SlideShare a Scribd company logo
1 of 59
Repetitive Nerve Stimulation
Plan of the talk ,[object Object],[object Object],[object Object],[object Object]
 
 
definitions ,[object Object],[object Object],[object Object],[object Object],[object Object]
definitions ,[object Object],[object Object],[object Object],[object Object],[object Object]
Calcium and quanta dynamics ,[object Object],[object Object],[object Object],[object Object]
Potentiation ,[object Object],[object Object],[object Object],[object Object]
 
Relationship -EPP,AP,CMAP
Neuromuscular   junction disorders ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Repetitive nerve stimulation ( RNS) ,[object Object],[object Object],[object Object]
RNS- technique ,[object Object],[object Object],[object Object],[object Object]
RNS-technique ,[object Object],[object Object],[object Object],[object Object]
Muscle selection ,[object Object],[object Object],[object Object],[object Object]
Machine setup for RNS 30-50 Stimulus rate -high <5 Stimulus rate -low 0.1 Stimulus duration (msec) 2-3 High filter (KHz) 2-5 Low filter (Hz) 2 Sweep time (ms/div) 2-5 Sensitivity (mV/div)
temperature ,[object Object],[object Object],[object Object],[object Object]
Effect of temperature on RNS
Stimulus technique ,[object Object],[object Object],[object Object],[object Object]
Effect of different stimulation rates
Activation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Measurement technique ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Slow RNS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Slow RNS
Rapid RNS ,[object Object],[object Object],[object Object],[object Object]
Rapid RNS
Patterns of response to slow RNS
Activation cycle in MG
Criteria for abnormal decrement ,[object Object],[object Object],[object Object],[object Object],[object Object]
RNS in pre and post synaptic disorders Decrement or normal Increment  High rate RNS Decrement Present Present  Decrement  Present  Absent ,[object Object],[object Object],[object Object],[object Object],Normal  Small  CMAP amplitude Post-synaptic   Pre-synaptic   Parameter
Double step  RNS   ,[object Object],[object Object],[object Object],[object Object]
Regional curare test ,[object Object],[object Object],[object Object],[object Object],[object Object]
SFEMG
Jitter and block
Myasthenia gravis
Electrophysiological investigation   ,[object Object],[object Object],[object Object],[object Object]
RNS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Baseline and 10sec exercise
60sec exercise-exhaustion
Congenital Myasthenic Syndromes ,[object Object],[object Object],[object Object],[object Object],[object Object]
Repetitive CMAP
Lambert Eaton Myasthenic Syndrome (LEMS ) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
LEMS
LEMS ,[object Object],[object Object],[object Object],[object Object],[object Object]
Incrementing response after brief exercise (10-15 sec) in LEMS. Increment is 10-fold, with CMAP of 3.2 mV. CP CMAP amplitude is 0.35 mV (normal >1 mV).
Incremental response in LEMS
50hz RNS-increments
Botulism   ,[object Object],[object Object],[object Object],[object Object],[object Object]
Botulism ,[object Object],[object Object],[object Object],[object Object]
Miscellaneous conditions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
 
[object Object]
References ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Thank you

More Related Content

What's hot

Anomalous innervations
Anomalous innervationsAnomalous innervations
Anomalous innervationsNeurologyKota
 
Nerves conduction study
Nerves conduction study Nerves conduction study
Nerves conduction study Sachin Adukia
 
H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)Murtaza Syed
 
Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Murtaza Syed
 
Evaluation of autonomic nervous system
Evaluation of autonomic nervous systemEvaluation of autonomic nervous system
Evaluation of autonomic nervous systemnikhilzandu
 
Nerves conduction study
Nerves conduction studyNerves conduction study
Nerves conduction studyAhmad Shahir
 
Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Mohit Patel
 
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYNERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYPGIMER,DR.RML HOSPITAL
 
