[PPT]PowerPoint Presentation - REHAB al... · Web viewNeonatal physiotherapy is an advanced...

PowerPoint Presentation

AlWasl Hospital - Rehabilitation Section

Rehabilitation Approach of Children with Cerebral Palsy

Presented by

Amal AlShamlan

Head of Rehabilitation Section

AlWasl Hospital

Dubai Health Authority

outline

Definitions

Model of care

Classification

Outcome measures

Intervention strategies & philosophies


What is Cerebral Palsy?

It is a group of conditions results in permanent disorders of movement & posture due to damage in fetal or infant brain

Features:

1.epilepsy.

2. involuntary movement

3. abnormal sensation & cognition

4- abnormal vision , hearing & speech.

5- mental retardation.

6. abnormal movement / behaviour.


What is Rehabilitation ?

Rehabilitation is combined and coordinated use of medical , therapeutic , social , educational and vocational measures for training or retraining the individual to highest possible level of function

Holistic Approach

QOL


Aims

Improve functional status

Prevent secondary impairments & functional limitations

Efficiently use resources when there is reasonable prognosis for improvement

Facilitate integration into the community


Model of care

Functional & social vs disease-based

Growth & development

Child-focused & family centered.



International Classification of Functioning, disability and Health (ICF)

condition

Body Function &

structure

Activities

Participation

Environmental Factors

Personal Factors

World Health Organization , 2001


International Classification of Functioning, disability and Health (ICF)

C.P.

Impairments

Muscle weakness

Muscle hypoextensibility

Poor balance

Poor endurance

Activity Limitation

Walking on slopes

Walking in crowds

Climbing on equipment

Participation

Walking to class room

Play during recess

P.E class

Environmental Factors

Teachers concern

Distance to play ground

Children crowded in equipment

Personal Factors

Childs attitude toward:

being transported

Adult assistance

Multidisciplinary Team


client

Social worker

psychologist

Physician

Orthotists

Speech /language

therapists

Occupational

Therapists

Physiotherapists

Care Pathway


referral

screening

Initiate therapy

Cross referral - therapy

Interdisciplinary clinic

Discharge / long term follow up

Interdisciplinary Approach

Working for common goals

Pooling of expertise

Opportunity for personal growth & development

Forum for problem solving


Classification of CP

Etiology

Body involvement

Movement disorder


impairment

GMFCS for children with CP

GMFCSDescriptionLevel IWalks without restrictions; limitation in more advanced gross motor skillsLevel IIWalks without assistive devices; limitations are walking outdoors and in the communityLevel IIIWalks with assistive mobility devices; limitations are walking outdoors and in the communityLevel IVSelf-mobility with limitations; children are transported or use powered mobility outdoors or in the communityLevel VSelf-mobility is severely limited even with the use of assistive technology


Outcome measures

Validate progress

Provides accountability to child/family/third-party payers for intervention used

Aides in plan of care

Provides normative data to obtain developmental levels e.g. age equivalent , standard score


Tests Measuring Developmental Age , Activity , or participation Abilities

TestDevelopmentalFunction/ActivityParticipationAIMSXXGMFMXPDMS IIXXTIMPXQuestXLAPIXPEDIXX


Assess postural control & alignment needed for age appropriate functional activities in early infancy

34 wks gestational age to 4 mths post full term delivery date

TIMP

Assess gross motor function including maturation of skills and postural alignment of of infants from birth to 18 mths of age

AIMS

PDMS

Specifically designed for CP , developed to measure change over time . Consists of activities in 5 dimensions: lying & rolling, sitting, creeping & kneeling, standing & walking, running & jumping.

GMFM

LAPI

QUEST

Assessment of motor tone & oromotor function for preterm babies

More than 33 wks corrected age 1 mths post term

Used to evaluate quality of UE functions in 4 domains: dissociated movement, grasping, protective extension & weight bearing

Assesses normative performance of gross/fine motor function for children from birth to 72 months of age

communication rating scale

skill%Pointing0 10Gestures11- 20Gestures with speech sounds21- 30Speech sounds31- 40Single words41 50Phrases51 60Short sentences61 70Complete sentences71 80Complex sentences81 90paragraphes91 - 100


17

Spasticity

Spasticity is one of the most common UMN lesion problem seen in children with CP resulting in postural control & movement disorder thereby limitting, delaying or arresting the sensory motor development.(also other areas like communication, cognition, social , perception etc).



