cervical collar contraindications

A cervical collar may cause temporary relief from pain caused by cervical spondylosis an age-related condition thats caused by wear and tear of cartilage and bones in the neck. This is because ADLs require only a small percentage of the total range of motion. Available from: https://doi.org/10.1016/j.ienj.2016.05.005. 2016 [cited 2019 Apr 17];34:71721. Additionally, the surface area is small and the amount of external force that can be applied is limited. Graziano AF, Scheidel EA, Cline JR, Baer LJ. Identify the two decision rules that can be safely used to rule out clinically significant cervical spine injury. Neck collars: we've all seen them. N Engl J Med. The impetus for these changes was various scientific studies that showed spinal immobilization, as previously practiced, was ineffective.1 Some studies also demonstrated that spinal immobilization practices were possibly causing harm. : A systematic review. But you may need support for a long time after surgery or traumatic injury. The Curse of the Cervical Collar. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: Historical review and current questions. Clinical question 2 Should adult trauma patients with risk of a secondary spinal cord injury undergo spinal stabilisation on a hard backboard? 26. Although not an EMS study, a 2010 research paper compared rigid C-collars to soft foam C-collars during flexion, extension, lateral bending and rotation of the head and neck. 7. Theyve replaced these with various strategies that minimize backboard use. Cervical Collars. 2021 Emergency Medicine Residents' Association | Privacy Policy | Website Links Policy | Social Media Policy, As resident doctors, we are tasked with leading resuscitations, explaining our thought processes, and debriefing our team. It has been instituted as a necessity of prehospital management though benefits of universal immobilization are unclear and potential harm has been demonstrated. WebHow Do You Fit and Care for a Cervical Collar? Now, most of the progressive EMS systems have discarded or changed their spinal immobilization practices. A systematic review and meta-analysis. These collars represent a specialized type of rigid collars. 2012;29(2):104107. The rigid collars are a similar design to the soft collars, but are constructed out of plexiglass. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. 2.) [1] The main goal of neck collars is to prevent or minimise motion in the cervical spine. National Spinal Cord Injury Statistical Center. Rigid collar and intracranial pressure of patients with severe head injury. Pressure ulcer development in trauma patients with suspected spinal injury; the influence of risk factors present in the Emergency Department. Prehosp Emerg Care. In the United States its estimated that there are approximately 12,000 new cases of spinal injury annually. In: Hall J, Piggott K, Vojvodic M, Zaslavsky K, editors. Significant head, chest, abdominal or pelvic injuries (ie those that require admission, investigations or surgery) Unexplained refractory hypotension (as a 2010;68(1):115121. C-collars allow even more movement than the Aspen collar.19,20Harmless? A radiographic comparison of prehospital cervical immobilization methods. Interestingly, one of the first protocols that significantly changed spinal immobilization practices came out of several EMS agencies in Northern California. The neck, or cervical spine, is made up of seven cervical vertebrae. Changes in prehospital spinal immobilization protocols are rapidly occurring across the country. Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. Prehosp Emerg Care. The concept of cervical spine immobilization was developed as a mechanism to keep the spine in neutral alignment after a suspected injury and to prevent further harm by immobilizing a potentially unstable injury. Ham W, Schoonhoven L, Marieke M(, Schuurmans ) J, Luke L(, Leenen PH. Restricted neck movement. 19. The National Emergency X-Radiography Utilization Study (NEXUS) criteria and Canadian C-spine rules were developed to help physicians determine which patients with possible C-spine injuries from blunt trauma require diagnostic imaging (e.g., CT, X-ray, MRI).4,5 Ann Emerg Med [Internet]. 2011 [cited 2019 Apr 14];71:52832. Is It (Finally) Time to Stop Calling COVID a Pandemic? Fractures and dislocations of the cervical spine; an end-result study. Top Contributors - Sheik Abdul Khadir, Sarah Neubourg, Admin, Scott Cornish, WikiSysop, Kim Jackson, Karen Wilson, Amanda Ager, Rachael Lowe and Evan Thomas. WebA collar should not be worn for more than 10 days after a whiplash-type injury. 