Evoked potential - An overview
Evoked potential - An overviewEvoked potential - An overview
Evoked potential - An overviewAnbarasi rajkumar
 
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedSomato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedMurtaza Syed
 
Motor evoked potentials - IONM Basics
Motor evoked potentials -  IONM BasicsMotor evoked potentials -  IONM Basics
Motor evoked potentials - IONM BasicsSimon Jeba Kumar
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studiesSanjogChandana
 
Nerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower LegNerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower Legsm171181
 
Blink reflex 1
Blink reflex 1Blink reflex 1
Blink reflex 1sujinsk
 

What's hot (20)

Anomalous innervations
Anomalous innervationsAnomalous innervations
Anomalous innervations
 
Nerves conduction study
Nerves conduction study Nerves conduction study
Nerves conduction study
 
Overview on Motor evoked potential
Overview on Motor evoked potentialOverview on Motor evoked potential
Overview on Motor evoked potential
 
H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)H reflex (Hoffmann's Reflex)
H reflex (Hoffmann's Reflex)
 
Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)Repetitive Nerve Stimulation (RNS)
Repetitive Nerve Stimulation (RNS)
 
EEG & Evoked potentials
EEG & Evoked potentialsEEG & Evoked potentials
EEG & Evoked potentials
 
Evaluation of autonomic nervous system
Evaluation of autonomic nervous systemEvaluation of autonomic nervous system
Evaluation of autonomic nervous system
 
Electrodiagnosis 2
Electrodiagnosis 2Electrodiagnosis 2
Electrodiagnosis 2
 
Blink reflex
Blink reflex Blink reflex
Blink reflex
 
Nerves conduction study
Nerves conduction studyNerves conduction study
Nerves conduction study
 
Repetitive Nerve Stimulation
Repetitive Nerve Stimulation Repetitive Nerve Stimulation
Repetitive Nerve Stimulation
 
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHYNERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
NERVE CONDUCTION STUDIES, ELECTROMYOGRAPHY
 
Evoked potential - An overview
Evoked potential - An overviewEvoked potential - An overview
Evoked potential - An overview
 
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza SyedSomato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
Somato Sensory Evoked Potentials (SSEP) By: Murtaza Syed
 
Motor evoked potentials - IONM Basics
Motor evoked potentials -  IONM BasicsMotor evoked potentials -  IONM Basics
Motor evoked potentials - IONM Basics
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studies
 
Nerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower LegNerve Conduction Studies- Lower Leg
Nerve Conduction Studies- Lower Leg
 
Interpretation of NCS and EMG
Interpretation of NCS and EMG Interpretation of NCS and EMG
Interpretation of NCS and EMG
 
Emg presentation
Emg presentationEmg presentation
Emg presentation
 
Blink reflex 1
Blink reflex 1Blink reflex 1
Blink reflex 1
 

Viewers also liked

Viewers also liked (8)

GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)GBS Acute Polyneuropathies (GBS)
GBS Acute Polyneuropathies (GBS)
 
Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1Rapid Nerve Stimulation study Part 1
Rapid Nerve Stimulation study Part 1
 
EMG
EMGEMG
EMG
 
EMG
EMGEMG
EMG
 
Emg fundamental
Emg fundamentalEmg fundamental
Emg fundamental
 
CIDP and NCS protocol
CIDP and NCS protocolCIDP and NCS protocol
CIDP and NCS protocol
 
Electromyography
ElectromyographyElectromyography
Electromyography
 
Electromyogram
ElectromyogramElectromyogram
Electromyogram
 

Similar to repetitive nerve stimulation

Basics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgBasics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgNeurologyKota
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studiesmahmood wajeeh
 
ncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studyncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studypiyushbhardwaj93
 
electrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashelectrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashmrinal joshi
 
Melior Neurophysiology Models
Melior Neurophysiology ModelsMelior Neurophysiology Models
Melior Neurophysiology Modelsjagruner
 
