https://www.facebook.com/104948598405993/

Sindh physiotherapy & Rehabilitation clinic, Karachi (2025)

21/11/2022

DROOLING IN CHILDREN WITH CP AND INTERVENTION

DISCLAIMER: This information is solely for educational purposes. Images attached are used for purposes of clarity. None of the images used in this post do we have copyright to use. They are directly picked up from google to support our content for better understanding.

INTRODUCTION:
One of the major problems faced by children with CP is drooling. Drooling occurs when saliva flows outside the mouth, defined as “saliva beyond the margin of the lip”. In a normal case, a person can feel the excessive production and can swallow the saliva. But children with CP exhibit sensory dysfunction which in turn make it difficult to recognize drooling. Adding on this their anatomic or motor dysfunction of swallowing may also impede the ability to manage increased secretion. Reduce drooling in children.

It is always appropriate to consider getting professional advice before you try self-treatment at home. Nevertheless the following are some tips you can follow as parents/ caregivers of children with drooling.

TIPS FOR DROOLING CONTROL

These techniques below help your child to increase oral sensory awareness.Earlier the intervention better the prognosis or chances of improvement i.e any rehabilitation including speech therapy should start in the early years. The primary goals will be to improve jaw stability and closure, to increase tongue mobility, strength, and positioning, etc. reduce drooling in children

1. Eating and drinking skills
Poor eating skills can exacerbate drooling.
Special attention and developing better techniques in lip closure, tongue movement, and swallowing may lead to improvements to some extent.
Acidic fruits and alcohol stimulate further saliva production, so avoiding them will help to control drooling.

2. Oral facial facilitation
This will help to improve oral motor control, sensory awareness, and frequency of swallowing. This is usually done by speech therapists but at home, you can take up the following simple techniques:

•Icing:
This increases oral stimulation and awareness. Using popsicles, ice, etc. move over the lips from the middle outward and then ask the child to smile. If they are sensitive to ice try wrapping ice in a towel and place it in and around the cheek muscles in a clockwise and anti-clockwise direction. This helps in improved sensation, and tone which in turn reduces drooling to an extent.

•Brushing:
You can use a finger brush or a brush with soft bristles to stimulate the sensations of your buccal /cheek muscles It is better to undertake before meals.

•Vibration:
Battery-operated vi*****rs can be used to stimulate the muscles of the cheeks and lips. Vi*****rs come in all shapes but you should use one with a small head. A battery-operated toothbrush (its back head) can be used as an alternative.

•Manipulation:
Close your child’s upper and lower lip and stimulate the area around the lips by tapping, stroking, patting, firm pressure directly to muscles using fingertips. This will help to improve oral awareness and in turn, will be able to voluntarily control drooling to an extent.

Oral motor sensory exercise:
Playing the kissing game – To make it interesting put lipstick on the lips and leave a kiss on a mirror, tissue, or hand.

Whistle – Blowing musical instruments like a mouth organ or whistle.

Hold it tight – Holding paper or a spatula between the lips for increasing lengths of time.

Straw Drinking – Sucking liquid up straws of various thickness, starting with a short straw. You can use a thick milkshake instead to make the task difficult at the same time this will be a better option for kids at risk of aspiration.

Blowing Games – Tempt the child to blow out their cheeks and push the air from one side to another. Make it more fun by making them blow out candles and bubbles.

Playing games that require sucking air up a straw. This activity has the objective of picking up a pea or small pieces of paper, ensuring that the peas are larger than the straw! Counting the number of peas transferred can be a fun activity.
Have your child hold a tongue depressor between their lips (without using their teeth) during times when they are concentrating on something, like drawing or storytime.

Add sour and spicy foods like lemonade or salsa and cold foods such as frozen fruit or popsicles to the child’s diet to “wake up” the mouth.
Apply flavored lip balm (containing only edible ingredients) to increase awareness.
Rub a variety of textured cloths around the child’s mouth.

21/11/2022

RADICULOPATHIES AT INDIVIDUAL LEVELS IN CERVICAL RADICULOPATHY

C5 radiculopathy. This might present as pain associated with tingling and numbness which might radiate down from the neck into the shoulder and going down the arm upto the thumb. Patient might experience some weakness in the shoulder and upper arm.