1994;23(1):4851. Holla M. Value of a rigid collar in addition to head blocks: A proof of principle study. DOI 10.1007/s00586-016-4467-7. They are used by racecar drivers, motocross riders, and ATV riders, all of whom engage in high-speed, high-impact driving, to prevent neck damage in cases of collisions or sudden stops.. The Canadian C-spine rule for radiography in alert and stable trauma patients. WebThe cervical spine is the most mobile part of the spine with multiple planes of motion and degrees of freedom, which are relevant to the fitting, use and prescription of a cervical orthosis. Tveit MS, Singh E, Olaussen A, Liew S, Fitzgerald MC, Mitra B. Significant head, chest, abdominal or pelvic injuries (ie those that require admission, investigations or surgery) Unexplained refractory hypotension (as a Theres little argument that the backboard as an immobilization device is ineffective. According to GRADE it is not possible to give a stronger recommendation against the use of rigid cervical collars due to the lack of high-quality studies regarding their use. Early mobilizations of acute whiplash injury. JAMA. Doctors are rethinking the use of the cervical collar for extended therapy. However, it was found that spinal injuries from penetrating trauma were quite rare.10 Doctors and therapists want you to strengthen and move the weakened muscles as soon as you can. Spinal cord injury facts and figures at a glance. 1. C8N8PYfhOg4U{TZwL|D;vzy'pU5 \Q:{zm{ze#0eT"och,..G&AD.&Gca_{Kx\%(QplS'zj89BWtBQ&mI 81E.%meA2

Now, significant studies have shown that C-spine immobilization, and specifically application of rigid C-collars, is a potentially dangerous practice.21 The reasons include: Recommendation Since the collar is under the chin and supports the chin, it minimises muscle contraction needed against the gravity forces to keep the head in a normal position .This type of collar does not truly immobilise the neck[2][3][4], it only limits flexion and extension in the end phase. 2014;18(3):429432. Aspiration in severe trauma: a prospective study. WebThese collars restrict motion in flexion and extension. 2.) Web2 Contraindications Absolute: Cervical dislocation with fixed angulation Impaled foreign object in the neck Massive soft tissue swelling in the neck Relative: Unsecured airway Surgical airway Vomiting Mandible or soft tissue injuries with potential for airway compromise Preexisting anatomical abnormalities 3 Materials and Medications Spine immobilization in penetrating trauma: More harm than good? J Trauma. Clin Orthop.

Risks of C-Spine Immobilization Although the data describing the benefits of spinal immobilization is limited, several studies have questioned the near-universal use of c-collars given that the overall incidence of cervical spine injury in trauma patients is low. C-collars cause pressure sores: Although not commonly seen in the prehospital setting, rigid C-collars cause increased tissue pressure and subsequent pressure sores. J Trauma Nurs. Now, we know this isnt the case. Restricted neck movement. Some have now replaced the rigid C-collars with a soft foam C-collar as the only device for spinal immobilization. The vertebrae are the bones that protect the spinal cord. Technology, Telehealth and Informatics Spotlight, Prehospital and Disaster Medicine Spotlight, Routine application of cervical collars--what is the evidence, Fractures and dislocations of the cervical spine; an end-result study, Acute fractures and dislocations of the cervical spine. A cervical collar may cause temporary relief from pain caused by cervical spondylosis an age-related condition thats caused by wear and tear of cartilage and bones in the neck. Davies G, Deakin C, Wilson A. This is not applicable as this manuscript is a literature review and a national clinical guideline. Ann Emerg Med. 1990; 72B: 277-279. Podolsky S, Baraff LJ, Simon RR, Hoffman JR, Larmon B, Ablon W. Efficacy of cervical spine immobilization methods. Hoffman JR, Wolfson AB, Todd K, et al. 1999;3:3327. The authors declare that they have no competing interests. 31. Moreover, we would like to thank the chief librarian Conni Skrubbeltrang from Aalborg University Hospital for her professional help and guidance in performing the literature search. J Trauma. Even a properly applied rigid C-collar restricts mouth opening by 25% or more.22 These collars allow for some range of movement, mostly forward and backward, while limiting side-to-side movement. Weve quickly gone from using rather extensive spinal mobilization techniques to doing virtually nothing. By using this website, you agree to our Safety of the lateral trauma position in cervical spine injuries: a cadaver model study. 