TAP CHI Y DLTQC LAM S A N G 108 Tap 9 - S6 1 /2014
Phuc hoi chirc nang cho benh nhan sau m6 chuyen re C7 tu' ben lanh trong dieu t n nho, dut hoan toan cac re than kinh dam roi canh tay
The Post-operative Rehabilitation of C7 Nerve Root Transfer for the Patients with the Brachial Plexus Injury
.Nfju>un Trong Luu, Nguyen Thi Phuffng Chi, Benh vien Trung uang Qudn ddi 108 Pham Thj Le Hang va cs
Muc tieu: Danh gia hieu qua eua phuong phap phuc hdi chUc nang cho benh nhan sau md chuyen re C7 tir ben lanh trong dieu tri nhd. dUt hoan toan cac re than kinh dam rdi canh tay. Phuang phap: 19 benh nhan het hoan toan dam rdi than kinh canh tay da dugc phau thuat chuyen re C7 tU ben lanh tai Vien Chan thuong chinh hinh, Benh vien Trung UOng Quan doi 108. Benh nhan dugc tap PHCN ket hgp kich thich dien chi tren. Danh gia dUa tren sU phat trien van dgng va phuc hdi chUc nang cua chi tren.
Ket qua. 16/19 trUdng hgp (84,21%) phuc hdi gap khuyu (than kinh cO bi) tU bac 1 den bac 4; 10/19 trudng hop (52,63%) phuc hdi van dong co tay bac 1-2 va 3/19(15,79%) phuc hdi van dong cua ngon tay bac 1-2 Ket luan: lap PHCN ket hgp kich thich dien cd tac dyng tdt tren phuc hdi chUc nang chi tren sau md chuyen re C7 dieu tri nhd, dUt hoan toan cac re than kmh dam rdi canh tay,
Tdkhda: ton Xhaang dam rdi than kinh canh tay, kich thich dien, phuc hdi chUc nang.
Summary:
Objectives: To assess the effect of post-operative rehabilitation of C7 nerve root transfer for the patients with brachial plexus injury. Methods: Nineteen patients with the brachial plexus injury were operated C7 nerve root transfer. The paralysed limb had been applicated by an exercise associated with an electrical stimulation to re-educate muscles. The motor development was used as a criteria index.
Results: Sixteen cases (equal to 84.21%) have recovered the elbow flexor at the first to the fourth level.
Ten cases (equal to 52.63%) have recovered the wrist flexor at the first to the second level and three (equal to 15.79%) have recovered finger flexor from the first to the second level. Conclusions: The exercise associated with an electrical stimulation has a good rehabilitative effect for the postoperated patients of C7 nerve root transfer to treat the brachial plexus injury
Keywords: Brachial plexus injury. Electrical stimulation, Rehabilitation.
IMiuii 1)1911 lilioH Ii9c: GS TS NGUYEN VAN T H 6 N G
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N"1 /2014
1 . D a t v a n d e
Tdn t h u o n g nho tat ca re t h a n kinh t h u d c dam rdi canh tay rat t h u d n g gap, hau het la chan t h u o n g kin do tai nan giao t h d n g . Benh khdng tU hdi phuc nen de lai di chdng Net hoan toan van d d n g va cam giae cua chi the. Viec dieu tri rat khd khan va la m d t thach thUc Idn vdi y hgc hien dai.
Hien nay Vien Chan thuong chinh hinh (Benh vien TLfQO 108) tien hanh phau thuat mo chuyen re C7 tU ben lanh de dieu tri nhd, dUt hoan toan eae re than kmh dam rdi canh tay nham phuc hdi chUc nang gap khuyu va cam nam eua ban tay eho ngudi benh. Sd benh nhan dugc phau thuat da tang dan (thdng ke nam 2012 eua Vien Chan thuong chinh hinh cd 24 trudng hop dugc mo ghep than kinh cheo ngUc cd mach nudi [1]. Thdng ke tai Khoa Vat ly trj lieu - Phuc hdi chdc nang cung cho thay sd benh nhan ton thuong than kinh ngoai bien chiem ty le khoang 5-6%;
trong do cd mdt sd lugng benh nhan ton t h u o n g dam rdi than kinh canh tay. Viec dieu trj vat ly can phai phdi hop nhieu phUong phap khae nhau, trong dd ben canh viec tap luyen van ddng ngUdi benh cdn dugc dieu tn hd tro bang cac phuong phap kich thich dien nhSm thuc day qua trinh tai tao than kinh sau phau thuat, ddng thdi giup duy tri lUc co va tinh trang dinh dudng cua chi the. Qua trinh dieu trj va phyc hdi chUc nang phai dUOc tien hanh thudng xuyen va lien tuc;
tiidng thudng phai trai qua mdt giai doan tap luyen kha lau dai ngUdi benh mdi cd the phuc hdi lai chUc nang cua chi tren.
