INSTITUTO TÉCNICO S.M.A.R.

T
Resolución Ministerial 008/2019

FINAL PROJECT

THE LIFE AFTER A STROKE IN ORURO

EMILY ELENA RIVERA TOVAR

PROJECT ADVISOR
Mr. LUIS SALVATIERRA

Project presented in order to obtain the certification in

“CAPACITACIÓN EN INGLÉS”

November 2019
Oruro – Bolivia
Acknowledge

I am extremely grateful to my parents, my mother Maria Elena Tovar and my father

Emilio Rivera, who show me every day no obstacle is difficult enough for to someone
gives up. They are fighters, strong and my main motivation why I want to change our
environment and society as much as possible in order to help others. I would like to
express my deep and sincere gratitude to Dr. Valerio Sarmati, his passion and
dedication in his purpose to help others, encouraged me to follow with this project. My
completion of this project could not have been accomplished without the guidance of
my tutor Luis Salvatierra, and his accuracy to correct my mistakes. Finally, my thanks
go to all the people who have supported me to complete the project directly or
indirectly.

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Index Contents

CHAPTER 1: INTRODUCTION 3
1.1 Problem Statement 5
1.2 Objectives 6
1.2.1 Overall Objective 6
1.2.2 Specific Objectives 6
CHAPTER 2: THEORETICAL FRAMEWORK 7
2.1 About Stroke 7
2.2 Types of Strokes 7
2.3 Stroke Symptoms 8
2.4 Stroke Risk Factors 10
2.4 Consequences of Stroke 11
2.6 Live well today for a healthier tomorrow 13
2.5 Life after Stroke 14
2.5.1 First Moments after Stroke 15
2.5.2 Coming back to home 16
2.5.3 Go for a walk 16
2.5.4 Looking for a Program Recover 17
CHAPTER 3: PRACTICAL FRAMEWORK 22
3.1 Recovery in home 22
3.2 Looking for new recovery alternatives 23
3.3 A walk by the Ecological Park of Oruro 25
3.4 Public places 26
3.5 A psychology appointment 27
3.6 Spreading information about stroke worth it 28
CHAPTER 4: PRACTICAL WORK 31
4.1. Survey 31
4.1.1 Survey Description 31
4.1.2 Results and Analysis 32
4.2 Expert Interview 40
4.2.1 Expert Interview translated to English 41
4.2.2 Expert Interview in Spanish 42

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 4.3 Photographic Memory 44
4.3.1 Neurocognitive exercises 44
4.3.2 Pictures Memory 45
4.3.3 Interview with Sandra 45
4.3.4 Ecological Park 46
4.3.5 Stroke Topic In Social Networks 47
CHAPTER 5: CONCLUSIONS 49

References 50

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CHAPTER 1: INTRODUCTION

Disability, dementia, depression, and death are the main consequences due to
cerebrovascular accidents (stroke).​[1] The loss of brain cells has an enormous impact
on a person’s life and also in the life of his or her closest family and friends.
Worldwide, stroke is the second cause of death and is within the first causes of
disability.​[1-2] In the entire world, 87% of strokes happen in low and middle-income
countries.​[1]

The life after a stroke is particularly hard and different in every patient and it depends
on a lot of the environment the person is living in. The rehabilitation is based on the
capacity of the brain to adapt to change and new needs what is called by experts,
brain plasticity.​[3] Bolivia as a lower-middle-income country​[4] does not offer the correct
rehabilitation process and its cities do not suitable for people who have some grades
of disability. In the daily living of a person who had this kind of accident, it is
practically impossible to go out from home, there are so many obstacles and
limitations because of the bad state of the streets, because of few places like
restaurants, parks, squares which were built thinking in these people as well, and
principally because our society is not prepared to this kind of situations, all of the
statements above do not make the adequate environment that is needed.

The purpose of this project is not about to find a new medicine or discover a novel
technique in order to enhance the rehabilitation process, is about to tell how is living
after a stroke and reach as many people as possible, because the more people know
how they can help as individuals and also as a society, the better environment will be
created for everybody. The second point is to share information about the prevention
strategies that high-income countries have to avoid a stroke through social media and
spread all the experiences that it could be gathered before and during this project in
order to help families who are in the daily fight of dealing and overcoming the harm
that a brain injury can trigger.

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1.1 Problem Statement
Despite all the serious and complex consequents due to a cerebrovascular accident,
in Oruro, this kind of accident is not well known like other critic health conditions. This
is the first important problem; how we can prevent something we do not even know. It
worth mention a stroke occurs when a blood vessel that carries oxygen to the brain is
either blocked by a clot or it bursts. When that happens, part of the brain cannot get
blood what implies the lack of oxygen in this brain portion, so its brain cells die.​[5] A
stroke-like another sort of accident happens suddenly; and after it took place every
minute matters and that determines the grade of the brain injury or in the worst cases
the death of the person.​[6] The stroke has its risk conditions, everyone should know
what they are because no one will be safe from having a cerebrovascular accident if
the person does not reduce these risk factors.

People do not know enough or almost nothing about strokes, their knowledge about
what they should do in the accident moment or after, during the rehabilitation process
is even less. That is the second big problem and when there are neither the right
procedures in the medical institutions nor the specialists that are needed, this second
problem becomes worst because the patients and their families do not have the
necessary support and information. Generally, the own families must look for
information about what is the next step they should take and the rehabilitation
process is even harder. That is what happens in Oruro and also in other cities in
Bolivia.

Finally, the last problem is that Oruro does not provide an adequate environment it
needs. There is not any rehabilitation center focused especially on cerebrovascular
accidents or capable to manage correctly the process rehabilitation of people after a
stroke as it should. On the other hand, living with some disability in Oruro is actually
complicate; the environment produced on its streets is few friendly and ordered, the
most of the people do not follow correctly the behavior norms on streets and in public
places, we do not realize how much our actions affect in good or bad way others.
With all these conditions, going out in order to have a fun time and change the daily
routine, it becomes a challenge and instead of improving the day it brings stress,
angry and discomfort thus it is better to stay at home.

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1.2 Objectives

1.2.1 Overall Objective

To increase awareness as many people as possible about how it is to live after a
stroke inside all the limitations of Oruro by means of social networks in order to more
people take action to decrease this limitation.

1.2.2 Specific Objectives

● To spread information about what is a stroke, its risk factors, its consequences,
and the prevention strategies.
● To show the differences between adequate process rehabilitation and the
rehabilitation that is offered in Oruro.
● To tell the daily life experiences of a person who has suffered a stroke and
their family.

