Hjem > Rehabilitering og behandling af patienter med rygmarvsskader – tetra- og paraplegi

Rehabilitering og behandling af patienter med rygmarvsskader – tetra- og paraplegi

Traumatisk eller non traumatisk rygmarvsskade på cervikalt, thoracalt og lumbalt niveau. Rehabiliteringen/behandlingen varetages af 2 højt specialiserede centre.

I Øst Danmark på Afdeling for Rygmarvsskader i Hornbæk, Glostrup Hospital og i Vest Danmark på Vestdansk Center for Rygmarvsskade i Viborg. Rehabilitering/behandlingen foregår i tæt tværfagligt samarbejde med og omkring patienten. Patient og pårørende inddrages i alle beslutningsprocesser.

Formål

Formålet med den ergoterapeutiske behandling og rehabilitering af rygmarvsskadede patienter er at medvirke til, at patienten opnår så aktivt og deltagende et liv som muligt ved:

  • At møde patienten, dér hvor patienten er, ved at betragte situationen fra patientens perspektiv
  • At inddrage og indgå i et samarbejde med patienten i målsætning og planlægning af behandlingen
  • At have den coachende tilgang i kommunikationen med patienten i relation til aktivitetsproblematikker og målsætning
  • At motivere patienten til at træne til størst mulig grad af fysisk selvstændighed
  • At fokusere på patientens egne ressourcer og de ressourcer der står til rådighed omkring patienten
  • At formidle viden og erfaring til patient og pårørende om hvordan en hverdag med funktionsevnenedsættelser kan gribes an, bl.a. ved at introducere/møde andre rygmarvsskadede (rollemodeller) der har et velfungerende hverdagsliv samt etablere kontakt til bruger organisationer
  • At støtte patienten i den psykiske bearbejdning af hverdagslivets forandrede betingelser ved at hjælpe patienten med at komme til en forståelse med sig selv. Det gælder i forhold til den daglige livsførelse som rygmarvsskadet
  • At vejlede, rådgive og hjælpe patienten omkring boligmæssige, fritid- og sport, transport-, uddannelses- og erhvervsmæssige forhold
  • At introducere muligheder for nye aktiviteter og nye former for deltagelse

Fremgangsmåde

  • Vi benytter OTIPM som arbejdsprocesmodel
  • COPM til at identificere aktivitetsproblemerne
  • SCIM (Spinal Cord Independence Measure, version 3) som et tværfagligt scorings redskab på færdigheder

Målsætning: Der udarbejdes målsætning - mål på kort og på lang sigt i relation til aktivitet, grad, tid og sted - i samarbejde med patienten ca. hver 14. dag.

Den ergoterapeutiske behandling består af følgende områder:

  • Færdighedstræning (ADL)
  • Funktionstræning
  • Hjælpemidler
  • Boligtilpasning
  • Psykiske støtte og krise bearbejdning
  • Sundhedsfremme og forebyggelse
  • Sociale tiltag
  • Opfølgning

Færdighedstræning:

  • Spisning
  • Personlig hygiejne
  • Badning
  • Af- og påklædning
  • Arbejde fra en kørestol, arbejdsstol el. ståstøttestol
  • Køkkentræning
  • Træning i at færdes udendørs med fokus på tilgængelighed og anvende offentlige transportmidler
  • Dyrke fritidsaktiviteter
  • Ophold i træningslejlighed
  • Holdtræning efter behov

Funktionstræning:

  • Muskelkraft
  • Ledbevægelighed
  • Koordination
  • Kropsbalance
  • Kompenserende træning (ved nedsat eller ophævet muskelstyrke og sensibilitet)
  • Funktionel Elektrisk Stimulation
  • Robottræningsarm Armeo
  • Styrketræning
  • Udholdenhedstræning
  • Afprøvning/tilpasning af skinner/bandager
  • Profylaktisk behandling for at undgå ødem og kontrakturer

Undersøgelser, tests, beskrivelse og vurdering af funktionsproblematikker:

  • Håndfunktion - THT, Grasp/release test samt andre Trofiske forhold
  • Ledbevægelighed - passiv og aktiv Tonus - Spasticitet (Modificeret Asworth Scala)
  • Muskelkraft (muskeltest: Daniels and Worthingham´s, MULE: e-håndfunktionskraft)
  • Sensibilitet (test af stillingssans og 2 Pd)
  • Koordination (Grasp/realease test, Box & Block, Pegboard)
  • Smerter (Numerisk Rating Scale - NRS)
  • Lejring
  • Forflytning
  • Dysfagi (FOTT)
  • Færdigheder (SCIM og ADL skema)

Håndfunktion:
En af de væsentligste opgaver i forbindelse med træningen af tetraplegikere er generhvervelse af håndfunktion. Det drejer sig om vurdering og stillingtagen til hvilke typer af greb, det er muligt at opnå. For tetraplegikere med høje cervicale læsioner kan det ofte være nødvendigt med individuelt tilpassede skinner.