Oe tai nay dUOc tien hanh vdi muc tieu: "Ddnh gid hieu qua cua phu'Ong phdp phuc hoi chdc ndng clio benh nhdn sau mo chuyen re C7 tU ben Idnh trong dieu tri nho, dut hodn todn cdc re thdn kinh ddm roi canh tay".
2. D6\ t u g n g va phUOng p h a p n g h i e n cijfu 2.1. Ddi tupng
19 benh nhan Net hoan toan van d d n g va earn giac chi t r e n d o ton t h u o n g dam rdi than kinh canh tay da duoc phau thuat chuyen re C7 tU ben lanh tai Vien Chan t h u o n g chinh hinh, Benh vien TWQO 108.
Nam: 15; nU: 3.
Tuoi cao nhat: 35; t h a p nhat: 19; t r u n g binh:
2 4 , 6 3 ± 7 , 1 7 t u d i . 2.2. PhUcfng phap:
- Tien eCru, can t h i e p , danh gia trUdc va sau dieu tri, khdng cd n h d m chUng.
- Tieu chuan danh gia dUa vao: sU phat trien van d d n g (bac 0: khdng cd co cO; bac 1: cCf d d n g co co khdng tao ra hoat d d n g k h d p ; bac 2: co co cd ci) d d n g khdp loai b d t r g n g lue; bac 3: co co thing t r g n g luc chi t h e ; bac 4: co co t h a n g luc de khang;
bac 5: ca binh t h u d n g ) , su phat trien cam giac (xuc giae, ban the), thay doi khdi lugng co (chu vi ehi the), hoat d d n g chUc nang (nhat, g i d d d vat). Ket quti g d m 3 mUc: t d t (van d d n g tU bac 3 t r d len), trung binh (van d g n g bac 1-2), kem (van d g n g bac 0).
2.3. Quy trinh dieu trj vat ly Ke hoach tap luyen cu thenhusau:
Trong 3 tuan dau sau m d : bat dgng khdp khuyu va ban tay bang mang b d t tU the gap de tranh cang keo v u n g m d va vi t r i khau noi than kinh, tao dieu kien cho qua t r i n h lien vet t h u o n g tien trien tdt. CU d d n g ehu d d n g tU d o chi lanh.
- TU 3 - 5 t u a n : ap d u n g cac bai t a p thy ddng nhe nhang de ngan ngUa t i n h trang dinh, cUng khdp khuyu va cac khdp eua ban tay cd t h e gay nen hau qua tan phe dang tiec. Can ehu y tranh cang keo dau day than kinh bj khau ndi. Bai t a p d u g c t h u c hien 3-4 lan/ngay xen ke vdi hoat d d n g tri lieu.
- TU 6 - 8 tuan: xoa b d p sau, ket h g p sieu am x u n g de p h d n g tranh seo d i n h . A p d u n g thu thuat tao thuan t h a n kinh PNF cac mau cU d g n g gap dang, khuyen khich cU d g n g dudi cd tay va cac ngdn.
- TU 8 - 10 t u a n : t a p van d d n g cd de khang tang t i e n tuy t h e o mdc do phat trien than kinh. Neu tam hoat d d n g khdp bj gidi han, d u n g p h u o n g phap keo dan t h u d d n g (passive stretching). Su keo dan cham rai ket hop vdi thCi t h u a t thU gian de tranh kich thich phan xa keo dan (stretching reflex) va lam mang bot tang tien (serial stretch plasters).
- Khi xuat hien cam giac d Idng ban tay va ngon tay, can tap luyen cho benh nhan biet nhan thUc do vat bang each cam nam cac khdi go cd trgng lugng va hinh dang khac nhau. Tiep tuc chuong trinh nay tai nha.
