Stroke Rehabilitation Three Exercise Therapy Approaches RUTH DICKSTEIN, SHRAGA HOCHERMAN, THOMAS PILLAR, and RACHEL SHAHAM

The purpose of this study was to compare the therapeutic efficacy of three exercise therapy approaches. Three groups of adult stroke patients (N = 131) participated in the study. The first group received conventional treatment that consisted of traditional exercises and functional activities. The treatment of the second group was based on proprioceptive neuromuscular facilitation tech­niques. The third group was treated using the Bobath approach. The improvement of each patient was evaluated after six weeks of treatment in terms of 1) functional gains in activities of daily living as measured using the Barthel index, 2) changes in the muscle tone of the involved limbs as measured using a five-point ordinal scale, 3) changes in the isolated motor control of the ankle and wrist as measured by tests of muscle strength and range of motion, and 4) changes in the patients' ambulatory status as measured using a nominal scale of four categories. The therapeutic effects of exercise according to each of the three approaches were compared using descriptive and nonparametric statistical meth­ods. No substantial advantage could be attributed to any one of the three therapeutic approaches.

Key Words: Activities of daily living, Cerebrovascular disorders, Exercise therapy, Physical therapy.

Several methods of exercise therapy for the rehabilitation of stroke patients are in common use today. A generally accepted classification of these methods differentiates between the conventional versus the neurophysiological treatment approaches, the latter claiming a basis in neurophysiological principles. Even treatment methods that purportedly are based on neurophysiological principles, however, do not have a fully compre­hensive and experimentally proven neu­rophysiological basis.1-3 Furthermore,

some stroke rehabilitation methods used by physical therapists have been criti­cized for their lack of evidence demon­strating a specific therapeutic benefit.4,5

The conventional approach to the treatment of stroke patients involves training such patients to use their re­maining motor capabilities to com­pensate for those that were lost.6,7

Neurophysiological approaches, how­ever, focus on rejuvenation of the lost motor capacities.8-10 In that sense, Knott and Voss referred to "hidden po­tentials" for recovery,9 and Bobath re­ferred to "some untapped potential for more highly organized activity."10 This theoretical difference between the con­ventional and the neurophysiological approaches translates into a difference in the amount of time and effort devoted to treatment. Treatment sessions in which neurophysiological methods are used require closer physical therapist-patient contact than those in which con­ventional methods are used. Patients who are treated with neurophysiological methods usually are treated over longer periods of time than patients who are treated with conventional methods be­cause a higher level of improvement is expected, and it is a slow, step-by-step

process. The developers of both the pro­prioceptive neuromuscular facilitation (PNF) and Bobath methods claim their methods have greater therapeutic effects than the conventional approach. Be­cause Bobath rejected some of the main principles on which the PNF method is based,10 however, more than one alter­native to the conventional treatment ap­proach may exist.

The need to compare the effectiveness of the main neurophysiological treat­ment procedures with each other and with the conventional approach has been emphasized frequently,1,11 but only two such comprehensive studies have been reported.12,13 Stern and his associ­ates found comparable improvement in two groups of hemiplegic patients, one treated with conventional exercises and the other with techniques based on the PNF and Brunnstrom approaches.12 Lo-gigian et al compared the effectiveness of the conventional techniques with that of facilitation techniques adapted from the methods of Rood and Bobath and also found that the different approaches yielded comparable results.13 Despite the substantial differences between these two studies, the inclusion of an index of activities of daily living (ADL) as a cri-

Dr. Dickstein was Supervisor, Physical Therapy Department, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel, when this study was conducted. She is currently Director, School of Physiotherapy, Wingate, Institute, Department of Physical Therapy, Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Dr. Hocherman is Senior Lecturer, Department of Physiology and Biophysics, Faculty of Medicine, Technion-Israel Institute of Technology, PO Box 9649, Haifa 31096, Israel.

Dr. Pillar is Director, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel.

Ms. Shaham is a registered physical therapist, Flieman's Hospital, PO Box 2263, Haifa 31021, Israel.

This study was supported by a grant from the Chief Scientist's Office, Israel Ministry of Health.

This article was submitted December 12, 1984; was with the authors for revision 28 weeks; and was accepted December 5, 1985.

Volume 66 / Number 8, August 1986 1233

terion variable was common to both. The inclusion of this variable in both studies is not surprising, because gaining functional independence generally is ac­knowledged as the major goal of physi­cal rehabilitation.

The purpose of our study was to com­pare the effectiveness of the conven­tional, PNF, and Bobath approaches by applying separately treatments based on these methods to three groups of pa­tients who were hospitalized in the same institution. We considered improve­ment in ADL to be the main criterion measurement, supplemented by other potential treatment-affected variables. An important difference between this study and its predecessors was our intent not only to compare the conventional approach with the neurophysiological approaches, but also to compare the im­provement of the PNF-based treatment group with that of the Bobath-based treatment group.

METHOD

Subjects One hundred and ninety-six consec­

utive hemiplegic patients who were re­ferred to the physical therapy depart­ment of a geriatric-rehabilitation hospital over a period of 18 months were admitted to the study. All patients had had a recent cerebrovascular accident and came for a rehabilitation program after an average stay of 16 days (the mode was 8 days) in a general hospital. Sex distribution was equal. The mean age was 70.5 years (s = 7.65 years). Each patient was assigned to one of the 13 physical therapists who participated in this study. This assignment depended on the administrative procedures of the hospital and, therefore, essentially was random. Because the methods we used are well substantiated in physical ther­apy practice, the patients were not asked for their informed consent. Only 131 of the patients completed the six-week treatment program and were included in the data analysis. The distribution of patient characteristics, based on combi­nations of variables adapted from those reported by Gordon et al,14 is shown in Table 1.