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationTrans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationNeurologyKota
 
Interpretation of NCV.pptx
Interpretation of NCV.pptxInterpretation of NCV.pptx
Interpretation of NCV.pptxKetakiPatani1
 
Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Shehzad Hussain Raja
 
russiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfrussiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfBMmugal
 
Russian current (Electrotherapy)
Russian current (Electrotherapy) Russian current (Electrotherapy)
Russian current (Electrotherapy) Apatel99094
 
Neuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyNeuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyPradeep Singh Narwat
 
NEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxNEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxKavitaKadyan1
 

Similar to repetitive nerve stimulation (20)

RNS
RNS RNS
RNS
 
Basics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emgBasics of rnst,vep ,baer and emg
Basics of rnst,vep ,baer and emg
 
118194784-4-NCV1.ppt
118194784-4-NCV1.ppt118194784-4-NCV1.ppt
118194784-4-NCV1.ppt
 
Nerve conduction studies
Nerve conduction studiesNerve conduction studies
Nerve conduction studies
 
Ncs
NcsNcs
Ncs
 
ncs study - basics of nerve conduction study
ncs study - basics of nerve conduction studyncs study - basics of nerve conduction study
ncs study - basics of nerve conduction study
 
electrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakashelectrodiagnostics for pmr - dr henry prakash
electrodiagnostics for pmr - dr henry prakash
 
Melior Neurophysiology Models
Melior Neurophysiology ModelsMelior Neurophysiology Models
Melior Neurophysiology Models
 
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic applicationTrans cranial magnetic stimulation - Diagnostic & Therapeutic application
Trans cranial magnetic stimulation - Diagnostic & Therapeutic application
 
RNS
RNSRNS
RNS
 
Interpretation of NCV.pptx
Interpretation of NCV.pptxInterpretation of NCV.pptx
Interpretation of NCV.pptx
 
Electrodiagnosis 1
Electrodiagnosis 1Electrodiagnosis 1
Electrodiagnosis 1
 
Anatomy of neuromuscular junction
Anatomy of neuromuscular junction Anatomy of neuromuscular junction
Anatomy of neuromuscular junction
 
Additional notes on MG.pptx
Additional notes on MG.pptxAdditional notes on MG.pptx
Additional notes on MG.pptx
 
Russian current
Russian currentRussian current
Russian current
 
russiancurrent-180205124702.pdf
russiancurrent-180205124702.pdfrussiancurrent-180205124702.pdf
russiancurrent-180205124702.pdf
 
Russian current (Electrotherapy)
Russian current (Electrotherapy) Russian current (Electrotherapy)
Russian current (Electrotherapy)
 
Neuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacologyNeuromuscular transmission and its pharmacology
Neuromuscular transmission and its pharmacology
 
Gbs Eps Am
Gbs Eps AmGbs Eps Am
Gbs Eps Am
 
NEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptxNEUROMUSCULAR MONITORING .pptx
NEUROMUSCULAR MONITORING .pptx
 

More from Neurology resident slides

lithium in treatment of motor neuron disease
 lithium in treatment of motor neuron disease lithium in treatment of motor neuron disease
lithium in treatment of motor neuron diseaseNeurology resident slides
 
Differential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisDifferential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisNeurology resident slides
 
neurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisneurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisNeurology resident slides
 
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUapproach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUNeurology resident slides
 

More from Neurology resident slides (19)

MS diagnostic criteria
MS diagnostic criteriaMS diagnostic criteria
MS diagnostic criteria
 
Differential diagnosis of LETM in adults
Differential diagnosis of LETM in adultsDifferential diagnosis of LETM in adults
Differential diagnosis of LETM in adults
 
journal club ccsvi
journal club ccsvijournal club ccsvi
journal club ccsvi
 
lithium in treatment of motor neuron disease
 lithium in treatment of motor neuron disease lithium in treatment of motor neuron disease
lithium in treatment of motor neuron disease
 