What is spasticity?

Spasticity is a motor disorder characterized by a velocity dependent increase in stretch reflexes(muscle tone) with

exaggerated tendon jerks resulting from hyper excitability of the stretch reflex as one component of the UMN syndrome (Lance, 1980).

Spasticity is a movement disorder affecting both the neural & non-neural characteristics of postural tone and can be described by the positive & negative UMN symptoms (D. Burke, 1988).

Neural components of UMN symptoms

Positive symptoms

Spasticity.

Spasms (flexor & extensor).

Exaggerated tendon reflexes.

Clonus.

Babinski response.

Negative symptoms

Weakness.

Loss of dexterity.

Fatigability.


Non-neural component of UMN symptoms

Altered muscle length (elasticity): muscle fibres shorten (hypoextensible).

Altered muscle structure (viscosity): filaments become sticky affecting muscle glide(stiffness).

Abnormal co- contraction (reciprocal innervation) : due to bio- mechanical effects of abnormal position. (too much stability & not enough mobility).

Changes in visco-elastic properties leads to stiffness, tightness & contracture.



Normal postural tone

Normal patterns of movement

repetitions

Normal functional Skills achievements

Success in normal patterns of movement


CP?

Abnormal postural tone

Abnormal patterns of movement

Success in abnormal patterns of movement/ stereotyped

repetition

Deformity/ less functional skills acheivments


Intervention Philosophies & strategies

Evidence based?

There is no evidence that any one treatment method is superior to another.

Therapists select from the variety of treatments available those that best meet the childs and familys need.

Analyzing

Analysing the postural tone & patterns of movement.

What the child can do? How? /cant do ? why?

Choosing appropriate intervention/frequency depends on:

Age (infant, toddlers, preschool, adolescent etc)

Distribution of postural tone (diplegic, hemiplegic, quadriplegic etc)

Quality of postural tone (mild, moderate or severe).

Associated problems.(vision, hearing, cognitive, seizure, SPD etc)



Early intervention

Studies focused on child and family reported favorable outcomes.

The analysis also suggested that parent participation might have a greater impact on childs outcomes for children younger than 3 yrs.


Neonatal physiotherapy is an advanced practice subspecialty area of paediatric physiotherapy and involves a highly complex set of skills in observation, examination and intervention procedures for the extremely fragile NICU population.

Main objective to identify developmental delay in 1st year of life

Early intervention can change abnormal movement pattern in mild to moderate cerebral palsy

Those whom deemed to be delay remain delay if no intervention started.

Neonatal Developmental screening


All high risk preterm infants with meeting criteria:

Gestation 32 weeks and below

Birth weight < 1.5 kg

IVH GR.3&4, PVL

Chronic lung disease or O2 dependency

Ventilated for RSD

Neonatal Developmental screening

NICU : LAPI

Outpatient : TIMP , AIMS , PDMS

2008 37 - 11 detected

2009 57 - 17 detected


Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit


Relative comparison of sensitivity and specificity of unit assessment and BUSS in this audit



Neurodevelopmental Therapy ( NDT)

Moving through normal movement patterns to experience normal movement

Major components : reflex-inhibiting posture, inhibition of abnormal reflexes, normalization of muscle tone, and adherence to normal developmental sequence of motor progression


NDT

Inhibiting abnormal movement patterns.

Facilitating normal movement patterns.

No strong evidence that supports the effectiveness of NDT for children with CP with respect to normalizing muscle tone , increasing rate of attaining motor skills, and improving functional motor skills

Butler C, Darrah J: Effects of Neurodevelopmental treatment (NDT) for cerebral palsy: An AACPDM evidence report. Dev Med Child Neurol 2001 ; 43: 778 - 790




Sensory Integration Therapy

Principle: a neurobiological process organizes sensation from ones own body and from environment and makes it possible to use the body effectively within environment

Emphasis on importance of three body centered sensory systems : tactile , proprioceptive & vestibular


SI Therapy



Constrained - Induced Movement Therapy

Constraining non-affected arm to encourage performance of therapeutic task with the affected arm, which children normally tend to disregard.

Systematic review has found the effectiveness of CIMT for children with hemiplegic CP.