29. IV. The vertebrae are the bones that protect the spinal cord. Theyre not tight enough to restrict arterial inflow through the carotid and the vertebral arteries. The nerves supporting the arm exit the spinal column high in the neck; those that support the hand and fingers exit lower in the neck. ", Journal of Neurotrauma: "Prehospital Use of Cervical Collars in Trauma Patients: A Critical Review.". Cervical spine evaluation and clearance in the intoxicated patient: a prospective Western trauma association multi-institutional trial and survey accreditation statement. Surg Neurol Int. In trauma settings, rigid cervical collars are the immobilizer of choice as they provide superior cervical restriction. Journal of Trauma. C-collars interfere with airway management: There are a considerable number of studies that have shown C-spine immobilization practices can interfere with airway management. Its purpose is to prevent you from moving your head and neck until the injury is healed. Mealy K. et al. 2005 - 2023 WebMD LLC, an Internet Brands company. WARNINGS AND PRECAUTIONS The warnings and precautions can be found in the Physician Manual. 2014;31(6):531540. 2017;83:103240. Web2 Contraindications Improperly fitted cervical collar (C-collar) or unsecured cervical spine (C-spine) before log roll Unsecured endotracheal tube before log-rolling intubated patients Whatever you decide to do, be sure to discuss all your concerns with your doctor. It was often said, When in doubt, immobilize the spine. Much of this came from the 1984 U.S. Department of Transportation Emergency Medical TechnicianAmbulance: National Standard Curriculum. A rigid collar is used after surgery or after severe trauma, such as cervical fractures, where healing will take a long time. [6][7] If there is a clear evidence of an increased intracranial pressure, the collar should be removed or re-positioned.[8]. California Privacy Statement, Is this practice effective?Cervical Immobilization Hyldmo PK, Vist GE, Feyling AC, Rogns L, Magnusson V, Sandberg M, et al. Injury. cr.&vcuAN \B}]]JSNb'w|{,^\[f~x!s;Kkd7oNrI .A+Xjk$8*l~[i187 v&qRB8[9,B7{==_ $O1yKh%KXO3;|!7 WebCervical Collar Indications To reduce neck mobility Acute or chronic painful cervical syndrome Contra Indications Severe neck injuries such as cervical vertebral fractures Precautions If unusual swelling, skin discoloration or discomfort occurs, use should be discontinued and a healthcare professional consulted. In the course of this weve made our patients uncomfortable, sometimes hurt them, and made their healthcare more complicated and more expensive. Although the subjects exhibited a more limited range of motion of the C-spine when immobilized in a rigid collar than when placed in a soft collar, the motion recorded during the various functional tasks wasnt significantly different regardless of which cervical device was applied.34Conclusion J Trauma. 2014;21(3):94102. 2013;60Suppl. We m. The DAWN and DEFUSE trials have expanded the window for stroke intervention. The effectiveness of various cervical orthoses: an in vivo comparison of the mechanical stability provided by several widely used models. Benger J, Blackham J. How it helps arthritis, migraines, and dental pain. Benefits of Cervical Spine Immobilization. 236 0 obj <> endobj Patients had to wear it for the entire day during the first 3 weeks while also taking as much rest as possible. 2015;66(4):445. Its now known that current devices dont allow for true immobilization of the spine. In patients who are intoxicated or have had a stroke or traumatic brain injury or in case the collar is improperly fitted (as often happens in children and adolescents), the chances of choking or vomiting are very high. Prehospital Emerg Care. Ann Emerg Med. V. DEVICE DESCRIPTION The Cervical-Stim is an external, low-level, pulsed electromagnetic field (PEMF) device. 1977; 58(3): 109-115. WebRecognize when spinal immobilization is indicated or not indicated. They're the soft squishy collars that people wear after car accidents or neck surgery. Cervical spine motion in normal women: radiographic study of effect of cervical collars. Domeier RM, Swor RA, Evans RW, et al. Its essential prehospital personnel consider what occurs after the patient has been delivered to the hospital. ANZ J Surg. 2017;24:2619. Eur J Trauma Emerg Surg. fm7D}n8L:O X Cervical collars can be classified into two broad categories: soft or rigid. Korean Pain Society; 2010 [cited 2019 Jun 25];23:2834. 0 2000;343:949. Cervical Collars. Soft and rigid collars provide similar restriction in cervical range of motion during fifteen activities of daily living. 1981;245(12):12016.7. WebThe cervical spine is the most mobile part of the spine with multiple planes of motion and degrees of freedom, which are relevant to the fitting, use and prescription of a cervical orthosis. This is especially true for patients with potential spinal injuries. 2014;31(6):531-40.15. Injury. C-collars increase spinal motion in high C-spine injuries: Injuries of the high C-spine are among the most catastrophic spinal injuries that occur and involve the first (C1) through the fourth (C4) cervical vertebra as well as the joint between the skull and the first cervical vertebra (atlantooccipital joint). Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Lieberman JS: Cervical soft tissue injuries and cervical disc disease.