Vurdering af OE i samarbejde med håndkirurg: Tilbud til alle patienter med tetraplegi inden udskrivelse med henblik på eventuelle håndkirurgiske indgreb.

Vurdering af OE i samarbejde med ortopædkirurg: I forhold til behov for Botox i spastiske muskler med henblik på mulighed for seneforlængelser.

Hjælpemidler:

  • Afprøvning og tilpasning af hjælpemidler
  • Fremstilling og tilpasning af individuelle hjælpemidler
  • Afprøvning af større tekniske hjælpemidler
  • Udvikling af nye hjælpemidler
  • Kontakt til forhandlende firmaer og hjælpemiddelmarkedet
  • Ansøgning af hjælpemidler

Med specialtilpassede ”håndremme” og ”håndklemmer” til bestik, køkkenredskaber, computer og redskaber til personlig pleje kan patienten træne i at spise, lave mad, benytte computer og at klare personlig hygiejne helt eller delvist.

Boligtilpasning:

  • Vurdering af eksisterende bolig og eventuelt at medvirke til at finde ny bolig
  • Vejlede og rådgive kommune og patient med at ændre bestående eller ny bolig
  • Udarbejdelse af hjemmebesøgsrapport

Psykisk støtte og krise bearbejdning:

  • Støtter og motivere patienten og dennes pårørende i at finde frem til og afprøve nye handlemuligheder samt at hjælpe til at få kontrol over eget liv
  • At støtte patient i at få en forståelse for en fremtidig identitet, der indeholder aktivitet og deltagelse trods nedsat funktionsevne
  • At støtte patienten i at udvikle nye roller og reorganisere sin identitet

Forebyggelse og sundhedsfremme:

  • Forebyggelse har til formål at forhindre yderligere funktionsnedsættelser og sygdom. Det betyder, at den ergoterapeutiske behandling skal være profylaktisk eksempelvis i relation til ødem, kontrakturer, tryksår med fokus på livsstil. Ergoterapeuten har undervejs i behandlingsforløbet den profylaktiske tankegang med i alle behandlingstiltag. Vi formidler, kontinuerligt den viden vi har til patient og pårørende.
  • Sundhedsfremme satser på mobilisering af ressourcer, handlekompetencer og mestringsstrategier. Ergoterapeutens opgave er at vende opmærksomheden væk fra sygdom over mod sundhed og afdække de faktorer, der støtter sundhed med fokus på livsvilkår.

Sociale tiltag:

  • Familie
  • Sexualitet (individuel rådgivning til kvinder ved ergoterapeut og sexolog - for mænd ved læge og sexolog eller i et tværfagligt team)
  • Borgerstyret Personlig Assistance (§96)
  • Venner
  • Fritidsinteresser
  • Sport
  • Job
  • Uddannelse

Opfølgning:
Patienterne følges livslangt i hospitalets regi. De ergoterapeutiske opgaver er opfølgning af samtlige ovennævnte punkter.

Målgruppe

Patienter med rygmarvsskade.

Hyppighed

Indlæggelsestiden for nytilskadekomne er afhængig af skadens omfang typisk mellem 3-10 måneder. Patienter med para- og tetraplegi deltager i ergoterapeutisk behandling/træning individuelt og/eller i grupper under indlæggelsen. Behandlingsbehovet vurderes af den behandlende ergoterapeut sammen med patienten og fortsætter så længe, der er træningspotentiale.
I praksis foregår den ergoterapeutiske behandling for tetraplegikere ved individuel træning ca. 45 min. 4 til 5 gange ugentligt. For paraplegikeres vedkommende 1 til 5 gange ugentligt.

Der dokumenteres løbende, min. hver 14. dag i elektronisk patient journal (OPUS og SCi basen)