Serial casting

Serial casting may serve to reduce spasticity in muscles by decreasing the strength of abnormally strong tonic foot reflexes.(Bertoli 1996).

Serial casting in the CP population has been shown to improve ROM.( Brouwer 2000)

Casting provides stability and prolonged stretch of a muscle which is immobilized in a lengthened position(Mosley 1997).

At least 6 hrs of prolonged stretch is needed for effectiveness(Tardieu 1987).


Botox + serial casting

Botox reduces spasticity and improves ambulatory status.(Flett 1999)

When used in combination with serial casting it has shown to help maintain and improve muscle length and passive ROM.(Kay 2004)

Without conservative interventions such as serial casting, (with & without botox injection) more expensive procedures may be necessary. (Flett 1999)


Body Weight Supported Treadmill Training


Uses theories of motor learning & importance of early task specific training

Theory : activate spinal & supraspinal pattern generators for gait


Strengthening

Progressive resisted exercise improves muscle performance & functional outcomes in CP children

Research had supported effectiveness on increasing force production in CP

Dodd et.al. systematic review of strengthening for individuals with cerebral palsy . Arch Phys Med Reh,83:1157-1164, 2002



NMES

Multiple studies have demonstrated the effectiveness of NMES,

Reduce spasticity.

Increase ROM & strength.

Increase force production.

Promote initial learning of selective motor control.



Orthotic devices , splints , cast

Goals :

Maintenance or increase ROM

Protection or stabilization of a joint

Promotion of joint alignment

Promotion of function



Ankle Foot Orthosis

Compared with barefoot gait, AFOs enhanced gait function in diplegic subjects. Benefits resulted from elimination of premature PF and improved progression of foot contact during stance.



Assistive Technology & Adaptive Equipment

Optimizes alignment, posture & function.

Inhibits spasticity patterns.

Facilitates more normal movement.

Adjunct therapies

Hippotherapy.

Aquathearpy.

suits.

Theratogs.



Speech & Language Therapy

Oralmotor function using strengthening / Intraoral stimulation

verbal ( PROMPT) & non-verbal communication skills ( AAC & PECS , macatone)

auditory training for HI

audiometry screening

swallowing function



Psychological Assessment & Management

Social support


Out of 32 patients received botox 69% attended PT & 31% did not attend


Out of 22 patients, 91% fully attended PT Mx.


% of patients who improved in ROM post botox 3-6 weeks & 3-6 months.


Benefits of communication

Case selection.

Goal setting.

Educating parents/caregiver in active participation

Compliance


Thank you


BUSS SENSITIVITY

54.5

45.5

final outcome Nfinal outcome A

AUDIT SENSITIVITY

34.60%

65.40%

outcome Noutcome A

Chart454.545454545545.4545454545

BUSS SENSITIVITY

Sheet1total no. patientUsualUnusualAtypical5731917USUAL SPICIFICITYNDANDA31280390.30.09.7UnusualNDANDAD+A953155.633.311.144.4ABNORMAL IN Atypical GROUPNDANDAD+A1774641.223.535.358.8SENSITIVITY (A+UN)InitialFinalLAPI SENSITIVITYoutcome Noutcome A65.4%53.8%34.60%65.40%ATYPICALBUSSNO BUSS17152NDANDANDA90.30.09.755.633.311.141.223.535.3ab had BUSS initiallyresult Nresult A1596NDANDANDA2803531746BUSSNAND5738118ABNORMAL BUSS SENSITIVITYfinal outcome Nfinal outcome Afinal outcome Nfinal outcome A116554.545.5NORMAL BUSS SPICIFICITYfinal outcome Nfinal outcome Afinal outcome Nfinal outcome A3829976%23%

Sheet2

Sheet25731917

TOTAL RESULT LAPI

Sheet3

PERCENTAGELAPI SPICIFICITY9.7%0.0%90.3%NDA90.3209.67ATYPICAL GROUPNDAD+A41.223.535.358.8EFFECT OF INTEVENTIONInitialFinal0.6540.538UNUSUAL GROUPNDAD+A55.633.311.144.4BUSS IN UNITBUSSNAND5738118BUSS SPICIFICITYfinal outcome Nfinal outcome A0.760.23BUSS SENSITIVITYfinal outcome Nfinal outcome A54.545454545545.4545454545SENSITIVITY correctly detected abnormaloutcome Noutcome A0.3460.654090.320009.67055.6033.3011.1041.2023.5035.3NDANDANDA2803531746