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CHAPTER 2: THEORETICAL FRAMEWORK

“One day we will be able to talk about a stroke and what it used to be and
how had a hand in stopping them”

Brandy Johnson

2.1 About Stroke

A stroke is a medical emergency that is why it is called cerebrovascular accident as
well,​[7] the term accident refers it happens suddenly, in some case the reasons cannot
be explained exactly and has as a consequence a brain injury, the lapse time since
the accident moment until the medical intervention is so important that early action
can minimize the damage and the serious potential complications.​[7]

But what is really occurring in the human body when a person has a stroke? Why is
the damage so huge that the patient loses important and vital abilities? Well, the
answer to the first question is the stroke is caused when brain cells die because they
are not able to get enough oxygen and nutrients of the blood due to the amount of
blood is reduced or totally interrupt.​[7-8] The second question about the huge damage
in the people’s abilities can be explained for the importance of the brain has in the
humans, the brain controls almost everything in the body, not just muscles for the
movement or intern organs which conform the vital systems, it controls the cognitive
process as well​[9] like the perception, the memory, the time and space conscience;
therefore, the death of neurons, brain cells, has deep implications in the human. On
the other hand, neurons, in order to make possible all their tasks, need a lot of energy
and die faster when they do not have enough resources.​[10]

2.2 Types of Strokes

The blood supply can be reduced for two main reasons; when arteries are blocked or
narrowed what is called ischemic stroke or blood vessels bursts what is known as a
hemorrhagic stroke.​[7-8] Inside hemorrhagic stroke, there are also rare cases, as an
injury to an artery due to a sudden head or neck movements.​[12]

The most frequently ischemic stroke is caused by blood clots, when the blood clot is
formed in brain arteries has the name of thrombus and triggers a thrombotic stroke,

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while in the case when the blood clot is formed in arteries away from the brain
(embolus) but then this clot is carrying by the blood flow to close zones of the brain, it
triggers embolic stroke.

Maybe the aspect less spread into people’s knowledge about cerebrovascular
accidents is the concept of Transient Ischemic Attack (TIA), It refers a temporary
decrease of blood supply to a part of the brain, what produce the same symptoms of
a stroke but by contrast the symptoms are temporary;​[7] however, a person who
suffers a TIA has more possibilities to have a stroke. These transient attacks in some
cases are confused by headaches so that we should take care of what is really
happening with our body and know the symptoms correctly.

2.3 Stroke Symptoms

Stroke has a hallmark, it is the weakness or numbness of one side of the body,
however, is important to know what are all the symptoms a cerebrovascular accident
can trigger.

● Problem with speaking and understanding abilities. The person may start
speaking strange and present difficulties to express clearly, she or he may use
words that do not fit well in the current context; on the other hand, she or he
could not understand other people.

“…I am listening to the phone, and my college picks up the phone and
he says to me, <Woo woo woo woo>, and I think to myself, <Oh my god,
he sounds like a Golden Retriever! And so I say to him clearly in my
mind, I say to him: <This is Jill! I need help!> And what comes out of my
voice is, <Woo woo woo woo>…I could not know, I did not know that I
could not speak or understand language until I tried”

Jill Bolte Taylor, TED 2008.​[11]

“At that moment my friends scoffed of me because they believed I was

drunk”
F. G.​[9]

● Paralysis or numbness of the face, arm or leg. The person may feel
weakness, numbness or paralysis of the parts of his or her body like the face,
arm or leg. This usually happens on one side of the body this is called
hemiparesis.

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 ● Problem with the sight in one or both eyes. ​The person may start seeing
darker, blurred, double or very strange images.

“​ And I am looking at the card on the top and even though I could see
clearly in my mind’s eye what my business card looked like, I could not
tell if this was my card or not, because all I could see were pixels.”

Jill Bolte Taylor, TED 2008.​[11]

● Headache. ​The person may present a sudden severe headache and it may be
accompanied by vomit, dizziness or altered consciousness.

“And then I felt a headache as I had never had before, as though

somebody had stabbed my head”

M. R.​[9]

● Problem walking. ​The person may lose the control of his or her body and may
have trouble to walk because walking is a complex activity that required
different abilities like space perception stability and coordination.

There is a technique that is being used and spread by international stroke institutions
in order to a fast recognition whether someone is having a stroke or not and as a
result of a prompt reaction to getting a treatment, this technique is called F.A.S.T. and
every letter represents to a different test that the person has to do in order to
recognize the signs better.

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Fig. 1 The test called ‘F.A.S.T.’ is used to spot stroke signs and know when to call to
emergencies.​[12]

2.4 Stroke Risk Factors

The risk factors are so important to prevent any kind of accidents and diseases, in
particular case, there are some habits or lifestyles which can increase the possibility
to have a cerebrovascular accident and there are also medical factors some people
have to control.

Lifestyle risk factors Medical risk factors

Being overweight or obese High blood pressure

Physical inactivity Smoking or exposure to secondhand smoke

Heavy or binge drinking High cholesterol

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 Use of illicit drugs such as cocaine Diabetes

Stress Cardiovascular disease

Fig. 2 Lifestyle and Medical risk factors.

On the other hand, there are aleatory risk factors like harsh knocks on the head, age,
family history, race, gender which cannot be controlled. On this approach in the
elderly is more common to have a stroke, for women and the black race the
cerebrovascular accidents are more common as well.

2.4 Consequences of Stroke

The brain is the most complex organ in human beings, it has an extremely important
function, it process all the sings our senses are capturing of the environment, so then
the brain can build in our mind the word we insight, and also the brain is the main
director of our body functions.

The brain complexity is enormous even now we do not the accuracy in order to be
able to explain or describe how exactly the brain can do all the things a human being
does. In general, the neuroscientists explain the brain has zones and each zone is
focus in the control of a particular function body, for example, the brain back is in
charge of the vision, all the signs, which our eyes receive, are sent to this part of the
brain to be processed and form the images, what would it happen if this part of the
brain was damaged?, what it would happen is the person would have serious vision
troubles like it was explained in the symptoms section.

The effects of stroke are closely related to two aspects the first is the location of the
injury and the second is how long the brain has exposed a lack of blood flow, which
implies how much brain tissue was damaged.​[12] The first aspect indicates what will be
the specific body function troubles and the second the magnitude of those problems.
If the stroke occurs on the left or right side of the brain, the person may have some or
all of the conditions explained in the followed scheme respectively.