Referencer

  • OTIPM, the Occupational Therapy Intervention Process Model (Fisher A.G 2009)
  • COPM, Canadian Occupational Performance Measure, (Mary Law, Sue Baptiste, Anne Carswell, Mary Ann McColl, Helene Polatajko,and Nancy Pollock) Dansk oversættelse af det Canadiske undersøgelsesredskab,
  • COPM, ved Ane Andersen, Ulla Ross, Jytte Tjørnov og Eva Wæhrens, 2000. Revideret version af 3. udgave; revideret af Anette Enemark Larsen, MScOT, 2007.
  • Biering-Sørensen Fin, Rygmarvsskader. I: Danneskjold-Samsøe, Lund, Avlund (red.) Klinisk reumatologi for ergoterapeuter og fysioterapeuterred. 2002 Kap. 47 s. 711-725 Munksgaard, Danmark
  • Grasp/release test, Wuole et al. 1994, Smith et al. 1996
  • THT - Tetra Hand Test, Gregersen H. et al, 1999 +2004
  • SCIM, Spinal Cord Independence Measure (SCIM III) Cats et al. 2007
  • Preservation of Upper Limp Function Following Spinal Cord Injury: A clinical practice Guideline for health-care Professionals, Consortium for Spinal cord medicine by Paralyzed Veterans of America 2005
  • Holtz A. og Levi R., Rygmärgsskador, Studentlitteratur 2006
  • Para- og tetraplegi – en håndbog for rygmarvsskadede 2002
  • Brudstykker – rygmarvsskadede fortæller 2002
  • Pårørende – tæt på rygmarvsskadede 2009
  • E-learning, http://www.iscos.org.uk/elearning 2012
  • Wangdell J, Fridén J. Satisfaction and performance in patient selected goals after grip reconstruction in tetraplegia. J Hand Surg Eur Vol. 2010 Sep;35(7):563-8.
  • Rothwell AD, Sinnott KA, Mohammed KD, Dunn JA, Sinclair SW.Upper limb surgery for tetraplegia: a 10-year re-review of hand function. 2003 May;28(3):489-97.
  • Mudarra-García J, Forner-Valero JV, Vilar-de-la-Peña R. The role of upper limb surgery in tetraplegia. Spinal Cord. 2003 Feb; 41(2):90-6.
  • Murphy CP, Chuinard RG. Management of the upper extremity in traumatic tetraplegia. Hand Clin. 1988 May; 4(2):201-9.
  • Snoek GJ, Ijzerman MJ, Hermens HJ, Maxwell D, Biering-Sørensen F. Survey of the needs of patients with spinal cord injury: impact and priority for improvement in hand function in tetraplegics. Spinal Cord 2004; 42:526-32.
  • Biering-Sørensen F, Pedersen V, Clausen S. Epidemiology of spinal cord lesions in Denmark. Paraplegia 1990; 28:105-18.
  • Curtin M, Development of a tetraplegic hand assessment and splinting protocol. Paraplegia 1994; 32; 159-160.
  • Waters RL, Sie IH, Gellman H, Tognella M. Functional Hand Surgery Following Tetraplegia. Arch Phys Med Rehabil Vol 77, January 1996
  • Harvey LA. Hand function of C6 and C7 tetraplegics 1-16 years following injury. Spinal Cord 2001; 39; 37-43.
  • Popovic MR, Popovic DB, Keller T. Neuroprostheses for grasping. Neurol Res. 2002 Jul; 24(5):443-52.
  • Hamid S, Hayek R. Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview. Eur Spine J 2008;17:1256–69
  • Taylor P, Esnouf J, Hobby J. The functional Impact of the Freehand System on Tetraplegic Hand Function. Clinical Results. Spinal Cord 2002, 40: 560-566.
  • Taylor P, Esnouf J, Hobby J. Patterns of use and user satisfaction of Neuro Control Freehand system. Spinal Cord 2001, 39: 156-160.
  • Popovic MR, Kapadia N, Zivanovic V, Furlan JC, Craven BC, McGillivray C. Neurorehabil Neural Repair. 2011 Jun; 25(5):433-42.
  • Kowalczewski J, Chong SL, Galea M, Prochazka A. Neurorehabil Neural Repair. 2011 Jun; 25(5):412-22.
  • Zariffa J, Kapadia N, Kramer JL, Taylor P, Alizadeh-Meghrazi M, Zivanovic V, Willms R, Townson A, Curt A, Popovic MR, Steeves JD. Spinal Cord. 2012 Mar; 50(3):220-6.
  • Esnouf J, Taylor P, Hobby J. Improvement in Activities of Daily Living using the Freehand: a System Designed for People with Tetraplegia. British Journal of Occupational Therapy, March 2003; 66 (3), 113-117.
  • Moberg E. Surgical treatment for absent single-hand grip and elbow extension in quadriplegia. Principles and preliminary experience. J Bone Joint Surg Am. 1975 Mar; 57(2):196-206.