C6 radiculopathy. Radiation of symptoms usually follows the arm into the index finger. Weakness might be elicited in the biceps or the wrist.
C7 radiculopathy. Tingling, numbness, and/or pain may be felt down the arm and into the middle finger. Weakness might be experienced in the triceps.

C8 radiculopathy. Symptoms may radiate down the arm and into the little finger. Handgrip strength might be reduced.

16/11/2022

Myasthenia Gravis

🔵 Myasthenia gravis is one of the most common disorder affecting the signal transmission to skeletal muscles impairing voluntary actions.

🔵 The classic presentation is a fluctuating weakness that is more prominent in the afternoon.

🔵 It usually involves muscles of the eyes, throat, and extremities.

🔵 A wide variety of conditions can precipitate the condition such as infections, immunization, certain surgeries, and drugs.

🔵 It is an autoimmune disorder .It manifests as a ocular or a generalized muscle weakness which can eventually involve the respiratory muscles and lead to a myasthenic crisis, which is a medical emergency.

🔵 There's no cure for myasthenia gravis, but treatment can help relieve signs and symptoms of the disease.

🔵 Symptoms

🔸droopy eyelids.
🔸 double vision.
🔸Difficult to produce facial expressions
🔸 problems in chewing and difficulty in swallowing
🔸 slurred speech
🔸 weakened arms, legs or neck movements
🔸 shortness of breath and occasionally serious breathing
🔸 Many patients complain of pain because of poor posture caused by the myasthenic weakness.
🔸 In myasthenic patients, the risk of myocarditis (inflammation of the heart muscle ) is increased . They complain about Chest pain, Shortness of breath, Feelings of having a fast-beating, fluttering, or a pounding heart

🔵 Causes

🔹Myasthenia gravis is caused by a problem with the signal transmission between the nerves and the muscles.

🔹 It's an autoimmune condition, which means it's the result of the immune system (the body's natural defense against infection) mistakenly attacking a healthy part of the body.

🔵 Risk Factors

◻️Women are more likely to develop MG between the ages of 20-30.
◻️Men are more likely to develop MG between the ages of 60-70.
◻️ People with certain genetic markers are more likely to develop MG.

🔵 Factors that can worsen myasthenia gravis

◼️ Fatigue
◼️Certain bacterial and viral infections
◼️ some Surgeries
◼️Stressful life events
◼️Some drugs or toxins
◼️Pregnancy or delivery
◼️ Menstrual periods
◼️ Hyperthyroidism

🔵 Physiotherapy Management

▫️Patients suffering from Myasthenia Gravis find it difficult to carry out simple routine activities which is why only a few patients are physically active.

▫️The goal of physiotherapy is to restore lost functions or to limit disability. Hence, the rehabilitation programmes for patients with myasthenia gravis should be individually adapted to the needs of the patient .

▫️All current symptoms and the occurrence of disease exacerbations should be taken into account.

▫️ It should also be remembered that the inappropriate speed of motions , high intensity exercises (including running, squats and push ups ) ,high temperature and air humidity, may exacerbate the symptoms of the disease.

▫️Respiratory rehabilitation of Weakened respiratory muscles .

▫️Improves the functional outcome and reduces fatigue in patients.

13/11/2022

Congenital Hand Deformities

🔵 Congenital anomalies are deformities of the hand that develop in a child before birth.

🔵 Any type of deformity in a newborn can become a challenge for the child as he or she grows.

🔵 Hand deformities can be particularly disabling; as the child learns to interact with the environment through the use of his or her hands.

🔵 The degree of deformity varies from a minor deformity, such as unequal or uneven fingers or thumb deformity to a severe deformity, such as total absence of a bone.

🔵 According to Congenital Malformations Committee of the International Federation of the Societies for Surgery of the Hand, there are currently 7 groups of deformities of the hand.

🔵 Different conditions related to the 7 groups of deformities of the hand

🔵 Problems in formation of the parts

🔸This occurs when parts of the body stop developing while the baby is in the womb.

🔸This causes either a complete absence of a part of the body, such as the hand, or a missing structure, such as part of the arm bone.

🔸 Ex: - Radial clubhand.A radial clubhand is a deformity that involves all of the tissues on the thumb side (radial side) of the forearm and hand. There may be shortening of the bone, a small thumb, or absence of the thumb

🔸Ulnar clubhand.An ulnar clubhand is less common than a radial clubhand. This deformity may involve underdevelopment of the ulnar bone (the bone in the forearm on the side of the little finger), or complete absence of the bone.