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 Fig. 3 Stroke characteristic effects in a left-brain injury and a right brain injury

But, what does it happen when the stroke is in the brain stem? In this case, the injury
can affect both sides of the body. Inside all the importance the brain has in the body,
the steam is extremely important to the brain because it is the only nerve connections
path of the motor and sensory systems from the brain to the rest of the body.​[13]

Fig. 4 Human Brain illustration

Besides, the brain steam plays an important role in the control of basic activities like
consciousness, heart rate, breathing, sleeping, swallow and blood pressure.​[12-13]
Now, we can think about what would happen if the brain steam were damage, and
probably it cannot do part or all of its functions what implies in the worst case the
survivor would be able to do nothing without external help. If it were not bad enough
other bad aspects of this type of stroke are the symptoms, they may be difficult to
identify the person could have vertigo, dizziness and severe unbalance but without

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the typical symptom of the strokes, the weakness or numbness on one side of the
body,​[12] what produces people can confuse the symptoms with other conditions like
tiredness, stress or severe headaches.

2.6 Live well today for a healthier tomorrow

After we have read the serious effects of having a stroke can trigger, and also all the
risk factors we can understand how the risk factors can be decreased or avoided just
having a healthy life. American stroke association summarizes stroke and heart
disease prevention in eight steps.

Know your risk. The stroke risk increase with different factors
such as edge, smoking, drugs, obesity between others. The first
step is to know your risk factors, then you or your doctors will be
able to decide the best treatment.

Have a healthy diet. The healthy diet includes vegetables, fruits,

whole grains, legumes, nuts, plant-based proteins, lean animal
proteins, and fish. Limit refined carbohydrates, processed
meats, and sweetened drinks.

Be physically active. Having a physically active life is the best

way to maintain healthily and age well. Adults should get at
least 150 minutes of moderate-intensity aerobic activity.

Have a healthy weight. That means to lose weight if you are

overweight; you might start by eating fewer calories and moving
more.

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 Live tobacco-free. If you have never smoked in your life, do not
ever start; but if it is difficult for you to leave the smoking habit,
you should try to ask help in order to find correct methods to
kick the habit.

Manage conditions. If you have some conditions such as high

blood pressure, high cholesterol, high blood sugar, diabetes or
others, you should manage them changing some lifestyles.

Take the medicine. If the doctor prescribes medicine to control a

health condition, you should take them accuracy.

Be a team player. Working together with the doctors and

specialist on the prevention plan, asking a question and being
open about any challenge it will be presented in order to make
healthy changes.

Fig. 5 Steps to prevent a cerebrovascular accident.

2.5 Life after Stroke

“My name is Lisa Wagner I live in Wyoming I had a stroke on August 10, 2013,
this has been very hard, I want to tell people not be afraid to live your life now.
Everything has changed for us this is just a change this is not mean our life
over, we still alive, so be alive find something new to do that you maybe cannot
do before but now maybe you can, you have more time but live your life…keep
moving, stay alive. I hope this help, thank you.”

Lisa Catherine Wagner, Surviving Stroke with Crochet.​[14]

We have to understand the life of a stroke survivor changes in an instant, the

recovery is possible but it is a long a hard path. The environment around the
survivor’s life can make a big difference.

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2.5.1 First Moments after Stroke

Most of the patient independently of the injury size or the seriousness of the stroke,
their beginning is similar. The people enter the emergency room and after all the first
aid, the prognostic that the doctor says to the family is overwhelmed, they say the
survivor does not have much hope of getting recovery progress. Almost all the
survivors start laid in a hospital bed without the ability to move nothing, breathing, and
unconscious.

In the following weeks appear side effects like infections, pneumonia, sudden ups or
downs of blood pressure, temperature and heart rate. With these conditions is difficult
to have a rehabilitation program, but at that time the rehabilitation is not mattered
much for the family, the only thought is to have alive the loved one. When the critical
weeks can be overcome, the survivors if they are conscious enough have to face the
situation they could survive what is a huge felicity but now they and their family have
to overcome all the next obstacles and relearn how to live.

All those moments are a huge knock to the survivor’s life and the near family’s life;
everything has been changed for them. Continue working or studying is not an option
for the survivors for those moments and when there are not any rehabilitation and
medical health care centers available, the family is in charge of the all recover
process and all the medical decision, so that for the family continue working or
studying become a difficult task. The family should postpone their plans, reschedule
their normal activities and focus on the recovery of their loved one.

The characteristics of the most Oruro institutions like in other cities of Bolivia as well
produce that a cerebrovascular accident becomes even worse and more difficult to
recover. In the previous sections, it was mention that the time from the accident until
have treatment is very important and when it is shorter there are more possibilities of
having a less brain injury and developing fewer effects. However the immediate
action of the emergency task is a big problem in Oruro, the emergency help does not
arrive on time; there is not a correct protocol in hospitals to attend emergency
patients. And if the stroke happened at night, outside the normal work time, some
hospitals do not answer the emergency number, others do not provide transport, or
some are close.

In the next weeks when the survivor is interned in any hospital the medical institutions
do not provide any rehabilitation program adequate for stroke effects in both the first
week and then when the patient is stable enough to receive a proper recovery. The

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rehabilitation offered is a general physical recover focused on mussels work what is a
mistake and delay the recover instead to enhance it. There is not any health care
team that can help and guide the survivor and the families.

2.5.2 Coming back to home

When the survivor is stable enough and can breathe without external help, in most
cases they can return home and follow the rehabilitation at home. It is time to start
relearning how to speak, see, walk or use a wheelchair, have control of every part of
the body, wearing and else. Maybe we need to reform our house in some aspects,
have room to put all the medicines, get the material needed for the recover; make the
house a place safe. At the first times in house is more complicated because the family
has to take care of the family member who had stroke all the time even at nights, the
caretaker should look after their son or daughter or mother or father of not falling
down from the bed, the caretaker should be attentive if he or she wants to go to the
bathroom or needs something.

Over time the loved one who had the accident start realizing or being conscious about
her or his real situation, it is a hard knock for all the family. There are some days
when the situation is so difficult that the survivor does not want following living from
that way. Nonetheless, it is possible the recovery and if there is a big motivation and
also a strong family help.