  • Moberg E. The upper limb in Tetraplegia. A new approach to surgical rehabilitation. Stuttgart: Georg Thieme; 1978.
  • Hentz VR, Leclercw C. Surgical rehabilitation of the upper limb in tetraplegia. W.B. Saunders; Elsevier Science Ltd; 2002. ISBN 0 7020 2271 2.
  • Biering-Sørensen F, Gregersen H, Hagen E, Haugland M, Keith M, Larsen CF, Leicht P, Nielsen FH, Rabischong E, Sinkjær T. Forbedret håndfunktion hos tetraplegikere ved elektrisk stimulering via implanterede elektroder. (Improved function of the hand in persons with tetraplegia using electric stimulation via implanted electrodes) Ugeskr Læg 2000; 162:2195-8 (In Danish).
  • Medical Research Council (1942). War memorandum No. 7. Aids to the Investigation of Peripheral Nerve Injuries. H.M.S.O., London.
  • Biering-Sørensen T, Hansen RB, Biering-Sørensen F. Home aids and personal assistance 10-45 years after spinal cord injury. Spinal Cord. 2009 May; 47(5): 405-12.
  • Woulle KS, Bryden AM, Peckham PH, Murray PK, Keith M. Satisfaction with upper extremity surgery in individuals with tetraplegia. Arch Phys Med Rehabil 2003; 84:1145-9.
  • Rothwell AG, Sinnott A, Mohammed KD, Dunn JA, Sinclair SW, Upper limb surgery for tetraplegia: A 10-year re-review of hand function. The Journal of Hand Surgery Vol. 28A No 3 May 2003.
  • Spooren AIF, Janssen-Potten YJM, Snoek GJ, Ijzerman MJ, Kerckhofs E, Seelen HAM. Rehabilitation outcome of upper extremity skilled performance in persons with cervical spinal cord injuries. J Rehabil Med 2008; 40: 637-644.
  • Meiners T, Abel R, Lindel K, Mesecke U. Improvements in activities of daily living following functional hand surgery for treatment of lesions to the cervical spinal cord: Self-assessment by patients. Spinal Cord 2002, 40, 574-580.
  • Biering-Sørensen F, Holst-Nielsen F. Tetraplegi-håndkirurgi. Hvad hjælper håndkirurgi tetraplegikere? (Tetraplegia-hand surgery. What does hand surgery help tetraplegics?) Paraplegi 1988; 10(1):¬16-8 (In Danish).
  • Hamou C, Shah NR, DiPonio L, Curtin CM. Pinch and elbow extension restoration in people with tetraplegis: A systematic review of the literature. Journal of Hand Surgery; Vol.34A, April 2009.
  • Anderson KD, Fridén J, Lieber RL. Acceptable benefits and risks associated with surgically improving arm function in individuals living with cervical spinal cord injury. Spinal Cord 2009, 47, 334-338.
  • Daniels L and Worthingham C: Muscle testing Techniques of Manual Examination, Philadelphia, W:B: Saunders Co, 1986.
  • Curtin CM, Wagner JP, Gater DR, Chung KC. Opinions on the Treatment of People with Tetraplegia: Contrasting Perceptions of Physiatrists and Hand Surgeons. The Journal of Spinal Cord Medicine, Volume 30: Number 3, 2007
  • Snoek GJ, van TIL JA, Krabbe PEM, Ijzerman MJ. Decision for reconstructive interventions of the upper limb in individuals with tetraplegia: the effect of treatment characteristics, Spinal Cord 2008 46: 228-233.
  • Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey M, Schmidt-Read M, Waring W. J Spinal Cord Med. 2011;34(6):535-46.
  • Jaspers Focks-Feenstra JH, Snoek GJ, Bongers-Janssen HM, Nene AV. Long-term patient satisfaction after reconstructive upper extremity surgery to improve arm-hand function in tetraplegia. Spinal Cord. 2011 Aug;49(8):903-8.
  • Knútsdóttir K, Thónsdóttir H, Sigvaldson K, Jónsson H, Björnsson, Ingvarsson P. Epidemiology of traumatic spinal cord injuries in Iceland from 1975 to 2009. Spinal Cord 2012 Feb; 50: 123-126.
  • Bryden AM, Wuolle KS, Murray PK, Peckham PH. Spinal Cord. 2004 Mar;42(3):169-76.
  • Wagner JP, Curtin CM, Gater DR, Chung KC. J Hand Surg Am. 2007 Apr;32(4):483-90.
  • Wangdell J, Fridén J. Activity gains after reconstructions of elbow extension in patients with tetraplegia. J Hand Surg Am. 2012 May; 37(5):1003-10.
Sidst opdateret
20.02.2014

