Types of Cerebral PalsyTypes of Cerebral Palsy

Robyn SmithRobyn Smith

Department of PhysiotherapyDepartment of Physiotherapy

UFSUFS

20122012

1. Spastic Group 1. Spastic Group

Spastic QuadriplegiaSpastic Quadriplegia

Distribution Distribution

All four limbs similarly involvedAll four limbs similarly involved UL sometimes to a greater degree than LLUL sometimes to a greater degree than LL Distribution of tone may be assymetrical Distribution of tone may be assymetrical

with one side more involved with one side more involved or with one side in flexion and the other in or with one side in flexion and the other in

extensionextension Trunk often hypotonic or with increased Trunk often hypotonic or with increased

extensor toneextensor tone

EtiologyEtiology

AsphyxiaAsphyxia AnoxiaAnoxia Abruptio placentaAbruptio placenta Merconium aspirationMerconium aspiration

Usually indicative of severe cortical Usually indicative of severe cortical damage damage

DevelopmentDevelopment

SupineSupine

Asymmetrical ATNRAsymmetrical ATNR Uses retraction of Uses retraction of

head roll sidehead roll side No segmental No segmental

rotationrotation Spasticity with IR Spasticity with IR

hip may lead hip may lead dislocationdislocation

SittingSitting

Flexed postureFlexed posture Strengthens TLRStrengthens TLR Grasp weak due IR Grasp weak due IR

pronation armpronation arm Lifts head extension Lifts head extension

and retraction and retraction shoulders “chin shoulders “chin poke”poke”

DevelopmentDevelopment

ProneProne

Due to TLR battles lift headDue to TLR battles lift head STNR with neck flexion and STNR with neck flexion and

UL flexion with LL in UL flexion with LL in extensionextension

Often don’t tolerate proneOften don’t tolerate prone Mild – learns to lift head with Mild – learns to lift head with

extension and may even extension and may even creep.creep.

Uses TLR and STNR Uses TLR and STNR constantlyconstantly

TLR/STNR used to get into TLR/STNR used to get into M-sitting in mild casesM-sitting in mild cases

Standing & walkingStanding & walking

Very mild cases –seldom Very mild cases –seldom realisticrealistic

Uses extension spasticity Uses extension spasticity LL - ??? No true active LL - ??? No true active WBWB

No rotation or No rotation or dissociationdissociation

AP weight shiftsAP weight shifts Shuffling gaitShuffling gait As body weight increases As body weight increases

loose ability to walkloose ability to walk

Additional characteristicsAdditional characteristics

Associated with significant associated Associated with significant associated problems.problems.

Microcephaly & cerebral atrophyMicrocephaly & cerebral atrophy Mental retardationMental retardation Cortical blindnessCortical blindness EpilepsyEpilepsy Feeding problemsFeeding problems

Spastic DiplegiaSpastic Diplegia

DistributionDistribution

All four limbs involvedAll four limbs involved UL to a lesser degree than LLUL to a lesser degree than LL

???? Terminology you will aslo hear ???? Terminology you will aslo hear refering to assymetrical diplegia or a refering to assymetrical diplegia or a hemiplegia superimposed on diplegiahemiplegia superimposed on diplegia

EtiologyEtiology

Lesion lies near the para-ventricular Lesion lies near the para-ventricular region region

Forms part sub-cortical group lesionsForms part sub-cortical group lesions

Prematurity (PVL/ IVH)Prematurity (PVL/ IVH) HydrocephalusHydrocephalus

DevelopmentDevelopment

SupineSupine

Far better head and trunk Far better head and trunk control than quadcontrol than quad

Uses extension of head and Uses extension of head and retraction of head to rollretraction of head to roll

Later as flexion improves Later as flexion improves uses arm and upper body to uses arm and upper body to roll overroll over

No segmental rotationNo segmental rotation Kicking may notice Kicking may notice

scissoring legsscissoring legs

SittingSitting

No segmental rotation No segmental rotation cannot come up into sitting cannot come up into sitting through side lyingthrough side lying

Used STNR to get into M-Used STNR to get into M-sittingsitting

Pattern hip flexion and Pattern hip flexion and anterior pelvic tilt –becomes anterior pelvic tilt –becomes fixed deformityfixed deformity

Often shortening hamstrings, Often shortening hamstrings, long sitting difficult with poor long sitting difficult with poor balance and child uses arm balance and child uses arm supportsupport