🔵 Failure of parts of the hand to separate

🔹With this type of deformity, the parts of the hand, either the bones or the tissues, fail to separate in the womb. The most common type of this classification is syndactyly.

🔹Syndactyly: -Syndactyly is when 2 or more fingers are fused together.

🔹 Syndactyly refers to the soft tissue and/or osseous fusion of adjacent digits in either the upper or lower extremity.

🔹This results in the appearance of "webbed" or "super" digits depending on the extent of the anomaly.

🔹 Syndactyly is described as simple or complex, depending on the presence (complex) or absence (simple) of bony fusion.

🔹 Complete syndactyly extends to the tip of the digits with the inclusion of the nail folds, while incomplete syndactyly does not extend the full length of the digit.

🔹Complicated syndactyly is defined by the presence of abnormal bones. The most prevalent location is between the long and ring finger in the hand.

🔹Ex: Apert syndrome.The hand in Apert syndrome always includes fusion of the middle three digits; the thumb and fifth finger are sometimes also involved. Feeding issue is also common.

🔵 Duplications of fingers

◻️Duplication of fingers is also known as polydactyly.

◻️ The little finger is the finger that is most often affected.

🔵 Undergrowth of fingers.

◼️Underdeveloped fingers may include the following: the finger is small, muscles are missing, bones are underdeveloped or missing, there is complete absence of a finger.

◼️Brachydactyly:-Brachydactyly ("short digits") is a general term that refers to disproportionately short fingers, and forms part of the group of limb malformations characterized by defective formation of bone.

◼️ In isolated brachydactyly, the inheritance is mostly autosomal dominant. Physical therapy may improve the hand function in this condition.

🔵 Overgrowth of fingers.

▫️This causes an abnormally large finger.In this situation, the hand and the forearm may also be involved.

▫️In this rare condition, all parts of the finger (or thumb) are affected;

▫️ however, in most cases, only one finger is involved (usually the index finger).

▫️Macrodactyly:-Macrodactyly is a congenital condition in which a baby is born with abnormally large fingers due to an overgrowth of the underlying bones and soft tissue.

▫️There are two types of growth patterns for macrodactyly:

▫️Static — the enlargement of the fingers is present at birth, and the affected digits grow at the same pace as unaffected fingers or toes.

▫️Progressive — the affected fingers grow at a much faster rate than unaffected digits.

▫️The affected fingers or toes can become enormous and severely impact a child’s ability to perform normal activities
Children with macrodactyly may also have other musculoskeletal differences.

▫️The most common of which is syndactyly, webbed or conjoined fingers.

▫️The cause of macrodactyly remains unknown. Researchers believe the condition is not inherited, but may instead be linked to disruptions in prenatal development.

🔵 Congenital constriction band syndrome

▪️This occurs when a tissue band forms around a finger or arm, causing problems that can affect blood flow and normal growth.

▪️Ring constrictions are congenital (present at birth). The main clinical manifestations of congenital constriction band syndrome are digital amputations in the index, middle, and ring fingers.

🔵 Other generalized problems with the skeletal system

🔸These are rare and complex group of problems in skeletal system.

🔵 Causes for congenital hand deformities

🔹These congenital hand deformities increase with maternal age.

🔹 Mothers older than 40 years are twice as likely to have a child with hand deformity.

🔹These abnormalities may occur sporadically, it may follow a genetic pattern of inheritance, or may occur in the context of a specific syndrome.

🔹Most of congenital anomalies are multifactorial; it depends on multiple factors.

🔹Environmental factors such as diet and infections also can be less commonly cause but causes for some of conditions have remained unknown.

🔵 Specific treatment for congenital hand deformities will be determined based on;

◻️The age, overall health, and medical history

◻️Extent of the condition

◻️Cause of the condition

◻️Patient’s tolerance for specific medications, procedures, or therapies

◻️Expectations for the course of the condition

◻️ Patient’s (or parent’s) opinion or preference

🔵 Physiotherapy management

◼️Physiotherapy involves in limb manipulation (by feeling or moving it with the hand) and stretching to increase the range of motion of limbs.

◼️Shortly after a baby is born, therapists may use support to the affected limb to straighten the hand, stabilize the wrist and to prevent soft tissues from shortening.

◼️In some conditions physiotherapy management needs to start in the neonatal period.