Kommentarer

Expensive women http://viagranelius.com/ , but women viagra not work for the side grease Oh and if.

sildenafil how long do the effects last<br>
<br>

<a href="http://viagrabs.com/">buy generic viagra online</a><br>
<br>

apakah efek samping sildenafil<br>
<br>

[url=http://viagrabs.com/]best place to buy generic viagra online[/url]

can a man get a woman pregnant if he takes sildenafil<br>
<br>

cheap generic viagra - http://viagrabs.com <br>
<br>

was bewirkt sildenafil bei frauen<br>
<br>

[url=http://viagrabs.com/]cheap generic viagra[/url]<br>
<br>

<br>
<br>

Here is my web blog: viagra without prescription - http://www.viagrabs.com/

the facts about sildenafil<br>
<br>

<a href="http://viagrabs.com/">viagra generic</a><br>
<br>

sildenafil and cialis taken together<br>
<br>

[url=http://viagrabs.com]generic viagra canada[/url]

what happens with too much sildenafil<br>
<br>

cheap generic viagra - http://viagrabs.com/ <br>
<br>

how much is sildenafil on the black market<br>
<br>

[url=http://viagrabs.com/]buy generic viagra[/url]

seeing blue after sildenafil<br>
<br>

<a href="http://www.viagrabs.com/">cheap viagra online</a><br>
<br>

best site for sildenafil<br>
<br>

[url=http://viagrabs.com]viagra online without script[/url]<br>
<br>

<br>
<br>

my site :: <a href="http://viagrabs.com/">generic viagra online</a>

can sildenafil be used with ramipril<br>
<br>

https://salemeds24.wixsite.com/dapoxetine mail order dapoxetine<br>
<br>

brand name sildenafil no prescription<br>
<br>

lowest price dapoxetine - https://salemeds24.wixsite.com/dapoxetine <br>
<br>

böhmermann roche sildenafil<br>
<br>

<br>
<br>

Look into my page - buy online order amoxil - https://salemeds24.wixsite.com/amoxil

If some one needs to be updated with hottest technologies <br>
<br>

therefore he must be visit this web page and be up to date every day.<br>
<br>

<br>
<br>

<br>
<br>

<br>
<br>

Feel free to surf to my site :: <a href="http://www.allsuche.de/cgi-bin/suchen.pl?suchworte=3+Foods+Under+58+Cent... Burn Pills</a>

It's nearly impossible to find knowledgeable <br>
<br>

people in this particular subject, however, you seem like you know what you're talking about!<br>
<br>

Thanks<br>
<br>

<br>
<br>

Have a look at my web blog Mega Boost Perform XL - http://spudnugget.com/index.php?title=Amazing_Natural_Enhancement_In_You...

I'm not sure why but this website is loading incredibly slow for me.<br>
<br>

Is anyone else having this problem or is it a issue on my end?<br>
<br>

<br>
<br>

I'll check back later and see if the problem still exists.<br>
<br>

<br>
<br>

<br>
<br>

Also visit my web blog ... <a href="http://nobodysproperty.com/wiki/index.php?title=Get_Quite_Some_Thick_Pen... Mass Pro Male Enhancement</a>

You got a very wonderful website, Sword lily I observed it through yahoo.<br>
<br>

<br>
<br>

<br>
<br>

Also visit my webpage ... <a href="http://hardingemarketinglibrary.com/UserProfile/tabid/43/UserID/276788/D... Boost Perform XL</a>

I every time used to read article in news papers but now as I am a user of net therefore from now I am using net for articles,<br>
<br>

thanks to web.<br>
<br>

<br>
<br>

my blog post Neuro Brain Booster Reviews - http://www.manalsharqawai-lawfirm.com/index.php/component/k2/itemlist/us...

Heya! I just wanted to ask if you ever have any problems with hackers?<br>
<br>

My last blog (wordpress) was hacked and I ended up losing months of hard <br>
<br>

work due to no back up. Do you have any methods <br>
<br>

to prevent hackers?<br>
<br>

<br>
<br>

Look at my blog post - Neuro Brain Boost - https://cajfm.net/wiki/index.php/The_Busted_Fallacies_Rotating_About_Ome...

I'm not sure exactly why but this website is loading extremely slow for <br>
<br>

me. Is anyone else having this issue or is it a issue <br>
<br>

on my end? I'll check back later and see if <br>
<br>

the problem still exists.<br>
<br>

<br>
<br>

my homepage - <a href="http://horseshoehellbeta.com/w/index.php?title=Good_Health_Starts_With_G... Brain Boost Reviews</a>