DevelopmentDevelopment

Prone Prone

Creeps using arms to pull Creeps using arms to pull forwardforward

STNR to get into M-sittingSTNR to get into M-sitting ““Bunny hops” or crawls Bunny hops” or crawls

asymmetrically due to poor asymmetrically due to poor rotation and dissociationrotation and dissociation

On floor requires arm On floor requires arm support in sittingsupport in sitting

Often sitting chair more Often sitting chair more comfortable and stablecomfortable and stable

To get into kneeling pull up To get into kneeling pull up with arms, LL inactivewith arms, LL inactive

Standing & walkingStanding & walking

Lumbar lordosis & hip flexionLumbar lordosis & hip flexion No segmental rotation or No segmental rotation or

dissociationdissociation Lateral weight shiftsLateral weight shifts Often up on toesOften up on toes High guard and poor High guard and poor

balancebalance Tries get foot flatTries get foot flat Extension LL with scissoringExtension LL with scissoring Walking aid –swing through Walking aid –swing through

gaitgait

CharacteristicsCharacteristics

Near normal IQNear normal IQ EpilepsyEpilepsy Feeding problems may occurFeeding problems may occur

Spastic HemiplegiaSpastic Hemiplegia

DistributionDistribution

Arm and leg on the same side of body Arm and leg on the same side of body involvedinvolved

Arm usually to greater extent than legArm usually to greater extent than legBUT:BUT:

Arm more leg middle cerebral arteryArm more leg middle cerebral artery Arm =leg anterior cerebral arteryArm =leg anterior cerebral artery ““dense”dense”(arm, leg and face) (arm, leg and face) capsula capsula

interna interna

EtiologyEtiology

EmboliEmboli ThrombiThrombi Artery Artery

malformationsmalformations Prematurity with Prematurity with

anoxiaanoxia

DevelopmentDevelopment

Initially may not appear Initially may not appear asymmetricasymmetric

Start to become evident Start to become evident 6/126/12

Starts only using Starts only using unaffected armunaffected arm

Orientate themselves Orientate themselves only to unaffected sideonly to unaffected side

Retraction of hemi sideRetraction of hemi side Difficulty in rolling to Difficulty in rolling to

unaffected sideunaffected side Dislikes proneDislikes prone

Does not crawlDoes not crawl Sitting falls over hemi-Sitting falls over hemi-

side to compensate side to compensate shifts weight to normal shifts weight to normal sideside

Associated reactions Associated reactions commoncommon

Unable do bilateral Unable do bilateral hand activitieshand activities

Locomotes by bum Locomotes by bum shuffling shuffling

DevelopmentDevelopment

Standing no weight Standing no weight taken on hemi-legtaken on hemi-leg

Pelvis and hip in Pelvis and hip in retraction, LL flexion retraction, LL flexion up on toeup on toe

Walk by 18/12Walk by 18/12 Under-development Under-development

of hemi legof hemi leg

Postural deformities Postural deformities common e.g. common e.g. scoliosisscoliosis

CharacteristicsCharacteristics

MicrocephalyMicrocephaly Sensory involvementSensory involvement EpilepsyEpilepsy Intelligence varies –left cerebral hemisphere poor Intelligence varies –left cerebral hemisphere poor

prognosis prognosis

Left vs. right hemiplegia:Left vs. right hemiplegia:

Left hemi has speech, language and feeding Left hemi has speech, language and feeding problemsproblems

Right hemi has visual perceptual problemsRight hemi has visual perceptual problems

Children with spasticity Children with spasticity divided into 2 groups:divided into 2 groups:

Severe spastictySevere spastictyModerate spsticityModerate spsticity

Severe spasticitySevere spasticity

FeaturesFeatures

In a state of hypertonusIn a state of hypertonus The hypertonia does not change The hypertonia does not change Little or no movement ability due to tone. Little or no movement ability due to tone. Only small movements are Only small movements are Contractures tend to be more toward the mid- Contractures tend to be more toward the mid-

positionposition Balance reactions are absentBalance reactions are absent Problems e.g. respiration, feeding and speechProblems e.g. respiration, feeding and speech Emotionally child is fearful and cannot adjust to Emotionally child is fearful and cannot adjust to

movement. movement.