TAP CHl Y DU'Q'C L A M S A N G 108 Tap 9 - S o 1/2014
Phuang phdp kich thich dien:
- Sii d u n g d d n g dJen x u n g n h i p t h e due vdi cUc (+) d vung cd gay; 2 cue (-) dat tai mat trUdc canh tay (khdi ca nhj dau) va mat trudc c I n g tay (khdi co cang tay trudc). Cudng do d o n g d u manh gay co ca rd. Thdi gian dieu tri: 15-20 phut/Ian hang ngay; d o t dieu tri 20- 25 lan; cSch 2-3 thang dieu tri lap lai m d t lan.
- SCf d u n g d d n g dien Galvanic tac d u n g t o a n bd chieu dai chi the vdi eUc (+) d v u n g ed gay, cgc (-) d gan ban tay. Cudng d o d o n g 0,05 m A / c m ^ t h d i gian 20 phut/Ian hang ngay; d o t dieu trj 20-25 lan; each 2-3 thang dieu trj lap lai m g t lan.
3. K^t quS
3.1. Die diem ton tbuang truUc khi dieu trj:
Bang 3 . 1 . V i t r f t a y liet Tay Net
PhSi Trti
SL 5 14
26,32
%
73,68
Bang 3.2. Thcri gian b Th6i gian
< 1 t h a n g 1 - 3 thang
> 3 - 6 thang
> 6 - 1 2 t h a n g
> 1 2 t h a n g Trung binh
ton tliuang (tiiang) TCrkhtbjthacfng
den khi phau thuat SL
1 10 6 2 0
%
5,26 52,63 31,58 10,53 0 3,02±1,58
Tir khi PT den khi tap PHCN
SL 1 7 5 3 3
%
5,26 36,84 26,32 15,79 15,79 6,79±6,94
Nhdn xet: Hau het t o n t h u o n g tay trai. Ty le tay trai/tayph^i la 2,8 lan.
Nhdn xet: Thdi gian tU khi bj t h u o n g den khi 6\jgc phau thuat dai nhat la 7 t h a n g ; ngan nhat la 1 thang (trung binh 3,02±1,58). Thdi gian til khi dUOc phau thuat den khi tap PHCN dai nhat la 24 t h a n g ; ngan nhat la 1 thang (trung binh 6,79±6,94 ). Nhdm t h d i gian 1-3 thang chiem t;J'le nhieu nhat.
3.2. Kit qui phuc hoi chCte ning:
Dong tac G|p khui'U Th6i gian (th^ng) GSp c6 tay Thdi gian (thang) Gap ng6n Thdi gian (thang)
Bang 3.3. Phuc hoi BacO
3
-
9
-
16
-
B a d 4 7,75
6 18,33
2 18,S0
van dong Bac 2
4 13,25
4 19,75
1 21,00
Bac 3 7 16,14
0
0
Bac 4 1 15,00
0
0
-
Bac 5 0
0
0
N/idn xit: Van d o n g khuyu phuc hoi t o t (16/19 da cd van d o n g tir bac 1 den bac 4); van d p n g co tay va ngon tay con kem (10/19 co van d p n g co tay bac 1-2; 3/19 co van d p n g ngon bac 1-2). Thdi gian b i t dau xuSt hiSn cCr dpng khuyu la 7,75 t h a n g ; cCr d p n g cd tay la 18,33 t h a n g ; cCr dong ngon la 18,50 thang.
B i n g 3.4. Phuc hoi t a m van dong khdp (TVO) T5m van dpng khdp
Khdp khuyu Khdp cp tay Bin ngdn tay
TVB = 0 7 15 18
1/3 TVO 6 3 1
1/2 TVB 2 1 0
2/3 TVO 2 0 0
Het tam 2 0 0
49 j
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 • N"1 /2014
Nhan xet: Tam van d o n g khdp khuyu phuc hoi kha t p t (2 t r a d n g h p p van d o n g het t a m k h o n g co lUc cJn;
t r o n g 7 t r i / d n g h p p TVB=0 cd 4 t r u d n g h d p li/c c d bac 1 chaa t a p ra d u p c cCr d p n g khdp); van d p n g ban n g d n tay cdn han che.