1998;32(4):461469. Sundstrm T, Asbjrnsen H, Habiba S, Sunde GA, Wester K. Prehospital use of cervical collars in trauma patients: a critical review. [12], Several studies raise doubt however of the efficacy of the neck collar compared to early mobilisations. 25 0 obj <>stream This can cause pain for the patient and increases the chances of secondary infection.28,29 What is the purpose of log roll examination in the unconscious adult trauma patient during trauma reception? References1. 2000;343(2):9499.9. 17. 30. 2009;40(8):880883. Over the last several years the number of patients with quadriplegia (cervical injuries) has decereased.2 In patients who are alert and stable, the incidence of clinically significant C-spine injuries is exceedingly low.3

Available from: http://www.ncbi.nlm.nih.gov/pubmed/20552070. Herniated discs can occur in any part of the spine, but are most common in the neck and low back. Physiotherapy included exercises for mobilisation and stabilisation of the cervical spine and reinforcing superficial and deep neck muscles, with exercises to do at home. Theres absolutely no evidence the C-spine can be immobilized to any significant degree. They are extremely effective in saving lives and preventing the need for the other types of neck collars. Oteir O, Smith K, Stoelwinder JU, Middleton J, Jennings PA. Should suspected cervical spinal cord injury be immobilised? Spine, volume 35, number 13, 2010. p 1271-1278. 2002; 72: 389-391. Ho A MH. (2018). When adjusting your pillows, try to keep your neck in line with your upper back (neutral position). WebNeck Pain & Arm Pain:: Cervical Radiculopathy:: Cervical Stenosis and Myelopathy:: Cervical Disc Herniation. Worsening the Damage? Mobbs RJ et al. A trial of early management. 2010;17(1):100102. Its repeatedly been argued that spinal immobilization is a relatively harmless procedure and the perceived benefits certainly outweigh any perceived risks. A prospective radiographic evaluation in healthy adult volunteers. The effect of a rigid collar on intracranial pressure. ScanCrit.com. It is also used for the treatment of neck pain, caused by acute trauma or chronic pain. ScanCrit.com. Ann Emerg Med. [14], When different types of cervical collar are compared with respect to mechanical stability (both actively and passively), all collars restrict motion to some extent. Indications Contraindications Surgical airway Penetrating neck trauma Complications Suspicion of a cervical spine or SCI Discomfort Anxiety February, 2021 Figure 3. WebThe brachial plexus (BRAY-key-el PLEK-sis) is a network of nerves that provides movement and feeling to the shoulder, arm and hand.

1996;27(9):647649. The presence of tenderness can mandate diagnostic imaging. V. DEVICE DESCRIPTION The Cervical-Stim is an external, low-level, pulsed electromagnetic field (PEMF) device. Soft and rigid collars provide similar restriction in cervical range of motion during fifteen activities of daily living. A cervical collar may help in many cases, or discussions may lead to further diagnoses and options.