◼️The therapist can also assist the

13/11/2022

Tietze Syndrome

🔵 Definition/Description

🔸Tietze syndrome is a benign inflammation of one or more costal cartilages.

🔸 The condition is characterized by tenderness and painful swelling of the anterior (front) chest wall at the costochondral (rib to cartilage), sternocostal (cartilage to sternum), or sternoclavicular (clavicle to sternum) junctions.

🔸Tietze syndrome affects the true ribs and has a predilection for the 2nd and 3rd ribs, commonly affecting only a single joint.

🔸 Local swelling of the involved costal cartilages is visible and patients complain of chest wall pain.

🔸 Tietze's syndrome causes severe pain when coughing and deep breathing.

🔸It's not life-threatening or contagious but it is a fastidious and painful condition

🔵 Symptoms

🔹The most common symptoms of Tietze syndrome are chest pain and swelling.

🔹These can appear suddenly and disappear just as suddenly, or they may develop gradually then come and go for years.

🔹It's also possible for the pain to disappear even while the swelling continues.

🔹The pain of Tietze syndrome sometimes extends to the neck, arms, and shoulders.

🔹The pain can be mild or severe, dull or sharp.

🔹Some say it feels like being stabbed with a knife.

🔹Coughing, sneezing, exercise or other physical activity, breathing deeply, laughing, wearing a seatbelt, hugging someone, or even just lying down might make the pain worse.

🔹One might mistake the pain from Tietze syndrome for a heart attack but there are differences: Tietze syndrome usually only affects a small area of the chest while a heart attack covers the whole chest.

🔹 If you're having a heart attack, you may also be short of breath, nauseous, and sweating.

🔹Tietze’s syndrome leads to a limitation of muscle strength and upper limb range of motion.

🔹Patients with Tietze’s syndrome can be imitated in activities of daily living like: ironing, lifting, combing and brushing hair, but normally the disability of Tietze’s syndrome is minor.

🔵 Causes

◻️The exact cause of Tietze syndrome is unknown. However, researchers believe that it may be the result of small injuries to the ribs.

◻️The injuries may be caused due to Excessive coughing, severe vomiting, upper respiratory tract infections, including sinusitis or laryngitis, strenuous or repetitive physical activities, injuries or trauma

🔵 What are the risk factors?

◼️ The biggest risk factors for Tietze syndrome are age and possibly the time of year.

◼️Beyond that, little is known about factors that may increase your risk.

◼️ What’s known is that: Tietze syndrome mostly affects children and people under age 40.

◼️It’s most common in people who are in their 20s and 30s.

◼️A 2017 study noted that the number of cases was higher in the winter-spring period.

◼️And also, this same study found a higher proportion of women develop Tietze syndrome, but other studies have found that Tietze syndrome affects both women and men equally.

🔵How doe Tietze syndrome and costochondritis both cause chest pain around the ribs, but there are important differences:

▫️ Costochondritis is relatively common and typically affects people over age 40.

▫️Symptoms include pain but not swelling, involves more than one area in at least 90 percent trusted Source of cases and Most often involves the second through fifth ribs.

🔵 Physical Therapy Management

▪️The physiotherapist can:Reassure the patient by explaining the condition.
Instruct a good body position and give exercise advise.

▪️Patients need a good balance between exercise and rest.

▪️It is important that the physiotherapist gives good information about the posture of the patient during sitting and during daily activities.

▪️It’s also important that the patient avoids repetitive movements/ activities.

▪️Exercises in the range of motion should be induced as soon as possible.

▪️The patient may not have pain when he is doing the exercises.

▪️If powerful exercises exacerbate the symptoms, you need to stop and avoid these kinds of exercises.

▪️Teach the patient breathing exercises and ask

10/11/2022

PHYSIOTHERAPY IN DOWN SYNDROME

The intervention of physiotherapy or physical therapist is crucial in the management of a Down syndrome. Countless of symptoms may be presented by a child with Down Syndrome, but the few of them which will need intense physiotherapy care will be important for the child with Down Syndrome to live quality and independent life.

One of the problems many Down syndrome children face is the risk to have developmental delay. This is to mean that some important milestones may not be attained at the time they must be attained. Mostly this is believed to be due to changes in muscle tonicity, loosed joints and a decreased strength.

In this article we are looking at what can be done to help address developmental delay issue in Down Syndrome. However, subsequent post will address other interventions. Stay tuned for those ones.