Bang 3.5. Phuc hoi cam giac
Cam giac Canhtay Thdi gian (thang) cang tay Thdi qian (thang) Ban ngdn tay Thdi gian (thang)
Ndng Cd 18 12,56
12 17,75
5 25,80
Khdng 1
-
7 14Sau Cd
18 12,89
10 19,20
4 26,50
Khong 1 9
-
15
Nhdn xet: hau het da phuc hdi cam giac d canh tay (18/19 t r u d n g hgp); cam giac cang tay va ban tay phuc hdi cham hon.
Bang 3.6. Phuc hoi chuTc nang sinh hoat
ChiTcnang sinh hoat N h a t / c a m do vat to
Nhat / cam do vat nhd
Sd dung dung cu sinh hoat (thia, dua, luac, ban chai rang, butviet..)
Cd SL
0 0 0
%
0 0 0Khdng SL 19 19 19
100
%
100 100
A//idnxef;ChUa cd phuc hdi vechUe nang sinh hoat.
Bang 3.7: Chu vi doan chi (cm)
Canh tay Cing tay
Ben lanh 23,53±4,97 21,97±1,49
Ben tdn thdong 20,18±3,73 17,26±1,85
Chenh lech 3,34+1,47 4,66±1,42
P
< 0,001
< 0,001 Nhdn xet: Tay bi t h u o n g nhd hon tay lanh; cang tay giam nhieu hon canh tay (trung b i n h eanh tay gicim 3,34±l,47cm; cang tay giam 4,66± 1,42cm). SU khac biet giUa ben lanh va ben t d n t h u o n g cd y nghla thdng k e ( P < 0,001).
Bang 3.8. MuTc d o teo cO Giam chu vi doan chi ben
ton thuong 1 cm 2 cm 3 cm 4 cm 5 cm
> 5 cm Trung binh
Canh tay SL
0 6 6 4 2 1
%
0 31,58 31,58 21,05 10,53 5,26 3,34±1,47Cang tay SL 0 0 6 3 4 6
%
0 0 31,58 15,79 21,05 31,58 4,66±1,42P
<0,01 Nhdn xet: Phan Idn chu vi canh tay giam 2-3cm; t r o n g khi cang tay giam kha nhieu (100% giSm tren 3cm).
TAP CHl Y D t / a C LAM SANG 108
Bang 3.9. Ket qud d i l u tri lien he vdi thdi gian
Thdi gian
< 3 thang 3 - 6 t h a n g
> 6 - 1 2 t h a n g
< 1 2 t h a n g Cpng
TCrkhiWthirpngdenPT Tdt
6 2 0 0 8
TB 3 5 0 0 8
Kem 0 3 0 0 3
TSp 9 - So 1 COM
iliac phau t h u a t / t a p Tir khi PT den t i p PHCN Tdt
3 3 0 2 8
TB 3 2 2 1 8
Kem 2 0 1 0 3 Nhdn xet: Phau t h u a t sdm (< 3 thang) mang lai ket qua kha quan (6/8 t r u d n g hgp dat ket quci tdt); phau thuat mudn (sau 3 thang) lam han che ket qua phuc hdi (5/8 t r u d n g h g p t r u n g binh va 3/3 trUdng h g p kem).
Thdi gian t a p m u d n (> 6 thang) anh hUdng khdng t d t den ket qua phuc hdi (3/8 t r u n g binh; 1 /3 kem).
4 . Ban luan
Tdn t h u o n g dam rdi than kinh canh tay (DRTKCT) cd dac diem teo co va mat chUc nang van ddng cCia chi tren rat nhanh. Neu khdng dugc phau thuat ghep than kinh thi chUc nang chi the khdng the hdi phuc duoc. Trong sd 19 benh nhan cd 9 dugc phau thuat sdm (<3 thang), cdn lai hau het deu sir ly mudn (>3-6 thang), vi vay 100% deu da bj teo CO va mat chUc nang hoat d d n g eua ehi tren.
Mue tieu cua ky thuat ghep chuyen re C7 t d ben lanh la phuc hdi chUc nang gap khuyu (than kinh co bi) va gap co tay, ban n g d n tay (than kinh giUa) [3], [5], Sau mo benh nhan can m g t t h d i gian kha dai de chd than kinh tai tao. Trong q u a t r i n h d d , viec duy tri che do tap luyen (thu ddng) ket h g p kich thich dien chi the la rat can thiet. Ket qua phuc hoi chung phu thudc vao quang dUdng tai tao than kinh (do dai chi the) va che do tap luyen dugc ap d u n g . Tap luyen tdt se tao thuan Igi cho giai doan phuc hdi chUc nang chi the ve sau.