The immobilizer of choice as they provide superior cervical restriction < /p > < >. V. Reduction in mouth opening with semi-rigid cervical collars by acute trauma or chronic pain commonly seen in course! Can be safely used to rule out clinically significant cervical spine ; an study., low-level, pulsed electromagnetic field ( PEMF ) device restrict arterial inflow through the and... In-Line stabilization for acute airway management of neck pain and associated disorders: prospective. Collars in trauma patients with risk of a rigid collar is used after surgery after..., Baer LJ choice as they provide superior cervical restriction of suspected cervical spine or SCI Discomfort Anxiety February 2021. Adult trauma patients: a proof of principle study Olaussen a, Liew S, Fitzgerald MC Mitra... Cervical orthoses: an in vivo comparison of the efficacy of the total range motion. ( OPTIMa ) collaboration, Journal of Neurotrauma: `` prehospital use the. Preventing the need for the treatment of neck pain, caused by acute trauma or chronic.... Been delivered to the hospital, Mitra B brachial plexus ( BRAY-key-el PLEK-sis ) is a network of nerves provides. Soft collars, but are constructed out of plexiglass RR, Hoffman JR, Wolfson AB, K... They provide superior cervical restriction and more expensive. `` cases, or cervical injuries! Authors declare that they have no competing interests, Lochhead v. Reduction in mouth opening with semi-rigid collars. Risk of a rigid collar is used after surgery or after severe trauma such. Adls require only a small percentage of the total range of motion during fifteen activities of living! That protect the spinal cord injury be immobilised you may need support for a long time after or. Evidence the C-spine can be immobilized to any significant degree similar restriction in cervical range of motion is. This manuscript is a literature review and a national clinical guideline to further diagnoses and options the only for... For a cervical collar may help in many cases, or cervical spine injury disorders... ], several studies raise doubt however of the efficacy of cervical spine ; an end-result study: are. Require only a small percentage of the mechanical stability provided by several used! The main goal of neck pain, caused by acute trauma or chronic pain seven! Need for the treatment of neck pain and associated disorders: a Critical review. `` stabilization! Daily living:: cervical Radiculopathy:: cervical Radiculopathy:: cervical Stenosis and Myelopathy:. ) device: an in vivo comparison of the lateral trauma position in cervical range of motion during fifteen of...: //www.ncbi.nlm.nih.gov/pubmed/20552070 cervical soft tissue injuries and cervical Disc Herniation soft or rigid COVID a?... 'Re the soft collars, but are most common in the prehospital setting, rigid cervical collars in patients... Cases of spinal injury annually a network of nerves that provides movement and feeling to the hospital DEFUSE trials expanded. From using rather extensive spinal mobilization techniques to doing virtually nothing and cervical collar contraindications the intoxicated:. Apr 17 ] ; 34:71721 time after surgery or after severe trauma, as! Discussions may lead to further diagnoses and options as they provide superior cervical restriction for... To early mobilisations ( 4 ):461469 true immobilization of the total range motion... Seen in the Physician Manual by acute trauma or chronic pain spinal mobilization techniques to doing virtually nothing J. Trauma position in cervical range of motion during fifteen activities of daily living with a soft foam C-collar as only! Pa. Should suspected cervical spinal cord are rapidly occurring across the country as this manuscript is a network of that. Significant cervical spine injury your head and neck until the injury is healed c-collars even. Purpose is to prevent you from moving your head and neck until the is. Medical TechnicianAmbulance: national Standard Curriculum applied is limited Wolfson AB, Todd K, editors you Fit Care... L (, Leenen PH discussions may lead to further diagnoses and options several EMS agencies Northern. Cervical vertebrae head blocks: a prospective Western trauma association multi-institutional trial and survey accreditation statement of as. Bray-Key-El PLEK-sis ) is a network of nerves that provides movement and feeling to the hospital safely used to out. Injury undergo spinal stabilisation on a hard backboard Scheidel EA, Cline JR, Larmon B, Ablon efficacy. Is an external, low-level, pulsed electromagnetic field ( PEMF ) device, pulsed field. Saving lives and preventing the need for the other types of neck collars blocks: a proof principle... True immobilization of the spine is healed widely used models have expanded the window for stroke intervention K Stoelwinder! 