PHYSIOTHERAPY INTERVENTION FOR DEVELOPMENTAL MILESTONES:

Physical characteristics of the child with DS such as low muscle tone, loose joints and decreased strength may influence the speed of mastery or alter the form of the developmental milestone. Persons with DS generally naturally overcome these challenges through perseverance.

The goal of physiotherapy is not to ‘speed up’ the rate of development. It is simply to facilitate the development of optimal movement patterns. Depending upon capabilities and adaptations made, physical compensations such as pain or inefficient walking patterns may occur. A physiotherapist is to provide the building blocks to develop a solid physical foundation for movement and exercise that your family member can build on for life.

Physiotherapy sessions focusing on developmental milestones should be specifically tailored to each child’s current level of development. This very section is so important and must be understood and treated with all respect. It is always not the best to waste your time on things the child is able to do. It is important to observe the child’s abilities and determine what skills should be learned next. As each person is different, skills should be taught in the way the child learns best. It is important that tasks are broken into smaller parts and practiced using different methods based on individual learning styles and physical make up.

Encouraging the Family to be Involved in this is a crucial part of this part of our therapy.It is important to get family members involved with treatment. Practice at home is essential for mastery, and engaging family participation is key.You can teach the family to:

Use their child’s interests to encourage new skill development
Build on already mastered skills,Focus on what their child is willing to learn, Practice often and
Be patient.

10/11/2022

DOWN SYNDROME: STRENGTH TRAINING FROM PHYSIOTHERAPY.

In our previous post a list of impairments were listed to be associated with Down syndrome which we got to know those are key reason to put the child at a risk of having developmental delays. One of these we talked about is having low muscle tone which affects the strength of the child with Down syndrome. This post is also focused on the how physiotherapy intervenes to improve the strength of the child with Down Syndrome.

PHYSIOTHERAPY INTERVENTION FOR STRENGTH
Physiotherapy has been quite successful in strength interventions with persons who have DS. There are many techniques that can be used and resources which can be explored. Some of the most common methods to increase strength are:

1. Endurance training: Large groups of muscles working at moderate intensity for a more extended period.

2. Weight training: Small groups of muscles working at high intensity for a short period of time

3. Specific muscle training:Targeting specific weak muscles

Each of these techniques has been shown to equally increase exercise capacity, health and quality of life in individuals with DS. While these general workout types work well to increase strength, physiotherapists can also offer more specific exercises based on your child’s needs. Below are evolving exercise ideas you can discuss with your physiotherapist or read more about later in the wiki:

1. Tummy time
2. Treadmill training
3. Falls prevention exercises

The intervention of the family here is also very important. Encouraging the Family to Get Involved is paramount just like all the other treatment lines.

In order to achieve good results, it is important to advise the family on specific exercises, and correct technique. Increasing compliance to exercise will have positive benefits and can help with improving strength and development:

•Start early: Encourage the family to introduce strength training from a young age, this may help avoid later complications

•Encourage family members to do exercises with the child.

•Encourage other types of activities that can build strength such as sports
Incorporate strength training into things a child enjoys.

10/11/2022

ILIOTIBIAL BAND SYNDROME

Iliotibibial Band Syndrome is a contracture or thickening of the Iliotibial Band.The Iliotibial band is located on the outside of the leg running from the hip to the knee.

Iliotibial Band Friction Syndrome is inflammation and pain where the Iliotibial band crosses the lateral femoral condyle (outside of the leg near the knee). Iliotibial Band Syndrome or Iliotibial Band Friction Syndrome can either occur on one side of the body or both.

CAUSES OF ILIOTIBIAL BAND SYNDROME
An activity or occupation that places the knee and hip in flexion (bent knee and hip). Examples may be horseback riding, cycling or prolonged sitting Postural imbalances, Prolonged wheelchair use or bedrest.

CAUSES OF ILIOTIBIAL BAND FRICTION SYNDROME:
Prolonged repetitive activities such as running and cycling.

SIGNS AND SYMPTOMS OF ILIOTIBIAL BAND SYNDROME

Pain is frequently gradual at beginning and worsens with an activity. Pain is felt on the outside thigh and on outside of kneeIliotibial Band becomes shorter inflammation is possible due to the tight iliotibial band rubbing over the lateral femoral condyle on outside and close to the knee.