Sheet354.545454545545.4545454545

BUSS SENSITIVITY

BUSS SPICIFICITYfinal outcome Nfinal outcome A0.760.23PERCENTAGEAUDIT SPICIFICITY90.3%0.0%9.7%NDA90.3209.67AUDIT SENSITIVITYoutcome Noutcome A0.3460.654

95

60

4

1

24

16

4

16

58

0

10

20

30

40

50

60

70

80

90

100

PRETERM USUALPRETERM UNUSUALPRETERM SUSPECT

NORMAL

MILDLY

ABNORMAL

ABNORMAL

MBD0004BC44.

Chart30.3460.654

AUDIT SENSITIVITY


Sheet2

Sheet25731917

TOTAL RESULT LAPI

Sheet3


Sheet354.545454545545.4545454545

BUSS SENSITIVITY


95

60

4

1

24

16

4

16

58

0

10

20

30

40

50

60

70

80

90

100


NORMAL

MILDLY

ABNORMAL

ABNORMAL

MBD0004BC44.

AUDIT SPICIFICITY

9.7%

0.0%

90.3%

NDA

PERCENTAGE

BUSS SPICIFICITY

76%

23%

final outcome Nfinal outcome A

Chart590.3209.67

PERCENTAGEAUDIT SPICIFICITY9.7%0.0%90.3%


Sheet2

Sheet25731917

TOTAL RESULT LAPI

Sheet3


Sheet354.545454545545.4545454545

BUSS SENSITIVITY


95

60

4

1

24

16

4

16

58

0

10

20

30

40

50

60

70

80

90

100


NORMAL

MILDLY

ABNORMAL

ABNORMAL

MBD0004BC44.

Chart60.760.23

BUSS SPICIFICITY


Sheet2

Sheet25731917

TOTAL RESULT LAPI

Sheet3


Sheet354.545454545545.4545454545

BUSS SENSITIVITY


95

60

4

1

24

16

4

16

58

0

10

20

30

40

50

60

70

80

90

100


NORMAL

MILDLY

ABNORMAL

ABNORMAL

MBD0004BC44.

% of patients who did not attend PT Mx

31%

69%

Attended PT

management

Not attended PT

management

Sheet1Physiotherapy Management of Post botulinium injection in childeren with CPNOH.CAgeSexDiagnosisBotox DateLower Extrimity Passive Range of Motion (LE PROM)Right sideLeft sideR1codeR2codeR3codeL1codeL2codeL3code1Z265436815/23/06Fspastic diplegic CP6/7/09Hip flexion110211021102120211021102Thomas test5215070100100100Hip abduction300250351300300300Hip internal rotation602652552702652652Hipexternal rotation552722602502652602Popliteal angle650202352400152252Knee extension-20002-102-15002-101Ankle DF w/KE-150-52-101-15002-82Ankle DF W/KF-3012200-301521022M212167116/2/04Mspastic quadriplegia CP6/21/09Hip flexion100212021152100211021102Thomas test323002520252Hip abduction100202100100202130Hip internal rotation430502602602552602Hipexternal rotation702902902652852752Popliteal angle300251202280202102Knee extension020202020202Ankle DF w/KE-200-151-151-300-152-202Ankle DF W/KF8025225280202202CodingROM00-3(P)14-5(M)Lower Extrimity Passive Range of Motion (LE PROM)R1codeR2prepost1post 226-10(G)Pre Botox Assesment R1Hip flexion100Post Botox (3-6 wks) R2Thomas test0Post Botox (3-6 months) R3Hip abduction50Dorsi flexionHip internal rotation100Knee ExtensionHipexternal rotation0Knee flexionPopliteal angle50Knee extension0Ankle DF w/KE0Ankle DF W/KF50

Sheet2R1R2R3totalL1L2L3TotalHip flexion444Thomas test000Hip abduction021Hip internal rotation444Hipexternal rotation444Popliteal angle034Knee extension244Ankle DF w/KE032Ankle DF W/KF042