Ve hieu qua cua tap luyen, PHCN ndi den "Hdi chUng khdng sU d u n g d d n g tac". Khdng chi eo Net, m^ ke cci CO lanh neu khdng hoat ddng sgi eo se tho^i hda, CO bj teo yeu va dan tdi mat chUc nang [4]. Oanh gia ve t h d i gian t d khi bj t h u o n g den khi dugc p h l u thuat ghep than kinh, cung n h u t h d i gian tU sau khi phau thuat den khi dugc t a p PHCN, chung tdi nh3n thay t h d i gian nay cdn kha dai (thdi gian den khi dugc phau t h u a t la 3,02±1,58 thang; t h d i
gian sau m d den khi duge t a p PHCN la 6,79±6,94 thang). Dieu nay ed anh h u d n g den ket qu5 phuc hdi chUcnang (bdng 3.9). Bai tap t h u d d n g t r o n g nhUng giai doan dau giup duy tri cac cd d d n g cua he ca, khdp trong tam do hoat d d n g binh t h u d n g v d n cd cOa nd, nhd d d giU cho ca khdng bi teo nheo, khdp khdng bj cUng [7]. Tuy nhien, do thdi gian trUdc m d keo dai va sau md tap mudn nen teo co da phat then kha nhieu, nhat la d nhUng phan xa cua chi the (cang tay, ban ngdn) {bang 3.7 vd 3.8).
Khi da ed su tai tao than kinh (cd c^m giac van d d n g , cd su co eo) can khuyen khich ngUdi benh chuyen sang che do tap luyen chd d d n g cd sg t r g giup d cudi tam cCt d d n g nhSm day manh qua t r i n h tai tao luc co, tien tdi phuc hdi co luc hoan toan. Kottke F (1990) cho rang van ddng chu ddng la chia khda cua qua trinh phuc hdi chUc nang cua chi the [8].
Ve hieu qua cua kich thich dien, Hiroshl Karasuno (2004) cho rang kich thich dien giup tai ren luyen co theo eo che phan hdi ngugc (feeddac/c);
ngoai ra, kich thich dien cdn dugc xem la cd hieu qua t r o n g dieu tri cac benh ly cd suy glcim d d n g mau (the tich d d n g mau dugc tang cudng nhd kich thich dien lien tuc khi dat tdi 10-30% mUc co c o c h u d d n g tdi da). Giam the tich d d n g mau do giam hoat d d n g CO hay CO co khdng du lam eho ngUdi benh bi g i ^ m kha nang thuc hien cac co co chCi d d n g lap lai [6].
Theo Denise Kinlaw (2005), ki'eh thich dien dugc thuc hien tU giai doan 3-6 tuan sau m d va nen sd
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N"1 /2014
d u n g d d n g m d t chieu cd t h d i gian x u n g dai (>300ms) thi m d i d u kich thich cac cO da bj m a t chi phdi than kmh tai ren luyen van d g n g . Qua trinh hdi phuc cam giac t h u d n g eham va it hy v g n g cai tao t r o n g v d n g 2 nam dau [7].