Treatment would focus on reducing contracted fascia, muscles and pain. Techniques to reduce the Iliotibial band may come from massage, acupuncture and physiotherapy.

06/11/2022

Flat back posture

The condition can be very disabling when left untreated. In flat back, the normal lordotic curve within the lumbar region is lost and the spine now looks straight, making the lower back looks more flat.

This changes causes many postural distortions to the individual and the new features the body changes into can causes many innumerable symptoms to the victim which will need therapy.

Patients with flatback syndrome often may not know they have this condition because their spine has been changing gradually over time. When a patient has flatback syndrome they have lost the normal amount of lordosis, or inward curve, of their spine so the body adapts by tilting the pelvis, flexing the knees and hips so the patient can continue to stand upright.

Often patients present for therapy because of other associated symptoms including back or leg pain, difficulty with doing certain daily activities, or even a sensation of falling forward.

Patients may notice worsening posture over time and even sometimes have started to use a cane or walking stick to help with ambulation. Symptoms often worsen as the day progresses because the body is overcompensating leading to excess muscular fatigue. In some cases, patients with underlying flatback syndrome also have spinal stenosis which is a narrowing around the spinal canal which can cause other nerve symptoms.

The cause of flat back syndrome can either be of these reasons;
1. Congenital (present at birth)
2. Ankylosing spondylitis (a type of inflammatory arthritis of the spine)
3 Compression fractures of the vertebrae, such as due to osteoporosis
4. Degenerative disc disease

5. Flat back syndrome can occur after spine surgery, such as laminectomy. In the past, surgically implanted devices used to correct scoliosis often flattened the lumbar spine and resulted in flat back syndrome, especially with age. Updated surgical techniques have reduced this complication.

Managing the flat back syndrome mainly becomes more successful with physiotherapy. Exercises designed to help reverse the changes back to normal can be recommended by your therapist.

However, even before your therapist handles you, an X-ray of your lumbar spine will be requested to establish the presence of the condition. This can be confirmed when there is loss of the lordosis curve which naturally exist at every individual’s lower back.

When this is ruled out, then many of our protocols will be that which will help restore the normal lordotic curve, which in turns will correct all other changes to the other nearby joints and we also focus on symptom related management to set you free. These protocols will be but not limited to exercise therapy.

05/11/2022

GOUT

Gout is one kind of arthritis that results from a build-up of uric acid in the joints. When there’s an excess of uric acid in the blood, it crystallizes in the joints, usually in the big toes resulting in swelling and pain.

Gout is caused by a build-up of urate crystals in the toe joint. Uric acid is found in the blood and is a natural product of normal food digestion. The kidneys are responsible for eliminating uric acid through urination, but some people's kidneys don’t do this as effectively as others. Other people simply produce too much uric acid.

Although gout can occur in many areas of the body, the big toe is most commonly afflicted. A gout attack can manifest in your big toe quickly, often in the middle of the night. The joint will swell, turn red, and feel warm to the touch, and will be extremely painful, even to touch it gently.

A gout attack usually lasts a few days and then subsides on its own if left untreated. But, multiple gout attacks could have long-lasting consequences for your joint.

WHY IS GOUT FOUND IN BIG TOES COMMONLY
This is a very common and interesting question!. It is not just ordinary. There is a reason to this development.

Liquid uric acid becomes a solid at low temperatures. Because the human body has a harder time regulating the temperature of its extremities, and that the toes are the smallest and farthest away from the heart, they get the brunt of it. Since excess uric acid solidifies in the cooler temperature parts of your body, they get deposited in the joints of your big toe most of all.

While some people are genetically predisposed to developing gout, here is a list of things that can contribute to attacks of gout:

1. Pre-existing Health Conditions
Certain health conditions, such as high blood pressure, obesity, diabetes, and stress.

2. Medical Treatments
Those who have undergone surgery or chemotherapy can be affected.

3. Medications, supplements, and Diet
Some medications and vitamins can make you more prone, such as aspirin, diuretic “water pills,” and niacin. Even diets high in red meat, shellfish, kidney, liver, red wine, and beer.

Sindh physiotherapy & Rehabilitation clinic

21/11/2022

21/11/2022

16/11/2022

13/11/2022

13/11/2022

10/11/2022

10/11/2022

10/11/2022

06/11/2022

05/11/2022

Address

Telephone

Website

Alerts

Contact The Practice

Shortcuts

Share

Category