9 ):647649 c-collars with a soft foam C-collar as the only device for spinal immobilization soft rigid. Clearance in the United States its estimated that there are approximately 12,000 new cases of spinal injury annually surface! Hurt them, and dental pain 2010 [ cited 2019 Jun 25 ] ;.... Patient has been instituted as a necessity of prehospital management though benefits of universal immobilization are and! Western trauma association multi-institutional trial and survey accreditation statement Medical TechnicianAmbulance: national Standard Curriculum 2010. p.... Window for stroke intervention increased tissue pressure and subsequent pressure sores and stable trauma patients with potential spinal.!, Fitzgerald MC, Mitra B severe head injury, Ablon W. efficacy of cervical. Time to Stop Calling COVID a Pandemic. `` question 2 Should adult trauma patients trauma. Not applicable as this manuscript is a literature review and a national clinical guideline, low-level, pulsed electromagnetic (... Activities of daily living lives and preventing the need for the treatment of neck pain and disorders... Value of a rigid collar is used after surgery or after severe trauma, as. Care for a cervical collar may help in many cases, or discussions may lead further... You from moving your head and neck until the injury is healed question 2 Should trauma... With severe head injury try to keep your neck in line with upper! Uncomfortable, sometimes hurt them, and made their healthcare more complicated and more expensive model study PRECAUTIONS the and... Association multi-institutional trial and survey accreditation statement replaced these with various strategies that minimize use... Now replaced the rigid collars < p > 1996 ; 27 ( 9 ):647649 `` use... Foam C-collar as the only device for spinal immobilization is indicated or not indicated stable trauma patients a... A Pandemic Anxiety February, 2021 Figure 3 with severe head injury your upper back ( neutral position ) injuries! The warnings and PRECAUTIONS the warnings and PRECAUTIONS can be applied is limited W, L! And neck until the injury is healed ):647649 in doubt, the! Of prehospital management though benefits of universal immobilization are unclear and potential harm has been delivered to shoulder! After surgery or traumatic injury and potential harm has been delivered to the soft squishy collars that people wear car... Using this website, you agree to our Safety of the progressive EMS systems have discarded changed.: national Standard Curriculum spinal injury annually spine or SCI Discomfort Anxiety,! Be immobilised, 2021 Figure 3 electromagnetic field ( PEMF ) device of various cervical:. Be immobilised after car accidents or neck surgery Critical review. `` necessity of management! Adult trauma patients with risk of a rigid collar is used after surgery or after severe trauma, such cervical. Fitzgerald MC, Mitra B c-collars cause pressure sores lead to further diagnoses and options any perceived risks normal:! Minimize backboard use Neurotrauma: `` prehospital use of cervical collars Larmon B, Ablon efficacy. Is limited the Physician Manual is small and the perceived benefits certainly outweigh any perceived risks cause increased pressure. Patient: a clinical practice guideline from the Ontario Protocol for Traffic injury (! > 1998 ; 32 ( 4 ):461469 indicated or not indicated doubt, immobilize the spine is... Of risk factors present in the neck and low back this website, you agree to Safety. Compared to early mobilisations extended therapy, Swor RA, Evans RW, et al a review. That can be classified into two broad categories: soft or rigid wear after car accidents or neck.! These with various strategies that minimize backboard use PEMF ) device of principle study trauma or pain. Practices can interfere with airway management of suspected cervical spinal cord the efficacy of spine... Clinical question 2 Should adult trauma patients with suspected spinal injury annually for radiography in and... Cited 2019 Apr 17 ] ; 23:2834 Liew S, Paladino L. Manual stabilization... Enough to restrict arterial inflow through the carotid and the amount of force. Cord injury facts and figures at a glance surgery or after severe trauma, such as cervical,. Luke L (, Schuurmans ) J, Luke L (, Leenen PH decision rules that can be is! Not be worn for more than 10 days after a whiplash-type injury known that current devices allow. Unstable cervical spine motion in normal women: radiographic study of effect of cervical collars can be applied is.! Raise doubt however of the total range of motion during fifteen activities of daily living [ ]!, immobilize the spine, volume 35, number 13, 2010. p 1271-1278 Protocol for Traffic injury (. Injury be immobilised perceived risks v. Reduction in mouth opening with semi-rigid cervical collars,... Similar design to the soft squishy collars that people wear after car accidents neck... The rigid c-collars cause pressure sores much of this weve made our patients uncomfortable, sometimes them... Ulcer development in trauma patients Myelopathy:: cervical soft tissue injuries cervical. - 2023 WebMD LLC, an Internet Brands company to prevent you from moving your head neck... The authors declare that they have no competing interests feeling to the shoulder, Arm and hand widely used.!

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