2.5.3 Go for a walk

All the new experiences the survivor can have like: listening people conversation, the
sound of the birds or dogs, seeing strange people and their behavior, being able to
feel the wind the rain, the grass under his or her feet, being part of new environment
or situation such as in a restaurant or park or cinema are really profitable and
enhance the recovery, because the brain has new signs to feed its process and boost
the connection between neurons and also is a perfect time to go out of the routine.
However, for people with some limitations to transport or of other kind go out from
home in Oruro becomes something stressful.

On the streets you can find many people braking transit rules, most of them are
walking so fast or so slow and they do not pay attention in other needs, there are
people who sell different things on the streets, most of the cars do not respect
crosswalk and some do not stop in red traffic light and is the same for people who do
not respect traffic light, all these elements give as a result of a mess on the streets

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and for a people who have some disability is too difficult can transport. The sidewalks
are a big problem they present many holes, they are narrow and distance between
the street and the sidewalk is not the correct to can go up from the street to the
sidewalk with a wheelchair.

When finally you arrive at the bank or cinema or park, you may find other chaos, there
are stairs everywhere and no ramp to a wheelchair can go through it and even less
an elevator. But all these things are not the big problem, the main problem is the
people who are not friendly, who do not matter the needs of others, who do not give
some help und just seen what happens, and when the people make incorrect things
and do not respect others.

In these conditions, all the improvements should new experiences going out from
house are lost because instead of facing all the chaos mentioned before it is
preferable to stay at home.

“I went out with my family to a restaurant for a distract moment, but when
everything was great a worker started making a loud noise while we were
eating, that was so rude and he did not stop, my father who had a stroke and
one of his effects is that he cannot control their emotions was so angry and I
and my family should go home immediately, I was so stress and sad moment
for my family, we just have a quiet and different lunch, but go out was worst”

E.R.

2.5.4 Looking for a Program Recover

Is it possible for the recovery from a stroke? This is a frequent question of survivor’s
families, and another frequent question is, how long can somebody recover from a
Stroke? Both questions are narrowly related and in order to answer those questions,
it has to be known first that the total recovery can be reached, after progressive
improvements step by step,​[15] with the correct therapy. The best stroke rehab results
from a combined effort by the survivors of their family along with a team of healthcare
professionals.​[12]

Unfortunately, there is no stroke recovery center in Bolivia, the stroke survivor

receives physical traditional treatment with passive motions but this does not have
bases on the real issues behind cerebrovascular accidents, so the recovery is
inefficient. In Oruro, there are few specialists in physiotherapy who know to face all

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the aspects that are presented in a person by a stroke, but it does not enough to have
a correct recovery.

Fig. 6 Traditional therapy centers vs Neurocognitive therapy centers.​[9]

The own families have to look for information, the proper exercises, all the available
resources on​ ​the internet and all the possibilities that in Bolivia cannot get.

In the English search, there is bigger information available, the different organization
aims to stroke recovery and several stroke centers. American Stroke Association
established four main points that have to be present in any recovery program.

1)​ W
​ hat will stroke survivors do in rehab?

It depends on what they need to be independent. The areas may be needed include:

● Self-care skills such as feeding, grooming, bathing, toileting, and dressing

● Mobility skills such as transferring (from chair to bed or bed to chair, etc),
walking or self-propelling a wheelchair
● Communication skills in speech and language
● Cognitive skills such as memory or problem solving
● Social skills for interacting with other people

​2)​ W
​ hen does rehab begin?

The doctor decides when the patient is stable and able to benefit from it.

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3)​ W
​ hat is a rehab program?

A program may include:

● Rehabilitation Nursing
● Physical Therapy
● Occupational Therapy
● Speech-Language Therapy
● Hearing Therapy
● Recreational Therapy
● Nutritional Care
● Counseling
● Social Work
● Psychiatry/Psychology
● Chaplaincy
● Patient/Family Education
● Support Groups

Stroke rehab should include:

● Training to improve mobility and ability to do daily tasks

● The tailored post-stroke exercise program
● ​Access to cognitive/engagement activities (books, games, computer)

● Speech therapy, if stroke caused difficulty speaking or swallowing

● Eye exercises, if stroke caused a loss of vision
● Balance training for those with poor balance or with a fall risk
● Adaptive strategies to help you function within a “new normal”

In Spanish there is not much information, with a deep search the best website
founded was one called Stroke therapy which is a program created by an Italian
specialist in neurocognitive therapy for cerebrovascular accident recovery. This
program is focused on brain neuroplasticity due to the accident was in the brain and
not in the arms, hands, legs, and feet. The exercises enhance the brain perception of
the body they also have in their team a psychologist who is a support in the emotional
aspect of the survivors and their family. The unique particularity of this organization is
they use telecommunication technology in order to reach more people more survivors
and more families. Their therapies are made by using video calls, Facebook groups,
YouTube and else. More people in Latin America especially benefit due to this
program.

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 Fig. 7 Logo of Stroke Therapy Revolution an Organization who focus on
neurocognitive

The exercises and tasks of neurocognitive rehabilitation are design in order to stimuli
the neurosensory system, motor coordination and enhance muscular force.

Fig. 8 The Table exercise is a fundamental task for the walking recovery after a stroke

Fig 9. The Circles exercise is a fundamental task for movement sensibility of

articulations, for the representation of the arm in the brain and for spasticity,
amplitude and force control of the arm

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 Fig. 10 The finger recognition, this exercise shows that sensibility is more complex
than people think. The task is very simple, the patient closes the eyes and recognizes
what finger of his or her hand is been moving.

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CHAPTER 3: PRACTICAL FRAMEWORK

“You can have a stroke, but the stroke does not have to have you. There is
life after a stroke”

Wanda Walton

In this part of the project, I will share with ​you a little part of my own experience of
taking care of my father who is a stroke survivor, and the things were done during this
project.

3.1 Recovery in home

After all the walls my family and I had to live after my father’s stroke and all the first
shock moments filled with frustration, sadness, and despair of knowing nothing, we
finally can manage all the changes in our lives. Getting specialists who can give us an
adequate stroke recovery program was one of the most complicated things but we
finally could find two incredible people. They have been helping us with my father’s
recovery, both come to my house almost every day with big enthusiasm to work. In a
certain manner, they become my dad’s friends and make him laugh.