how long before sex should i take sildenafil pill<br>
<br>

https://salemeds24.wixsite.com/amoxil generic amoxil quick delivery<br>
<br>

power v8 sildenafil forum<br>
<br>

lowest price on dapoxetine - https://salemeds24.wixsite.com/dapoxetine <br>
<br>

clinical uses of sildenafil<br>
<br>

<br>
<br>

my blog post tadapox for sale - https://tadapox.wixsite.com/tadapox

what is the price of sildenafil in pakistan<br>
<br>

https://tadapox.wixsite.com/tadapox buy tadapox<br>
<br>

si mujer toma sildenafil<br>
<br>

<a href="https://salemeds24.wixsite.com/amoxil">lowest price on amoxil</a><br>
<br>

sildenafil her eczanede varmı

sildenafil pills how they work<br>
<br>

https://salemeds24.wixsite.com/dapoxetine dapoxetine for sale no prescription<br>
<br>

what meds not to take with sildenafil<br>
<br>

lowest price amoxil - https://salemeds24.wixsite.com/amoxil <br>
<br>

el sildenafil no me hace nada<br>
<br>

<br>
<br>

Also visit my webpage - buy online order clomid - https://salemeds24.wixsite.com/clomid

Some really interesting details you have written.Aided <br>
<br>

me a lot, just what I was looking for :D.<br>
<br>

<br>
<br>

Here is my site :: <a href="http://www.cityinspired.com/enlarge-your-penis-without-using-any-devices... Male Enhancement</a>

sildenafil and dvt<br>
<br>

https://salemeds24.wixsite.com/amoxil amoxil online<br>
<br>

what effect does sildenafil have on the heart<br>
<br>

dapoxetine for sale - https://salemeds24.wixsite.com/dapoxetine <br>
<br>

can take sildenafil twice one day

where to buy sildenafil in abu dhabi<br>
<br>

https://salemeds24.wixsite.com/dapoxetine discount dapoxetine<br>
<br>

how long to take sildenafil before<br>
<br>

<a href="https://salemeds24.wixsite.com/amoxil">amoxil for sale</a><br>
<br>

sildenafil edad se toma<br>
<br>

<br>
<br>

Also visit my website <a href="https://tadapox.wixsite.com/silagra">discount silagra</a>

I'm really inspired with your writing talents and also with the format <br>
<br>

to your weblog. Is that this a paid topic or did you <br>
<br>

modify it your self? Either way keep up the excellent high quality writing, it's rare to see a great weblog like this one these days..<br>
<br>

<br>
<br>

<br>
<br>

Check out my blog post - Mega Boost Perform XL Price - http://genesisflightschool.com/index.php?mid=board_nCHx32&document_srl=1...

Fantastic goods from you, man. I have understand your <br>
<br>

stuff previous to and you are just too excellent.<br>
<br>

<br>
<br>

I really like what you have acquired here, really like what you are saying and the way in which you say it.<br>
<br>

You make it enjoyable and you still take care of to keep it smart.<br>
<br>

I can not wait to read much more from you.<br>
<br>

This is really a tremendous web site.<br>
<br>

<br>
<br>

Here is my blog :: <a href="http://supertekcollision.com.au/UserProfile/tabid/43/UserID/2280664/Defa... Boost Perform XL Review</a>

Hello, its pleasant article about media print, we all be familiar with media is a impressive source of data.<br>
<br>

<br>
<br>

<br>
<br>

my site: Delta Mass Pro Pills - http://www.srecruiters.com/groups/how-am-i-able-to-get-an-even-better-pe...

Thanks for every other informative web site. Where else may just I am getting that kind of info written in such an ideal method?<br>
<br>

I've a undertaking that I'm just now operating on, and I have been at the look out for such information.<br>
<br>

<br>
<br>

Also visit my web site <a href="http://buyobo.com/groups/vitamins-and-foods-may-naturally-increase-penis... Male Enhancement Review</a>

Pretty component to content. I just stumbled upon your weblog and in accession capital to assert that <br>
<br>

I get in fact enjoyed account your weblog posts. Anyway I'll be subscribing to your feeds and even I fulfillment <br>
<br>

you get right of entry to constantly quickly.<br>
<br>

<br>
<br>

Here is my page: <a href="http://www.lmn3p.com//382xc">Keto Trim Results Diet Pills</a>

will sildenafil harm me<br>
<br>

https://tadapox.wixsite.com/silagra generic silagra quick delivery<br>
<br>

can you take sildenafil in your suitcase<br>
<br>

clomid sales - https://salemeds24.wixsite.com/clomid <br>
<br>

sildenafil on the national health

is the sildenafil online from canada safe<br>
<br>

https://salemeds24.wixsite.com/amoxil generic amoxil quick delivery<br>
<br>

taking sildenafil with tramadol<br>
<br>

<a href="https://salemeds24.wixsite.com/amoxil">online amoxil</a><br>
<br>

how long sildenafil start working<br>
<br>

<br>
<br>

My blog ... <a href="https://salemeds24.wixsite.com/clomid">mail order clomid</a>

how much is one sildenafil pill worth<br>
<br>

https://salemeds24.wixsite.com/dapoxetine dapoxetine for <br>
<br>

sale<br>
<br>

can you drink and use sildenafil<br>
<br>

over the counter clomid - https://salemeds24.wixsite.com/clomid <br>
<br>

best sildenafil to buy in uk

Very interesting topic, regards for posting.<br>
<br>

<br>
<br>

my website <a href="http://ksecondo.org/UserProfile/tabid/1351/UserID/6115719/Default.aspx">... Fit Garcinia</a>

