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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)