Germán Zarsury is a psychopedagogy and has a lot of ​experience working with kids
who have learning troubles. He is from La Paz and travels to Oruro every week, he
comes to my home from Tuesday to Friday. My father has memory and attention
difficulties. That is a big problem, almost all cognitive processes are based on these
two qualities but my dad is really smart and ingenious, he can figure out difficult tasks
even with all he has happened.

Fig. 11 My father’s psychopedagogy session.

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All people are surprised when they can see all my dad is overcoming. Germán does
not just bring novel activities in order my father’s brain is been exercised, he talks with
him about life, about anything and my father needs this kind of conversation.

On the other hand, Sandra is a physiotherapist and she comes to my home on

Monday, Wednesday, and Friday. She has also an incredibly good mood, I help her
with the therapy sessions and I am learning a lot. The end of the session is the part
my father likes because we help him to walk. Now, he can walk alone but I always
have to be beside him, since he is no stable enough to be alone. This is the final goal
that my father can be independent and my family and the specialists are working for
achieving it.

Fig. 12 My dad with Sandra in his physical therapy.

3.2 Looking for new recovery alternatives

In all this process, I have been searching constantly any information that can be useful
in order to improve the recovery and I find a webpage and then a facebook page from
an institution that offered a stroke rehab by using neurocognitive method, the

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company is called Stroke-Therapy and they help stroke survivors from differents
countries but especially survivors from Latin America.

I wrote them on September 1, they answered me immediately telling me they can help
us. On September 9, we start the recovery program.

“Hi Emily, It is a pleasure to know you, I am Carlos and I am going to be the

specialist who will guide you in your process, I am here for attending you in
all you need. Thanks for trusting in us.”

Dr. Carlos Carmona, Neurocognitive specialist.

The first step was to take two videos of my dad one walking and another grabbing
different kinds of stuff. In the afternoon, my parents and I have a video call with Dr.
Carlos Carmona and the stroke therapy founder Dr. Valerio Sarmati from Italy. That
appointment encourages my dad because we could talk with experts from other parts
of the word with other strategies and they would help us. The appointment was also
very useful and interesting for me, they answered questions anybody could before, we
understood more thing and they had encouraged us to still fighting.

“Dear Miss Emily and Mister Emilio

I am so happy, everything is going on well in our first appointment, so we

can follow the process. This is the exercise file we design for Emilio...As we
talk by phone, it is extremely important that you can upload the exercises to
support group, two exercises at least in order to one of us, the specialists,
can tell you the corrections and thereby you can do a perfect performance
at home what are we pretend to a good recovery..”

Dr. Carlos Carmona, Neurocognitive specialist.

Summarizing, we should perform two exercise hours daily, one hour in the morning
and another in the afternoon. Since that day I have been attempting to follow the
instructions correctly but is more difficult than it appears. They share my videos with
exercises and I need to study them and then I have to get the material in order to build
them, I did it but always I go by the most difficult path to reach the task.

Every weekday I try my dad to do the exercises but I need to record him as well so it
is a bit complicated to do everything alone. The most difficult is to persuade my dad to
do exercises, the most time he does not want to do it, I think is not easy for him to try
every day and realize he cannot understand what is happening and just know that he

24
is not able to do many things. But is also hard for my family, sometimes I do not know
what to do as well.

I and my sister built the stuff for the exercises, the last one was to build a hemisphere
of four-centimeter radio, I did it with my mom.

3.3 A walk by the Ecological Park of Oruro

One day Germán said to us that it would be really good if my father went out of the
house, new environments would have great effects on my dad. He did that affirmation
when he realized that day my dad had been having the low mood to develop tasks
and even to talk.

The only place we found to be relaxed surrounded nature was the Ecological Park. It
is very nice place and fortunately there were not many people the day we went, the
only problem was the ramps to go down or up were so steep, it was impossible for my
mom, my sister and me go on the ramps with my father so my father had to go by the
stairs carefully but besides of that it was a good moment.

Fig. 13 Photo of Ecological Park of Oruro.

My father laid on the grass next to a small tree, he seemed happy and relaxed, we
walked in the park for almost twenty minutes, my father loves to be near nature. We
went to Ecological Park in two opportunities both of them were great.

25
3.4 Public places
The bad side of going out from home comes now. There are fundamental people’s
behaviors and complete procedures structures that works wrong in Oruro and I do not
mean these kinds of problems happen just in Oruro maybe it is the same or less or
more complicated in other cities, but the worst is, I guess, when some people are so
used to things the way they are even if they are bad as to change bad aspects of our
society.

I will start with Oruro streets, I live almost in the center of the city and few sidewalks
are in good condition, those are the exception, the rule is the sidewalks are damaged.
It is ​a danger even for people who can walk by themselves, but it ​is more complicated
even it may become a challenge for people who can not see, who are on wheelchair
and elder people. When we went out of the house because we should go to the doctor
or the bank, we tried to avoid bad condition sidewalks, but we do not always could.
We spent the kind of fifteen minutes to move us three blocks. In all this time, we have
help from others ​a ​few times, but when that happens they always are kind to us and
any help is totally grateful.

26
Fig. 14 Photos of some streets of Oruro in bad conditions, any of them present ramps
in the corners.

The fact of going from one sidewalk to another is a difficult task for me, I do not have
enough force in my arms to do it. If my mom or I find sidewalks with ramps, we use it.
The path to arrive someplace becomes harder when pedestrians and drivers do not
follow the rules, for example, I saw many times cars on the crosswalk, cars do not
stop when the traffic light is in red. it is the same for some pedestrians and sellers on
the streets do not worried if their behavior can affect others.

Finally, when my parents and I arrive at the place, it can be a government institution or
not such as; a restaurant, a park, a bank or other, we find stairs if the place has floors
and if it has ramps, they are so steeps. It is a complete relief when it is time to come
back home.

Of all the times my family and I go out, I can say that just the twenty-five percentage
we had a good time, the rest of them we had so many problems and my father was
totally angry.

3.5 A psychology appointment

As a part of the Stroke-Therapy program we have been doing, on September 8, my
family and I could talk with a psychologist for the first time after my father’s stroke.

“...I introduce me, my name is Ariadna Camargo I am from Stroke-Therapy

I am a specialist in the psychology field, the emotional field. In the recovery
process, besides physical therapy, it is important to tell how we are feeling
both the patient and the family since in the end everybody ends up

27
 immersed in the situation and all of us, that event harms or benefits us in
different manners..”