Sheet4POPLITEAL ANGLEKNEE EXTENSIONKNEE EXTENSIONDF/KEDF/KFR2R3L2L3R2R3L2L3L3R3L2L3R2R3L2L3

final30.690.31

% of patients who did & didn't attend PT post botox protocol

final 1st0.690.31

category of patients%% of patients attended PT protocol

Chart30.690.31


Sheet5% OF PATIENTS WHO RECEIVED BOTOX INJECTION AND WAS INCLUDED IN PT TREATMENT ATTENDED THE THERAPY PROGRAM ACCORDING TO THE PROTOCOL GUIDELINEAttended PT management2269%Not attended PT management1031%No pts. Casted7

Sheet500

% of patients attended PT Mx

Chart985857585648259701610261637194131

poplitealKnee extensiondorsiflexion /knee extensiondorsiflexion /knee flexionpost botox% of improvement% of ROM improvemt in right leg between pre & post botox

Chart48516851075268516

Post 1 (YES)post 1(NO)ROM% improved%of ROM improvement between pre & post botox (3-6 wks)

Chart76437821959417031

post2 (YES)post 2 (NO)ROM% improved% of ROM improvement between pre & post botox ( 3-6 months)

final18516851075268516

Post 1 (YES)post 1(NO)ROM% improved% of ROM improvement 3-6 weeks post botox

final 26437821959417031

post2 (YES)post 2 (NO)ROM% improved% of ROM improvement 3-6 months post botox

Sheet3% OF IMPROVEMENT IN ROM BETWEEN PRE AND POST BOTOX INJECTIONPOPLITEAL ANGLEKNEE EXTENSIONDF/KEDF/KFR1R2R3L1L2L3post1R1R2R3L1L2L3R2R3L2L3R2R3L2L3R2R3L2L31YYYYYYYYYYYYYNYY2yyyyYYYYYYYYYYYY3YYYYYYYYYYNNYYYY4YYYYYNYYYYYYyyyy5YYYYYYYYYYYYyyyy6YYYYYYYYYYYYyNyN7YYYNNNYYYYYYYYYY8YNYNYYYYYYYYNYYY9yYNNYYYYNNYNNNYN10NNNNNNYNYYYYYYYY11YYYYYYYYNNYNYYYY12YNYYYYYYYNYNYNNN13YNYYYNYN14YNYNYYYYNYNYYYYY15NNNNYYYYYNYNNNNN16YYYYYYYYYYYYYYYY17YYYYYNNNNNNNYYYY18YYNNYNYY19NNNYYNNY20YNYNYYYYYNY%N%YNY%N%YNY%N%YNY%N%R21528812152881215575251738515L21338119133811914574261638416R31166535134762412860401286040L31066238142881311858421547921Post 1 (YES)post2 (YES)post 1(NO)post 2 (NO)popliteal85641637Knee extension85821019dorsiflexion /knee extension75592641dorsiflexion /knee flexion85701631

Sheet300000000

R2L2R3L3

R2L2R3L30000000000000000

% of patients included in PT Mx

91%

9%

Attended PT Mx

Dropped out


Sheet2R1R2R3totalL1L2L3TotalHip flexion444Thomas test000Hip abduction021Hip internal rotation444Hipexternal rotation444Popliteal angle034Knee extension244Ankle DF w/KE032Ankle DF W/KF042

Sheet4POPLITEAL ANGLEKNEE EXTENSIONKNEE EXTENSIONDF/KEDF/KFR2R3L2L3R2R3L2L3L3R3L2L3R2R3L2L3

final30.690.31

% of patients who did & didn't attend PT post botox protocol

final 1st0.690.31

category of patients%% of patients attended PT protocol

Chart30.690.31


Chart20.910.09

% of patients included in PT Mx

Sheet5% OF PATIENTS WHO RECEIVED BOTOX INJECTION AND WAS INCLUDED IN PT TREATMENT ATTENDED THE THERAPY PROGRAM ACCORDING TO THE PROTOCOL GUIDELINEAttended PT management2269%Not attended PT management1031%No pts. Casted7Attended PT Mx2291%Dropped out29%

Chart985857585648259701610261637194131

poplitealKnee extensiondorsiflexion /knee extensiondorsiflexion /knee flexionpost botox% of improvement% of ROM improvemt in right leg between pre & post botox

Chart48516851075268516

Post 1 (YES)post 1(NO)ROM% improved%of ROM improvement between pre & post botox (3-6 wks)