Children are often very passiveChildren are often very passive

Moderate spasticityModerate spasticity

FeaturesFeatures Tone moderate at rest increases activityTone moderate at rest increases activity More able to move due to changeability in toneMore able to move due to changeability in tone Inconsistent performance during execution taskInconsistent performance during execution task Contractures more dangerous in this groupContractures more dangerous in this group Associated reactionsAssociated reactions Balance reactions present but underdevelopedBalance reactions present but underdeveloped Emotionally these children are often frustrated and Emotionally these children are often frustrated and

insecureinsecure

Principles to use when Principles to use when treating a spastic childtreating a spastic child

Reducing the spasticity in itself will not Reducing the spasticity in itself will not make the child more functionalmake the child more functional

Therapist should always have a Therapist should always have a functional goal in mind. functional goal in mind.

Analyse the patterns of hypertonia and Analyse the patterns of hypertonia and the way in which it interferes with the way in which it interferes with postural control and the performance of postural control and the performance of functional tasks. functional tasks.

Asses the degree of compensationAsses the degree of compensation

Principles to use when Principles to use when treating a spastic childtreating a spastic child

Use of tone influencing patterns, postures Use of tone influencing patterns, postures and techniquesand techniques

Facilitate large range movements, free and Facilitate large range movements, free and rhythmicalrhythmical

Dissociation/ rotationDissociation/ rotation Mobile weight bearing in elongationMobile weight bearing in elongation Elongation of musclesElongation of muscles Correct biomechanical alignmentCorrect biomechanical alignment Reciprocal patternsReciprocal patterns Shaking and vibratingShaking and vibrating

Principles to use when Principles to use when treating a spastic childtreating a spastic child

Use patterns of activity that lead to Use patterns of activity that lead to function.function.

Facilitate active movements Facilitate active movements  Facilitate balance reactionsFacilitate balance reactions Prevent and minimize contracturingPrevent and minimize contracturing Grade stimulationGrade stimulation

2. Hypotonic Group2. Hypotonic Group

AetiologyAetiology

Most children with Most children with CP start out CP start out hypotonichypotonic

Premature babies Premature babies are hypotonicare hypotonic

Hypotonia usually Hypotonia usually transienttransient

True hypotonia is True hypotonia is rarerare

Complex differential diagnosisComplex differential diagnosis

The following other possible conditions need The following other possible conditions need to be excluded:to be excluded:

PNL e.g. GBSPNL e.g. GBS SC lesionSC lesion Neuromuscular junction diseases e.g. Neuromuscular junction diseases e.g.

Myasthenia GravisMyasthenia Gravis Muscle diseases e.g. SMA, DMDMuscle diseases e.g. SMA, DMD UMN = CPUMN = CP

NB:NB: valuable clinical tool is to test reflexes valuable clinical tool is to test reflexes as as hypotonic CP reflexes will still be hypotonic CP reflexes will still be presentpresent

Long term outcome for intial Long term outcome for intial hypotoniahypotonia

45 % 45 % HypertonicHypertonic 10%10% DiplegiaDiplegia 45%45% DyskineticDyskinetic ? %? % AtaxicAtaxic ?? %?? % True True

hypotoniahypotonia

FeaturesFeatures Little or no postural control against gravityLittle or no postural control against gravity Body takes up all the available supportBody takes up all the available support Move with difficultyMove with difficulty Uses limbs as post of postural control i.e. Wide baseUses limbs as post of postural control i.e. Wide base Hyper mobility of all jointsHyper mobility of all joints Apathetic/ passive. Reduced state of alertness. Apathetic/ passive. Reduced state of alertness.

Possible lack of motivation due to their inability to Possible lack of motivation due to their inability to respond . Placid, often describes as “good” baby respond . Placid, often describes as “good” baby

Delayed intellectual developmentDelayed intellectual development Usually problems with breathing, feeding and drinkingUsually problems with breathing, feeding and drinking Respiration often shallow with recession of the chest Respiration often shallow with recession of the chest

wall evident. Aspiration common. Children also wall evident. Aspiration common. Children also usually have a depressed cough reflex with usually have a depressed cough reflex with ineffective coughineffective cough

Principles to use when treating a Principles to use when treating a hypotonic childhypotonic child

Be careful of how stimulate child often hard to arouseBe careful of how stimulate child often hard to arouse Increase postural tone by stimulation techniques:Increase postural tone by stimulation techniques:

– CompressionCompression– Symmetrical patternsSymmetrical patterns– Static weight bearingStatic weight bearing– Rhythmical stabilizationRhythmical stabilization– All forms of tappingAll forms of tapping– Movements to be fast and resistedMovements to be fast and resisted

Work for head and trunk control and alignmentWork for head and trunk control and alignment Address associated problems of breathing, eating and drinkingAddress associated problems of breathing, eating and drinking Maximize positioning and handling to ensure the preservation of Maximize positioning and handling to ensure the preservation of

joint integrity and to prevent aspiration. joint integrity and to prevent aspiration. Prevent contractures especially postural deformitiesPrevent contractures especially postural deformities

3. Athetoid Group3. Athetoid Group

Athetoid groupAthetoid group

Characterised by:Characterised by:

InvoluntaryInvoluntary movements movements Abnormal or Abnormal or fluctuating posturalfluctuating postural tone tone

Athetoid groupAthetoid group

Classified according to Classified according to type of type of involuntary movementinvoluntary movement into 4 groups into 4 groups

Pure athetosisPure athetosis ChoreoathetosisChoreoathetosis Athetosis with dystonic spasmsAthetosis with dystonic spasms Athetosis with spasticityAthetosis with spasticity

Distribution toneDistribution tone

Pure athetosisPure athetosis

Tone varies very low Tone varies very low normalnormal Distal Distal > proximal> proximal Slow wreathing movementsSlow wreathing movements

ChoreoathetoidChoreoathetoid

Tone varies very low Tone varies very low high high Proximal > distalProximal > distal Large wreathing movementsLarge wreathing movements Poor grading of movementPoor grading of movement

Athetoid with dystonic spasmsAthetoid with dystonic spasms

Hypotonic OR hypertonicHypotonic OR hypertonic

Athetoid with spasticityAthetoid with spasticity

Moderate spasticityModerate spasticity Proximal Proximal > distal> distal Poor grading of movementPoor grading of movement

EtiologyEtiology

Kericterus hyperbilirubinaemia (severe Kericterus hyperbilirubinaemia (severe jaundice)jaundice)

Rh incompatabilityRh incompatability Prematurity Prematurity AsphyxiaAsphyxia Metabolic disordersMetabolic disorders Encephalitis/ meningitisEncephalitis/ meningitis Heavy metal poisoningHeavy metal poisoning Rhumatic feverRhumatic fever Degenerative disorders brainDegenerative disorders brain

Management of jaundiceManagement of jaundice

EtiologyEtiology

= damage to the = damage to the basal basal gangliaganglia

Basal ganglia are Basal ganglia are NBNB for: for: ControlControl of movement of movement Scale and amplitude determination of Scale and amplitude determination of

movementmovement Important in the control of Important in the control of eye eye

movementsmovements

CharacteristicsCharacteristics

High IQHigh IQ –cortex not involved –cortex not involved However usually However usually severely disabledseverely disabled Abnormal fluctuating toneAbnormal fluctuating tone Lack of Lack of proximal stabilityproximal stability Poor gradingPoor grading movement movement Poor balancePoor balance Contracturing usually not a concernContracturing usually not a concern Repetitive assymetrical movement patterns may lead Repetitive assymetrical movement patterns may lead

to deformitiesto deformities Joint hypermobilityJoint hypermobility Emotionally volatileEmotionally volatile Often Often frustratedfrustrated –temper tantrums –temper tantrums

Associated problemsAssociated problems

Speech Speech

Vocalization & Vocalization & speech problem –speech problem –speech poor and speech poor and indistinctindistinct

Hearing loss Hearing loss Can hear but does Can hear but does

not listennot listen

FeedingFeeding

Difficulty in swallowingDifficulty in swallowing Battle especially with Battle especially with

liquidsliquids

Associated problemsAssociated problems

VisionVision

Battle to focusBattle to focus May have May have nystagmusnystagmus= = rapid, rhythmic, involuntary rapid, rhythmic, involuntary

eye movements caused by eye movements caused by damage braindamage brain

Eyes unable move Eyes unable move independently headindependently head

Lack of stability of head Lack of stability of head affects visionaffects vision

DevelopmentDevelopment

Fluctuating tone present Fluctuating tone present sometimes birthsometimes birth

Initially seem hypotonicInitially seem hypotonic Develop extension Develop extension

head, neck, retraction head, neck, retraction shouldersshoulders

Persistent ATNRPersistent ATNR Due to involuntary Due to involuntary

movements movements fail to fail to develop adequate head develop adequate head and trunk controland trunk control