Theo ddi ket qua dieu t n phuc hdi, chung tdi nhan thay benh nhan cd cam giac van d d n g (bac 1) vao khoang t h d i gian 7,75 thang ddi vdi khdp khuyu;
18,33 thang ddi vdi khdp cd tay va 18,50 thang ddi vdi n g d n tay sau ghep than kinh [bdng 3.3); ed c d d d n g khdp (bae 2) vao khoang 13,25 thang doi vdi khdp khuyu; 19,75 thang ddi vdi khdp cd tay va 21 thang ddi vdi n g d n tay. Qua trinh phuc hdi hau het deu thay rd d nhdm ca nhi dau canh tay (than kinh CO bi) vdi ty le 16/19 (84,21%); t r o n g khi qua t r i n h phuc hdi d ban tay (ca van d d n g va cam giac) cdn kha cham, hau het benh nhan vSn ehUa t h e sU d u n g duoc chUc nang cua ban tay (cam nam, nhat vat...), moi c h i c d 10/19 (52,63%) cd cam giac van d d n g cua cd tay va 3/19 (15,79%) ed cam giac van d d n g cua n g d n tay, n h u n g chua thUc sU tao ra dugc cU d g n g cua khdp. SU phuc hdi cam giac cham hon so vdi phuc hdi van d d n g . Vd Van Chau (2005) theo ddi sau mo chuyen ghep than kinh XI vao than kinh co bi de phuc hdi gap khuyu 25 benh nhan thay ty le gap khuyu dat M3 t r d len la 18/25 (72%); t h d i gian tU khi phau thuat cho den khi bat dau ed co co sdm nhat 6 thang, m u d n nhat 17 t h a n g , t r u n g binh 12 t h a n g ; t h d i gian dat lUc co tU M3 t r d len sdm nhat 8 thang, m u d n nhat 26 thang, t r u n g binh 15 thang [2].
Nguyen Viet Tien (2010) m d chuyen r^ C7 cheo nguc dieu tri nhd cac re DRTKCT thay 29/29 trudng hop ghep than kinh co bi (1 doan ghep) dat gap khuyu tU mUc M2 den M4; 17/29 gap cd tay va n g d n tay dat mUc M l den M3; phuc hdi cam giac khu vuc than kinh giUa chi phdi dat 29/29 mUc SI den S3. Ghep 2 doan ghep 3 trudng hop deu dat ket qua t d t ca ve than kmh co bi va than kinh giUa [5]. Le Van Doan (2013) m d phuc hdi gap khuyu va giang vai bang pliau thuat chuyen than kinh t r o n g dieu trj t o n t h u o n g cac retrenORTKCTthay t h d i gian t r u n g binh tU khi tdn t h u o n g den khi phau t h u a t la 5,9±1,4 thang; thdi gian tU khi phau thuat den khi cd dau hieu phuc hdi van d d n g gap khuyu mUc M l la 3±0,6
t h a n g , mUe M 3 la 4±0,8 t h a n g , mUc M 4 la 6±0,7 thang. Tat ca b e n h nhan deu dat ket qua t U trung b i n h den t d t [3]. NhU vay, ket qua cua chung tdi dat t u o n g d u o n g ket qua cua Vd Van Chau ve t h d i gian va chua bang ket qua cua Nguyen Viet Tien va Le Van Doan ve t h d i gian hdi phuc cung nhU ty le ket qua t d t . Nguyen nhan cd t h e do nhieu benh nhan den tap kha m u d n (trung b i n h 6,79+5,94 thang sau md) va sd lieu nghien cdu cung chua d d nhieu nen ket qua ed t h e cdn han che.
5. Ket luan
Theo ddi 19 b e n h nhan sau m d chuyen re C7 tii ben lanh dieu tri nho, dUt hoan toan cac re than kinh dam rdi canh tay diigc tap luyen phuc hdi chUc nang, c h u n g tdi nhan thay:
- Ve van d d n g : 16/19 t r u d n g h o p (84,21%) phuc hdi gap khuyu (than kinh co bi) t U bac 1 den bac 4;
t r o n g d d 2 t r u d n g h g p van d d n g khdp het tam.
10/19 trUdng h o p (52,63%) cd cam giac van ddng c6 t a y v a 3/19(15,79%) c d c a m giac van d g n g cua ngon tay (than kinh gida).
Thdi gian xuat hien van d d n g bac 1 khdp khuyu la 7,75 t h a n g ; bac 2 la 13,25 t h a n g ; bac 3 la 16,14 thang. Thdi gian xuat hien van d g n g bae 1 khdp co tay la 18,33 t h a n g ; bac 2 la 19,75 t h a n g . Thdi gian xuat hien van d d n g bae 1 khdp n g d n la 18,50 thang;
bac 2 la 21 t h a n g .
- Ve cam giac: 18/19 t r u d n g h g p (94,74%) phuc hdi cam giac canh tay; 10-12 t r u d n g hgp phuc hoi cam giac den cang tay va 4-5 t r u d n g hgp phuc hoi cam giac den n g d n tay. Thdi gian phuc hdi cam giac cham hon phuc hdi van d d n g .
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