We are a group of volunteers and starting a brand new scheme in our community.<br>
<br>

Your web site provided us with valuable info to paintings on. You <br>
<br>

have done an impressive activity and our entire group will be grateful to you.<br>
<br>

<br>
<br>

<br>
<br>

Stop by my website: <a href="http://www.miami-limo-services.com/UserProfile/tabid/43/UserID/3367/Defa... Flawless Cream</a>

I've read some just right stuff here. Certainly price bookmarking for revisiting.<br>
<br>

<br>
<br>

I surprise how much attempt you set to create one of these <br>
<br>

fantastic informative web site.<br>
<br>

<br>
<br>

My page; Nitridex - http://www.arabuser.com/forums/entry.php?549643-Penile-Enhancement-Exerc...

Good day very nice web site!! Man .. Beautiful .. Superb ..<br>
<br>

I will bookmark your site and take the feeds additionally?<br>
<br>

I'm happy to search out so many useful info right here in the submit,<br>
<br>

we need work out extra techniques on this regard, thanks for sharing.<br>
<br>

<br>
<br>

. . . . .<br>
<br>

<br>
<br>

My page; <a href="http://tspro.co.za/index.php/component/k2/itemlist/user/27186">Mega Boost Perform XL Ingredients</a>

I really like your writing style, fantastic information, <br>
<br>

thank you for posting :D.<br>
<br>

<br>
<br>

Here is my web blog: Mega Boost Perform XL Reviews - http://larpgm.com/ait/wiki/index.php?title=Enhance_Your_Size_And_Your_Pl...

Hi there, just became alert to your blog through Google, and found that it is really informative.<br>
<br>

I am going to watch out for brussels. I'll appreciate if you continue this in future.<br>
<br>

<br>
<br>

Numerous people will be benefited from your writing. Cheers!<br>
<br>

<br>
<br>

<br>
<br>

My homepage: <a href="http://buyobo.com/groups/secrets-of-dry-natual-skin-care-5-things-youll-... Flawless Anti Aging Cream</a>

can you take oxycodone and sildenafil together<br>
<br>

https://salemeds24.wixsite.com/clomid clomid online sales<br>
<br>

your experience with sildenafil<br>
<br>

<a href="https://tadapox.wixsite.com/silagra">silagra for sale</a><br>
<br>

what is the sildenafil dosage<br>
<br>

<br>
<br>

my blog post <a href="https://tadapox.wixsite.com/tadapox">tadapox online sales</a>

uk chemists selling sildenafil<br>
<br>

https://salemeds24.wixsite.com/dapoxetine buy online order dapoxetine<br>
<br>

sildenafil kopen in apotheek<br>
<br>

<a href="https://tadapox.wixsite.com/silagra">silagra for sale</a><br>
<br>

sildenafil and cialis in combination<br>
<br>

<br>
<br>

my site - <a href="https://salemeds24.wixsite.com/amoxil">amoxil without prescription</a>

Some really interesting points you have written.Aided me a lot, <br>
<br>

just what I was searching for :D.<br>
<br>

<br>
<br>

Feel free to visit my web blog ... <a href="http://genesisflightschool.com/index.php?mid=board_nCHx32&document_srl=1...

We are a bunch of volunteers and starting a brand <br>
<br>

new scheme in our community. Your website provided us with valuable info to work on. You've performed a formidable task and our whole neighborhood might be thankful to you.<br>
<br>

<br>
<br>

<br>
<br>

Look into my weblog Simply Flawless Cream Reviews - http://www.tunes-interiors.com/UserProfile/tabid/81/userId/3828671/Defau...