Athetoid very Athetoid very intelligent and intelligent and quickly learn to use quickly learn to use pathological reflexes pathological reflexes for functionfor function

DevelopmentDevelopment

ProneProne

ATNRATNR get up on one get up on one armarm

TLRTLR and and STNRSTNR to get to get into M-sittinginto M-sitting

SittingSitting

Like to M-sitLike to M-sit as is stable as is stable positionposition

Uses Uses ATNR for hand ATNR for hand functionfunction

Chair –stabilises using Chair –stabilises using arm around backrest or arm around backrest or hooks foot around leg hooks foot around leg chairchair

Promotes further Promotes further asymmetry asymmetry

DevelopmentDevelopment

Gait Gait

Struggle to learn to walk due to Struggle to learn to walk due to fluctuating tone, poor central control fluctuating tone, poor central control and involuntary movementand involuntary movement

Asymmetry may be notedAsymmetry may be noted Lumbar lordosis and anterior tilt due Lumbar lordosis and anterior tilt due

to poor central controlto poor central control Knees locked togetherKnees locked together Arm held together or against leg for Arm held together or against leg for

stabilitystability Often appears in-coordinatedOften appears in-coordinated

Principles to use when treating a Principles to use when treating a child with athetosischild with athetosis

Try stabilizing Try stabilizing postural postural tonetone !!!! Remember !!!! Remember underlying muscle tone is underlying muscle tone is LOWLOW

CompressionCompression TappingTapping Rhythmical stabilizationRhythmical stabilization Use of small ROMUse of small ROM Weight bearing in good Weight bearing in good

alignmentalignment

Try and promote Try and promote symmetry symmetry

Children with Children with dystonic dystonic spasmsspasms

Try and inhibit spasmsTry and inhibit spasms Work slowly, small ROM and Work slowly, small ROM and

in a graded mannerin a graded manner Counteract development of Counteract development of

joint and postural deformitiesjoint and postural deformities

For the child with For the child with spasticityspasticity

apply the same principles you apply the same principles you would use for a spastic childwould use for a spastic child

4. ATAXIA4. ATAXIA

Characterised by:Characterised by:

In-coordinated movement

Usually noted proximally

EtiologyEtiology

Damage to the Damage to the Cerebellum Cerebellum

Cerebellar malformationsCerebellar malformations CerebellitisCerebellitis TraumaTrauma AsphyxiaAsphyxia Poisoning/overdose e.g. Poisoning/overdose e.g.

Tegretol and epilum toxicityTegretol and epilum toxicity Metabolic disordersMetabolic disorders Neoplastic (tumor)Neoplastic (tumor) InfectiveInfective Genetic Genetic

Importance of CerebellumImportance of Cerebellum

Responsible for Responsible for ensuring ensuring smooth, smooth, coordinated coordinated movementmovement

Important role in the Important role in the execution of the execution of the motor planmotor plan

Clinical featuresClinical features

Generally Generally Low toneLow tone. . Spasticity may be presentSpasticity may be present Intension tremorIntension tremor absent co-contraction absent co-contraction

around joint. Cannot give stability to moving partaround joint. Cannot give stability to moving part Overshoot/ DysmetriaOvershoot/ Dysmetria poor grading of poor grading of

movement movement Use Use eyes to “fixate”eyes to “fixate” and may have nystagmus and may have nystagmus Truncal sway when walking Truncal sway when walking Uneven stride length and staggering gait, wide Uneven stride length and staggering gait, wide

basebase Appear to be Appear to be clumsyclumsy. Tend to fall frequently . Tend to fall frequently

due inadequate balance reactionsdue inadequate balance reactions

Associated problemsAssociated problems

Visual problemsVisual problems Speech problemsSpeech problems Problems with swallowingProblems with swallowing Perceptual and motor planning Perceptual and motor planning

problemsproblems

Principles to use when treating a Principles to use when treating a child with ataxiachild with ataxia

Physiotherapy treatment aims to:Physiotherapy treatment aims to:

Improve postural controlImprove postural control Improve balance and coordinationImprove balance and coordination Improve their movement possibilities in a safe Improve their movement possibilities in a safe

environmentenvironment Prevent stiffness, deformities and Prevent stiffness, deformities and

contracturescontractures

Principles to use when treating a Principles to use when treating a child with ataxiachild with ataxia

