and time freq, use chart/whiteboard in pts room to doc progress
**DO NOT:** challenge pt to provide loc/date---they have STM loss and you'll piss them off even more!!!
77
Rancho Lvl VII:
**Automoatic-Approp**
| Deets
- MIN supervision for NEW learning, w/ **carry-over (into other tasks)**
- Initiation AND follow thru of basic ADLs
- MIN supervision for safety in home-routine/commun acts
- **Able to attend to HIGHLY familiar tasks in non-distract environ for @ least 30mins w/ MIN-A to complete tasks
Interventions? next cards
78
Rancho Lvl VII:
**Automoatic-Approp**
| Interventions:
**Motor probs**
- STRUCTURED **functional tasks**
- INC **complexity of tasks**
- Work on **coord/fine motor**
79
With **intervention guidelines**
Moving from **RLA IV (confused-agitated)** to **RLA V (confused INapprop), VI (Confused-approp), and VII (Automatic-Approp)**
**RLA IV--FOCUSED, structured**
RLA V, VI, VII-- MOVE from structured to more **complex environment**
NPTE Final Frontier
flashcards
Decks in class (19)
# Cards
-
Biomechanics and Kinematic Chain23
-
MSK Basic Interventions42
-
Neuro Examination57
-
Neuro Diff Dx75
-
Cardio Exam45
-
Lymphatics60
-
Pulmonary Exam61
-
Stroke and TBI80
-
GAIT: Normal33
-
GAIT: Abnormal34
-
GAIT: P & O38
-
Other Systems 160
-
Other Systems 256
-
NPTE FF: REHAB PROTOCOLS32
-
Motor Learning Principles23
-
Bonus Rehab Protocols + Red Flags26
-
MEGA REVIEW DAY 169
-
MEGA REVIEW DAY 259
-
Focus Topics Lecture56