I have learn several good stuff here. Certainly value bookmarking <br>
<br>

for revisiting. I wonder how a lot attempt you set to create any such excellent informative web site.<br>
<br>

<br>
<br>

<br>
<br>

Take a look at my homepage Nitridex Male Enhancement Reviews - <br>
<br>

http://www.bombayitsolutions.net/qtoa.bak/index.php?qa=131588&qa_1=legal...

herbal sildenafil vending<br>
<br>

https://salemeds24.wixsite.com/dapoxetine dapoxetine 60mg online<br>
<br>

catholic insurance and sildenafil<br>
<br>

dapoxetine without prescription - https://salemeds24.wixsite.com/dapoxetine <br>
<br>

how long before do you take sildenafil<br>
<br>

<br>
<br>

Also visit my website - online clomid - https://salemeds24.wixsite.com/clomid

I do trust all of the ideas you have offered in your post.<br>
<br>

They are really convincing and will certainly work. Nonetheless, <br>
<br>

the posts are very quick for newbies. Could you please lengthen them a little from next time?<br>
<br>

Thank you for the post.<br>
<br>

<br>
<br>

My web blog ... Simply Flawless Anti Aging Cream - http://athamusmc.com/wiki/index.php?title=How_The_Makes_The_Skin_Look_Yo...

daftar harga obat sildenafil<br>
<br>

https://salemeds24.wixsite.com/dapoxetine generic dapoxetine quick delivery<br>
<br>

what milligram does sildenafil come in<br>
<br>

<a href="https://salemeds24.wixsite.com/dapoxetine">online dapoxetine</a><br>
<br>

sildenafil shop in bangkok<br>
<br>

<br>
<br>

Here is my site; <a href="https://tadapox.wixsite.com/tadapox">tadapox without prescription</a>

sildenafil headache advil<br>
<br>

https://tadapox.wixsite.com/silagra generic silagra online cheap<br>
<br>

køb af sildenafil i thailand<br>
<br>

buy online order clomid - https://salemeds24.wixsite.com/clomid <br>
<br>

can you take sildenafil with poppers<br>
<br>

<br>
<br>

Look at my web blog: buy amoxil privacy - https://salemeds24.wixsite.com/amoxil

where can i buy sildenafil in benidorm<br>
<br>

https://tadapox.wixsite.com/tadapox discount online tadapox<br>
<br>

chuc nang cua thuoc sildenafil<br>
<br>

<a href="https://salemeds24.wixsite.com/amoxil">generic amoxil online cheap</a><br>
<br>

avoid headache after sildenafil<br>
<br>

<br>
<br>

Look at my website <a href="https://salemeds24.wixsite.com/clomid">buy clomid privacy</a>

counter pill that works like sildenafil<br>
<br>

https://tadapox.wixsite.com/silagra silagra online<br>
<br>

do you need a prescription for sildenafil in spain<br>
<br>

lowest price tadapox - https://tadapox.wixsite.com/tadapox <br>
<br>

sildenafil in england rezeptfrei<br>
<br>

<br>
<br>

my webpage - silagra for sale no prescription - https://tadapox.wixsite.com/silagra

what is sildenafil price in india<br>
<br>

https://salemeds24.wixsite.com/amoxil discount amoxil<br>
<br>

how much does one pill of sildenafil cost<br>
<br>

<a href="https://salemeds24.wixsite.com/dapoxetine">over the counter dapoxetine</a><br>
<br>

can you take sildenafil and xanax together

Aw, this was a really nice post. Spending some time and actual <br>
<br>

effort to make a great article? but what can I say? I hesitate a lot and don't <br>
<br>

manage to get nearly anything done.<br>
<br>

<br>
<br>

My web site :: Delta Mass Pro Pills - http://rockndata.net/UserProfile/tabid/61/userId/13527166/Default.aspx

I think this is one of the most important info for <br>
<br>

me. And i am glad reading your article. But wanna <br>
<br>

remark on few general things, The website style is wonderful, the articles is really excellent <br>
<br>

: D. Good job, cheers<br>
<br>

<br>
<br>

Check out my web blog: Simply Flawless - http://supjourney.com/natural-organic-skin-care-herbs-not-when-eating/

dùng thuốc sildenafil có hại gì<br>
<br>

https://salemeds24.wixsite.com/clomid clomid without prescription<br>
<br>

most effective time to take sildenafil<br>
<br>

buy silagra privacy - https://tadapox.wixsite.com/silagra <br>
<br>

sildenafil bez recepty warszawa

Hello there! This is my first comment here so I just wanted to give <br>
<br>

a quick shout out and say I genuinely enjoy reading your articles.<br>
<br>

Can you suggest any other blogs/websites/forums that deal with the same topics?<br>
<br>

Thanks a lot!<br>
<br>

<br>
<br>

Here is my blog post ... <a href="http://macrobioticresearch.com/Secrets_Of_Lovely_Skin">Simply Flawless Cream Review</a>

Sider

Tilføj en kommentar

To prevent automated spam submissions leave this field empty.

Mest læste ydelses-beskrivelser