Immunotherapy for gbs
Immunotherapy for gbsImmunotherapy for gbs
Immunotherapy for gbs
 
neurological illness in ICU
neurological illness in ICUneurological illness in ICU
neurological illness in ICU
 
Hirayama jc
Hirayama jcHirayama jc
Hirayama jc
 
Gbs hyperreflexia
Gbs hyperreflexiaGbs hyperreflexia
Gbs hyperreflexia
 
Differential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosisDifferential diagnosis of suspected multiple sclerosis
Differential diagnosis of suspected multiple sclerosis
 
Brachial plexus
Brachial plexusBrachial plexus
Brachial plexus
 
Artifacts in eeg final
Artifacts in eeg finalArtifacts in eeg final
Artifacts in eeg final
 
IIcranial nerve
IIcranial nerveIIcranial nerve
IIcranial nerve
 
V isual evoked potentials
V isual evoked potentialsV isual evoked potentials
V isual evoked potentials
 
Multiple sclerosis and rituximab
Multiple sclerosis and rituximabMultiple sclerosis and rituximab
Multiple sclerosis and rituximab
 
Management of parkinson’s disease
Management of parkinson’s diseaseManagement of parkinson’s disease
Management of parkinson’s disease
 
neurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitisneurologic presentations of systemic vasculitis
neurologic presentations of systemic vasculitis
 
oral drugs in multiple sclerosis
oral drugs in multiple sclerosisoral drugs in multiple sclerosis
oral drugs in multiple sclerosis
 
approach to neurologic illness in medical ICU
approach to neurologic illness in medical ICUapproach to neurologic illness in medical ICU
approach to neurologic illness in medical ICU
 
multiple system atrophy-newer developments
multiple system atrophy-newer developmentsmultiple system atrophy-newer developments
multiple system atrophy-newer developments
 

Recently uploaded

Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...narwatsonia7
 
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort ServicePremium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Servicevidya singh
 
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...astropune
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...chandars293
 
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...indiancallgirl4rent
 
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Dipal Arora
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Siliguri Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...astropune
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...Arohi Goyal
 
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore EscortsVIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escortsaditipandeya
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Dipal Arora
 
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...chandars293
 
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...perfect solution
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...parulsinha
 

Recently uploaded (20)

Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...Top Rated Bangalore Call Girls Richmond Circle ⟟  9332606886 ⟟ Call Me For Ge...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 9332606886 ⟟ Call Me For Ge...
 
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
 
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort ServicePremium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
Premium Call Girls Cottonpet Whatsapp 7001035870 Independent Escort Service
 
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
♛VVIP Hyderabad Call Girls Chintalkunta🖕7001035870🖕Riya Kappor Top Call Girl ...
 
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...Top Rated  Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
Top Rated Hyderabad Call Girls Erragadda ⟟ 6297143586 ⟟ Call Me For Genuine ...
 
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Ludhiana Just Call 9907093804 Top Class Call Girl Service Available
 
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
(Rocky) Jaipur Call Girl - 09521753030 Escorts Service 50% Off with Cash ON D...
 
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
 
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Varanasi Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Kochi Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Siliguri Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Siliguri Just Call 9907093804 Top Class Call Girl Service Available
 
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
Best Rate (Hyderabad) Call Girls Jahanuma ⟟ 8250192130 ⟟ High Class Call Girl...
 
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
All Time Service Available Call Girls Marine Drive 📳 9820252231 For 18+ VIP C...
 
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore EscortsVIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
 
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
Call Girls Bhubaneswar Just Call 9907093804 Top Class Call Girl Service Avail...
 
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Tirupati Just Call 9907093804 Top Class Call Girl Service Available
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
 
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
 
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
(Low Rate RASHMI ) Rate Of Call Girls Jaipur ❣ 8445551418 ❣ Elite Models & Ce...
 

repetitive nerve stimulation