Ariadna C. Psychologist

This conversation made me feel better and I learned how a strong event can go out
several emotions not only in people who live the event directly but people who are
around him or her. Everybody lives the event in a unique way it depends on their life
story, their resources or depends on the relationship they have with the survivor. being
with my father every day, in my specific case, shows I love him and I want him to
happy. I learned that there are good and bad moments and in any case could help if
we show and tell what we are feeling.

I took advantage to ask her all my doubts, I had all this time, but I could not ask all of
them if my family can have another appointment with her I will do.

3.6 Spreading information about stroke worth it

Over this project time, I have search about information about stroke, its symptoms, its
risk factors, what really happens when a stroke occurs, its huge range of effects that
can be produced, there is a lot of information about stroke seen from different
approaches. I have summarized the basic and fundamental concepts I think
everybody needs to know, that is why I thought the better manner to spread those
concepts because nowaday people enjoy more seeing another sort of information on
social networks than image about medical information. I shared some posts by using
my social networks mainly facebook and WhatsApp.

The pictures about stroke are in Spanish in order to arrive more people from Oruro,
Now I will show some of them.

28
Fig. 15 The risk factors are those
which increase your probabilities of
having an illness or medical
condition.

Fig. 16 The work stress is a sort of

stress that appears in work and it
can produce physical and mental
saturation and/or collapse in
people affecting other people’s life
fields.

29
 Fig. 17 A modification in the brain due
to a brain injury can have
repercussions on the way of elaborate
or give a sense at all main body
information, determining an alteration
of emotional management as well.

Fig. 18 The depression is a clinical

condition quite accurate that can be
severe and affect in the therapies. In
particular, after stroke, it delays the
recovery process.

As it can be seeing the is a different kind of information about stroke, those are just a
little part, I could not share all, I think even after one year reading about this topic I do
not know all about stroke but I will be still spreading more information, all I can. The
reactions to the posts were less than when I share other kinds of posts, for example,
an entertainment post, but it is a good start.

30
CHAPTER 4: PRACTICAL WORK

4.1. Survey
As a part of this project, it was collected important information about the real situation,
especially in Oruro, about stroke.

4.1.1 Survey Description

The stroke topic was focussed by two approaches; the first group of five questions
aimed to establish the real grade of knowledge we have about differents medical
aspects of stroke, and the second group of questions had the objective of recollecting
the people’s perspective about how society behaves in different contexts we are living
in, and for people with some grade of disability those environments could mean
limitations and challenges.

The poll had nine questions and it has been fill by forty-five people, most of them live
in Oruro and a small group of them is living for a couple of years in other cities of
Bolivia like La Paz or Cochabamba. The platform I used to do the survey was Google
forms, it is an easy manner to deliver any poll and reach more people. It is the main
reason why I do not exactly the characteristics of the people who answers the poll, but
in general, they were a group between twenty and thirty years old.

31
4.1.2 Results and Analysis

1. Do you know what the cerebrovascular accident is?

In this question, it was proposed to give four answer options in order to have more
detailed information and people who answered it feel identification with some of them,
so the results have fewer interpretations failures.

The graphic shows the thirty-nine percentage of people know a little about what a
stroke is. A twenty-two percent of them marked the option that indicates they have
ever heard something about stroke but they do not know what it is, and the same
percentage of people say they know what is a stroke. Finally, the percentage of
people who know nothing about stroke is seventeen dot one.

32
 2. Do you know somebody who suffered embolism or thrombosis or some kind of
severe head knock?

In this question were presented three medical conditions; embolism, thrombosis and
severe head knock, all of them are in the group of cerebrovascular accidents or
strokes. Those concepts are more known in our context and it could be possible that
people know somebody who suffered any of those medical conditions but they do not
know those conditions are cerebrovascular accidents.

This question aimed to discover the number of people who had a stroke principally in
Oruro, but in an indirect way, that is why those values are just approximations
because two or more people could know the same person who suffered a stroke.

The results show the sixty-five dot nine percent of people know somebody who
suffered embolism or thrombosis or severe head knock and the thirty-four of them do
not.

33
 3. Have you ever heard about Transient Ischemic Attack?

This question is about a medical condition very risk because it may be not detected
easily or may be confused for a severe headache. Unfortunately, people who suffered
Transient Ischemic Attack, have more possibilities of having a stroke in the future, and
even the Transient Ischemic Attack may become a cerebrovascular accident if it is not
treated.

The graphic present a seventy-three dot two percent of people who has no idea of this
concept against a twenty-six dot eight percentage who knows what is a Transient
Ischemic Attack. It is one of the concepts which have to be more deliver in order to the
people know the risk and how to prevent it.

34
 4. Do you know what the main stroke symptoms are?

The results show; a fifty-three dot seven percent of people know some of the stroke
symptoms, a thirty-one dot seven percentage has no idea, and the last fourteen
percentage know the symptoms.

35
 5. Do you know what the stroke effects are? (You can mark more than one option)

In this question, the person could choose more than one option and mark all the
effects he or she consider are due to cerebrovascular accidents. It is important to
mention all of the options are the stroke effects.

It is interesting that language troubles, memory loss, and death are the conditions
more known by people as stroke effects. Other conditions like vision troubles and
behavior control problems are in a meddle group that means a bit more the fifty
percent of people think they are stroke affects the other part do not. Finally, emotional
problems are not seen frequently as troubles people may present after stroke.

36
 6. Could you say you have a healthy life? That means to have a healthy diet, be
physically active, healthy weight, live tobacco-free and have a good managed
of some medical condition if you have some

This question is about the personal perception of our health. In many cases, people
are involved in the work or daily troubles that sometimes they forget to take care of
their health and live with bad habits.

It turns out that the thirty-nine percentage of people control most of the aspects that
may indicate they have a healthy life, and the same percentage of people think they
control some of the aspects mentioned in the question. The seventeen dot one
percent say that they consider they have a healthy life and finally only four dot nine
percent say they do not have a healthy life. It is interesting that both extremes options
are with less percentage.

37
 7. Do you think the public places in the city you are living in are suitable for people
with some grade of disability? (streets, banks, parks, others)

This question is about the people’s perception of the physical conditions of public
places, specifically if they are adequate for the needs of people with some disability.

The results show that a fifty-one dot two percent say the public places are not
suitable, a forty-one dot five percentage indicates the public places are a bit suitable,
which means there are a small number of public places where they are suitable for
everybody. Finally only a seven dot three percentage think the public places are
suitable.