Increase Increase postural tonepostural tone Work with Work with activities activities

incorporating rotationincorporating rotation to to improve flexion rotation improve flexion rotation controlcontrol

Improve balanceImprove balance and and movement abilities e.g. movement abilities e.g. obstacle courseobstacle course

Activities requiring limbs Activities requiring limbs to move separately from to move separately from bodybody

ResistedResisted activities e.g. activities e.g. walking pushing a walking pushing a box/chairbox/chair

Work on placement, Work on placement, grading, direction and grading, direction and timing movementtiming movement

Frenkel Frenkel exercises exercises

Address thoracic and Address thoracic and neck stiffness if present neck stiffness if present

Propriocetive re-Propriocetive re-education education

Principles to use when treating a Principles to use when treating a child with vestibular dysfunctionchild with vestibular dysfunction The vestibular system is the The vestibular system is the

part of the body responsible part of the body responsible for for balancebalance

Located in the inner earLocated in the inner ear Important part of the Important part of the sensory sensory

system as it co-ordinates system as it co-ordinates informationinformation from the from the vestibular organ, eyes, vestibular organ, eyes, receptors in muscles and receptors in muscles and joints, palms and soles of the joints, palms and soles of the feet and the proprioceptorsfeet and the proprioceptors

Results in the adjustment of Results in the adjustment of muscle tone, limb position, muscle tone, limb position, arousal and balancearousal and balance

Sensory systems Sensory systems involved in balance:involved in balance:

VisionVision Vestibular systemVestibular system Somato-sensory Somato-sensory

systemsystem

Symptoms of a vestibular Symptoms of a vestibular dysfunctiondysfunction

NauseaNausea NystagmusNystagmus Developmental delaysDevelopmental delays Visual spatial problemsVisual spatial problems Poor hand eye and hand foot co-Poor hand eye and hand foot co-

ordinationordination

Causes of vestibular Causes of vestibular dysfunctions:dysfunctions:

Chronic ear infectionsChronic ear infections Infarcts and vascular Infarcts and vascular

insufficienciesinsufficiencies Neurological disorders Neurological disorders

including cerebellar including cerebellar degeneration, CP, degeneration, CP, hydrocephalushydrocephalus

Head and neck traumaHead and neck trauma Immune deficiency Immune deficiency

syndromes e.g. HIV syndromes e.g. HIV Tumors of the brain Tumors of the brain

(posterior fossa) and (posterior fossa) and inner ear (acoustic inner ear (acoustic neuromas)neuromas)

Vestibular Rehabilitation Vestibular Rehabilitation Therapy VRTTherapy VRT

Sensory weighting-Sensory weighting- selection selection occurs between occurs between visual, vestibular visual, vestibular and somatosensoryand somatosensory inputs when inputs when attempting to balanceattempting to balance

VRT programme may include:VRT programme may include: Cawthorne-Cooksey exercisesCawthorne-Cooksey exercises Balance re-educationBalance re-education Gaze stabilizing exercisesGaze stabilizing exercises Visual dependance exercisesVisual dependance exercises Somatosensory dependence Somatosensory dependence

exercisesexercises Otholithic recalibration exercisesOtholithic recalibration exercises

Start with eyes open progress to Start with eyes open progress to eyes closedeyes closed

Can we incorporate principles in our

Treatment children with ATAXIA ????

5. Mixed group5. Mixed group

Most common type of Cerebral

Palsy

EtiologyEtiology

Asphyxia with diffuse cerebral damageAsphyxia with diffuse cerebral damage

Most common types mixed CP Most common types mixed CP are:are:

Spastic with dystonic movementsSpastic with dystonic movements Spastic with ataxiaSpastic with ataxia

ReferencesReferences

Brown, E. 2001. NDT basic course Brown, E. 2001. NDT basic course material (unpublished)material (unpublished)

Smith, R. 2009. Paediatric dictate, UFS Smith, R. 2009. Paediatric dictate, UFS (unpublished)(unpublished)

Smith, R. 2008. role of physiotherapy in Smith, R. 2008. role of physiotherapy in vestibular rehabilitation, PowerPoint vestibular rehabilitation, PowerPoint presentationpresentation

Images courtesy of Google images Images courtesy of Google images (2009)(2009)