Chart76437821959417031

post2 (YES)post 2 (NO)ROM% improved% of ROM improvement between pre & post botox ( 3-6 months)

final18516851075268516

Post 1 (YES)post 1(NO)ROM% improved% of ROM improvement 3-6 weeks post botox

final 26437821959417031

post2 (YES)post 2 (NO)ROM% improved% of ROM improvement 3-6 months post botox

Sheet3% OF IMPROVEMENT IN ROM BETWEEN PRE AND POST BOTOX INJECTIONPOPLITEAL ANGLEKNEE EXTENSIONDF/KEDF/KFR1R2R3L1L2L3post1R1R2R3L1L2L3R2R3L2L3R2R3L2L3R2R3L2L31YYYYYYYYYYYYYNYY2yyyyYYYYYYYYYYYY3YYYYYYYYYYNNYYYY4YYYYYNYYYYYYyyyy5YYYYYYYYYYYYyyyy6YYYYYYYYYYYYyNyN7YYYNNNYYYYYYYYYY8YNYNYYYYYYYYNYYY9yYNNYYYYNNYNNNYN10NNNNNNYNYYYYYYYY11YYYYYYYYNNYNYYYY12YNYYYYYYYNYNYNNN13YNYYYNYN14YNYNYYYYNYNYYYYY15NNNNYYYYYNYNNNNN16YYYYYYYYYYYYYYYY17YYYYYNNNNNNNYYYY18YYNNYNYY19NNNYYNNY20YNYNYYYYYNY%N%YNY%N%YNY%N%YNY%N%R21528812152881215575251738515L21338119133811914574261638416R31166535134762412860401286040L31066238142881311858421547921Post 1 (YES)post2 (YES)post 1(NO)post 2 (NO)popliteal85641637Knee extension85821019dorsiflexion /knee extension75592641dorsiflexion /knee flexion85701631

Sheet300000000

R2L2R3L3

R2L2R3L30000000000000000

68%

56%

0%

10%

20%

30%

40%

50%

60%

70%

80%

post 3-6 weekspost 3-6 months

post 3-6 weeks & months

%

post 3-6 weeks

post 3-6 months

Chart1

Chart2

prepost1post 2

Chart30

pre post1pre post1pre post1pre post1pre post1


Chart48812811965356238

YesNoR & L Post 2&3 POPLITEAL ANGLE ROM IMPROVEMENT% IMPROVED

Chart58812811976248813

YesNoPost botox duration% of patientsKNEE EXTENSION

Chart688816562888176887574605885846079

R2L2R3L3

Chart77525742660405842

YesNoR&L post injection% of improvementAnkle Dorsi flexion With Knee Extension

Chart88515841660407921

yesNoright & left post injection% of iimprovementankle dorsiflexion with kee flexed

fianal %0.680.56

improvedpost 3-6 weeks & months%

Sheet3% OF IMPROVEMENT IN ROM BETWEEN PRE AND POST BOTOX INJECTIONPOPLITEAL ANGLEKNEE EXTENSIONDF/KEDF/KFR1R2R3L1L2L3post1R1R2R3L1L2L3R2R3L2L3R2R3L2L3R2R3L2L31YYYYYYYYYYYYYNYY2yyyyYYYYYYYYYYYY3YYYYYYYYYYNNYYYY4YYYYYNYYYYYYyyyy5YYYYYYYYYYYYyyyy6YYYYYYYYYYYYyNyN7YYYNNNYYYYYYYYYY8YNYNYYYYYYYYNYYY9yYNNYYYYNNYNNNYN10NNNNNNYNYYYYYYYY11YYYYYYYYNNYNYYYY12YNYYYYYYYNYNYNNN13YNYYYNYN14YNYNYYYYNYNYYYYY15NNNNYYYYYNYNNNNN16YYYYYYYYYYYYYYYY17YYYYYNNNNNNNYYYY18YYNNYNYY19NNNYYNNY20YNYNYYYYYNY%N%YNY%N%YNY%N%YNY%N%R21528812152881215575251738515L21338119133811914574261638416R31166535134762412860401286040L31066238142881311858421547921improvedNpost 3-6 weeks68%post 3-6 months56%

Sheet300000000

R2L2R3L3

[PPT]PowerPoint Presentation - REHAB al... · Web viewNeonatal physiotherapy is an advanced...

Documents

Transcript of [PPT]PowerPoint Presentation - REHAB al... · Web viewNeonatal physiotherapy is an advanced...