38
 8. In your opinion, how many people do behave correctly in public places? that
means they are friendly with others, they follow the traffic rules, they take care
of their behavior in order not to affect the others.

This question is a complement of the previous one, it tries to show the people’s
perception about the behavior of others in public places. In some cases even when it
is not our intention our action can affect others.

In this case, the options are a reference at the number of people, in percentage, who
behave correctly in public places. It turns out a nine-dot eight percent of people says
the seventy-five percent of citizens behave correctly, a twenty-six dot eight believes
the fifty percent of citizens behave in a correct manner, a thirty-four dot one
percentage says the twenty-five percent of citizens have a correct behavior and finally,
a twenty-nine dot three believes that less of ten percent of people behave correctly in
public places.

39
 9. In your opinion, do emergency institutions such as firefighters and hospitals
have a prompt and adequate performance when an emergency event
happens?

The last question in the survey tries to reflects the people’s perception of how the
emergency teams react when an emergency situation occurs. This is a critical aspect
because if emergency organizations do not offer qualified work, people’s life will be at
risk. The survey shows a forty dot nine percent of people think the emergency
institutions have prompt and adequate performances, a thirty-nine percentage says
that the emergency institutions rarely have prompt works and finally, a fifty-six
percentage believes this kind of institution does not do adequate work.

4.2 Expert Interview

The interview was made to a specialist in physiatry, who has been working in the physical
recovery of my father. The interview presented five questions and the answers were

40
translated from Spanish to English because Sandra, the specialist, answered them in
Spanish.

4.2.1 Expert Interview translated to English

Me: How many people who suffered a stroke have you work with, in all your career as a
physiatrist?

Sandra: ​Well, over my career I have been able to reach treating fifteen patients
approximately, from the start to the ending of his or her treatment. With others who have been
in the ictus stage, I mean the first stage, I do not remember how many.

Me: What is the difference between to treat stroke survivors and people who had injuries in
other parts of their bodies?

Sandra: Well, the treatment that is done with stroke patients always has to be a
multi-disciplinary process, with the help of all the fields stroke needs, unlike other patients
with an injury, let’s say traumatic injury. In these cases, the complexity is not a big problem as
if to work with other health care specialists, because it is an easier treatment and they have a
faster recovery as well.

Me:​ Is it possible a complete physical recovery of stroke?

Sandra: This is different in each patient because of the kind of injury they present, I mean,
there are severe strokes, which could bring someone to death, or minor strokes or better said,
a patient who has been treated promptly and the brain injury is not complex and it does not
harm several systems. Therefore all depend on the kind of injury somebody has had to have
optimal results.

Me: ​This question is related to the previous one and it is: how long does it take for a stroke
survivor to recover?

Sandra: There is not a specific time in order to say how long it takes for a patient to go out of
the disabilities exactly. As I explained in the previous question about another kind of injuries
different to stroke, in those cases we can say the recovery will end in fifteen sessions, in
twenty sessions, in a month, three months, but with patients who have had a stroke is quite
different, the recovery time oscillates. there are patients who rehab in six months, one year,
two years, three years, the time is longer depending on something I had already mentioned
you, the type of injury it is presented in a patient who has suffered a stroke, It depends on the
type of affectation.

Me: These last months we have been working in my father’s recovery with new exercises,
these exercises are base on the neurocognitive method, which focuses principally on the
brain perception of our body so, what is your professional opinion about this method?

41
Sandra: Well, we have been working, how you have mentioned, all this time with this method
which for me it was something innovative. I consider if this method were worked by the start,
since an ictus how specialists call it since the stroke happens, the results would be better.
Because as the patient has lost the body perception, it is easier to teach the stroke survivors
all this neurocognitive method and they can take more advantage for it. Now, in this stage in
which we are with your father, an advanced stage called spastic, we have to fight against
stroke patterns they have been produced over the months. It is a great method, it has good
results, but we need more time in order to he can recognize again and block these patterns
he presents.

4.2.2 Expert Interview in Spanish

Yo: ¿Con cuántas personas que sufrieron un accidente cerebrovascular ha trabajado en toda
su carrera como fisioterapeuta?

Sandra: Bueno, en el transcurso de mi carrera he podido lograr atender a 15 pacientes

aproximadamente, desde el principio hasta el final de su tratamiento. Con otros que han
estado en etapa de ictus, o sea en etapa inicial, no recuerdo cuantos.

Yo: ​¿Cuál es la diferencia entre tratar a un sobreviviente de ACV y personas quienes

tuvieron lesiones en otras partes de su cuerpo?

Sandra: Bueno, el tratamiento que se realiza con pacientes con ACV siempre tiene que ser
un tratamiento multidisciplinario, con el apoyo de todas las áreas que involucra una lesión de
ACV, a diferencia de otros pacientes con una lesión por decir traumática. En estos casos no
es tanta la complejidad como para tratar con otros profesionales de la salud, porque es más
sencillo el tratamiento y más pronta también la recuperación.

Yo:​ ¿ Es posible la recuperación física completa del accidente cerebrovascular?

Sandra: Esto varía en distintos pacientes por el tipo de lesión que tienen, o sea hay lesiones
que un ACV puede ser más fuerte, que podría llevar a la muerte a algunos pacientes o
lesiones leves, o en todo caso un paciente que ha sido intervenido en forma inmediata.
Entonces la lesión que se causa a nivel del cerebro no es tan fuerte, no involucra distintos
sistemas. Entonces todo depende de qué tipo de lesión ha sido para llegar a tener un
resultado mas optimo.

Yo: ​Ésta pregunta está relacionada con la anterior y esta es: ¿Cuánto tiempo le toma a un
sobreviviente de ACV recuperarse?

Sandra: No existe un tiempo determinado para decir en cuánto tiempo exactamente un

paciente puede salir. Como lo mismo que te mencionaba en la anterior pregunta de una
lesión distinta a un ACV, ahí podemos decir que en 15 sesiones, en 20 sesiones, en un mes,
en tres meses, pero con pacientes que han tenido ACV es muy distinto, varía el tiempo. Hay

42
pacientes que recuperan en seis meses, un año, dos años, tres años, va recorriendo
dependiendo de lo mismo que te había mencionado, el tipo de lesión que se da en un
paciente que ha sufrido un ACV, según el tipo de afectación.

Yo: Éstos últimos meses hemos estado trabajando en la recuperación de mi padre con
nuevos ejercicios, estos ejercicios están basados en el método neurocognitivo, el cual se
enfoca principalmente en la percepción cerebral de nuestro cuerpo. Entonces, ¿Cuál es su
opinión profesional acerca de este método?

Sandra: Bueno, hemos estado trabajando, ya como mencionaste, todo este tiempo con éste
método que para mi también fue algo innovador. Considero que si éste método se trabajara
desde un inicio, desde un ictus que se denomina, desde que se dio el accidente cerebro
vascular, serían mejores los resultados, porque como el paciente todavía ha perdido la
percepción del cuerpo, enseñarle todo este tratamiento neurocognitivo, sería mucho más
fácil y favorable. Ahora en esta etapa en la que nos encontramos con tu papá, que ya
estamos en una etapa más avanzada que es la espástica, tenemos que luchar con patrones
que se han dado en el transcurso de los meses. Es un buen tratamiento tiene muy buenos
resultados, pero necesitamos más tiempo para que pueda nuevamente reconocer y bloquear
estos patrones que se han presentado.

43
4.3 Photographic Memory
All the activities they were mentioned before, are explained now with more details and
pictures.

4.3.1 Neurocognitive exercises

I and my father doing the neurocognitive

exercises: the first one is called ‘Little Board’ and
it focuses on the right tread perception on a little
board which had a fifteen grade slope, in this
case, my father had to recognize what was the
position of his foot-related with his other foot and
with his body as well. The second exercise is
called ‘Rules’ in which my father should say the
size of the piece between his fingers, there were
twelve pieces from one centimeter long to twelve
centimeters. The last exercise is called ‘guided
walking’ where I move my dad’s left leg on a
specific mark on the floor. The objective was he
learns to recognize in which position was is left leg
without to see, with just the brain perception of his
leg position.

44
4.3.2 Pictures Memory

After an exercise afternoon with my dad, we were

taking free time. I usually take photos of us
because it is a good strategy in order to help him
remember what we do every day. I can explain to
him with those pictures how his process recovery
has been progressing over time. How the photos
show the date when they were taken, I can tell him
with more detail all we have lived, before and after
his stroke. Frequently, he is confused about time,
he thinks we are in years when I was at school, he
thinks he has into this recovery for much time but it
is not true, so I tell him how it really was. That day
we were happy because he did the exercises
correctly, that was a great day.

4.3.3 Interview with Sandra

Picture about the interview I did to Sandra, we were talking about stroke as a part of this
project. The answers were surprising to me, especially the first one in which she explained to
me she worked with fifteen stroke survivors, she told me every case is unique and its
complexity depends on the grade of the injury.

45
4.3.4 Ecological Park

These pictures were taken during the

second time my sister, my parents and I
went to Ecological Park of Oruro. The
first picture shows my parents and I
sitting on the park bank, the bank had
behind like a tree wall that formed like an
umbrella on the top what produced the
sun rays did not arrive directly to our
faces. The second picture shows my
father, my sister and me walking through
the park. It was a great time for my
father he could walk in big places without
cars, and all the problems could be
produced by public places. Ecological
Park is a quiet place with many trees,
flowers, which is not seen frequently in
Oruro. We could lay on the grass
listening to music around all that
vegetation.

46
4.3.5 Stroke Topic In Social Networks

These last pictures show stroke topics in the social networks environment. The first one is a
picture I took of facebook live done by Valerio Sarmati, the founder of the stroke therapy
revolution. In that facebook live he spoke with Ariadna, a specialist in psychology, about how
emotions can be affected by critical moments not just for people who suffered directly, but the
family can be affected as well, in different manners. People from many countries of Latin
America participated in these facebook lives how it can be seen in the picture. The second
comment was published from Bolivia when I saw that comment I was happy because this
method has been spreading through Bolivian people as well. The comment was in Spanish
but the following text is the translation.

<< Good night Dr., thank you for all his support and orientation. We are hearing
from you here from Bolivia. Greetings to the specialist who is with you. Ruben and
Nelly.>>

47
The second picture shows a publication I did on facebook about why brain injuries are too
harmful to us, is not the same talk about brain injury and injury in other parts of the body, I did
that because I want people to know bad habits can produce several effects. I think it is the
start point to everybody feel interest in this kind of topics.

My comment was in Spanish because my friends know Spanish but the following text is the
translation in English.

<< What does it happen when we injury a ankle, or a leg, or an arm? Depending
on the injury severity we could not use that body part for a while, more or less
long. But what happens if the injury is in the brain. In this case, several body
functions are affected because the brain controls everything else, it processes all
we perceive from our environment, image, sound, temperature, etc. and gather all
this sings in something coherent. Stroke (cerebrovascular accident) or ICTUS
produces brain injuries. When it occurs we should act fast, because neurons die in
short times. I believe is good to know what are the risk factors that make a person
be susceptible to have these kinds of accidents in order to be able to avoid them.
>>

48
CHAPTER 5: CONCLUSIONS

To sum up, the conclusions of the project are:

1) The sample of people who answer the survey, the responses of the physiatrist
and Investigation of the company Stroke Therapy Revolution indicate that there
is an important percentage of stroke survivors in Oruro, which was the studying
object of this project, and in the same way in Bolivia. This fact does not
correspond with the recovery programs level offered by medical specialists in
Bolivia, by contrast, there is no an adequate guide or protocols in this topic
even when that lack can harm the lifestyle of stroke survivors and their families.
2) Stroke is a delicate medical emergency which changes the lives of people who
suffered it, according to the survey made in this project the meaning of stroke,
its symptoms, its effects, and its risk factors are not known proximately by more
of the seventy percent of people, so it is extremely necessary to spread this
kind of information, it has to be done continuously in order to arrive more
people.
3) The environment is a fundamental factor in the stroke recovery process. To
build suitable and friendly public places for people who have some grade of
disability and everybody, in general, is a huge help. According to the survey,
the 92.7% Oruro citizens think the public places are not adequate or just a bit
and the 63.4% think that only 25% or less of people behave correctly in public
places, these to results show the environment in Oruro is a limit for people with
some disability, in their recovery and in their life as well.
4) The neurocognitive method is a good method for stroke survivors are able to
have high rehabilitation and they can achieve more goals; therefore, this
method should be used in all physiotherapy centers in Bolivia.

49
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[15]​ Sarmati, V. Webinar sobre Terapia Neurocognitiva. ¿Cómo rehabilitar un

paciente hemipléjico?. Available on: ​https://www.youtube.com​ ​[checked on: March
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