Physical Therapists and Therapeutic Approaches

Mastery of the theory and practice of the three treatment methods was re­quired of the physical therapists partic-

TABLE 1 Subject Characteristics

Variable

Side of hemiplegia Right Left Bilateral

Sensory deficiencies Present Absent

Aphasia in right hemi-plegics

Present Absent

Unilateral neglect in left hemiplegics with sensory defi­cits

Present Absent

Territory of cerebro­vascular accident

Internal carotid ar­tery

Posterior cerebral or vertebrobasilar ar­tery

N

66 62

3

89 42

36 30

28 29

107

13

%

50.5 47.5

2.0

70.0 30.0

54.5 45.5

49.0 51.0

89.0

11.0

ipating in the study. All of the therapists were experienced in applying these methods, and each therapist was re­quired to be familiar with the profes­sional textbooks used as guidelines for the correct application of the neuro­physiological methods.9,10 In addition, during the study period two refresher courses in each of the two neurophysi­ological approaches were conducted, en­suring a review of these methods before shifting from one treatment method to another. Weekly meetings during the study period provided the physical ther­apists with further opportunities for dis­cussion of problematic issues. Treat­ment with any of the three methods involved regular patient assessments, which were an integral part of the ap­proach practiced. An outline of the most prominent features of each treatment procedure is provided in the Appendix.

Procedure

The data collection form for each pa­tient consisted of two main parts. The first part was used to record basic infor­mation regarding the patient's medical history, such as age, sex, body side af­fected, and location of the damaged ar­tery, and was completed on admission to the program. The second part was used to record variable data and was updated by the physical therapist every

other week. These updated variables re­lated to two groups of functions: 1) sen­sory functions of touch, pressure, pro­prioception, stereognosis, hemianopia, and unilateral neglect, which was ex­amined by the tests of Oxbury et al,15

and 2) values of the criterion variables, which will be described separately in the following section. Each physical thera­pist treated her first five patients with the conventional method, the next five with the PNF method, and the last five with the Bobath method. All patients were treated at least five days a week, and each treatment session lasted 30 to 45 minutes.

Criterion Measurements

The following criterion variables were measured for each patient on admission to the program and every other week thereafter: 1. Functional independence was deter­

mined with the Barthel index (BI)16

(Tab. 2). We used this index because of its simplicity, validity, and relia­bility.17,18 The BI also has been used as a criterion measurement in a com­parable study.13

2. Muscle tone of the involved extrem­ities was checked by passive move­ments of the extremities while the patient was in the supine position. It was graded using an ordinal scale composed of five points: a) flaccid, b) low, c) normal, d) high, and e) spastic. Similar scales are used in other clinical settings for comparable purposes.19

3. Isolated motor control over the in­volved ankle and wrist joints was determined with the following tests: a) Active range of motion of these joints was measured while the patient was in the supine position and was compared with that of the same joints on the sound side (for patients with limited ROM, the exact range was measured with a goniometer) and b) strength of the ankle and wrist dorsiflexor muscles was measured twice in a pattern-free isolated move­ment, first by manual muscle testing and second by the patient pulling a gauged spring. This second measure­ment was obtained from patients in the supine position with the limb placed straight on the tabletop and with the measured joint at the table's edge; the patient was instructed to pull the spring from extreme plantar flexion or palmar flexion.

1234 PHYSICAL THERAPY

RESEARCH

TABLE 2 Barthel Index-Test Items and Scoring

Test Item

Feeding Moving from wheelchair to bed and return Personal hygiene Getting on and off toilet Bathing self Walking on level surface;

if unable to walk, propelling wheelchair Ascending and descending stairs Dressing Controlling bowel Controlling bladder

Possible Score

With Help

5 5,10

0 5 0

10 0 5 5 5 5

Independent

10 15 5

10 5

15 5

10 10 10 10

4. Ambulatory status was assessed for indoor ambulation and classified with a nominal four-category scale: a) patient does not walk, b) patient walks with an assistive device and another person's help, c) patient walks with an assistive device, and d) patient walks independently.

Only the first and fourth measure­ments were included in the data analy­sis. The second and third measurements were used as indicators of trends of change.

Pilot Study

A pilot study involving 20 patients and 8 physical therapists was conducted in preparation for this study. In the pilot study, measurements of the criterion variables were rehearsed, and the uni­formity of the evaluations was tested. The interrater reliability for measure­ments of all criterion variables was found to be greater than .90.

Data Analysis

Descriptive statistics were used to re­port patient characteristics. The chi-square test was used to study associa­tions between the treatments and changes in the criterion measurements. The Kruskal-Wallis one-way analysis of variance (ANOVA) was used to com­pare average changes among the three groups. We used a multiple regression technique to study the relative contri­bution of each treatment method to the patients' improvement. The data were analyzed using the Statistical Package for the Social Sciences.20

RESULTS

Fifty-seven patients (43.5%) were treated with the conventional approach,

36 (27.5%) with the PNF approach, and 38 (29%) with the Bobath approach. The variables that constituted the crite­rion measurements were checked for randomization on admission to the pro­gram (by cross-tabulation and chi-square analysis) and were found to be distributed randomly among the three groups. Results of the comparisons of the three groups will be reported sepa­rately for each criterion measurement.

Improvement in Activities of Daily Living

The summed scores of the BIs of the three groups compared after six weeks of treatment were not significantly dif­ferent from each other (chi-square test). The average six-week improvement for all patients was 24.5 points (s = 17.0), and the between-group difference of this value also was not significant (Kruskal-Wallis one-way ANOVA). To increase the resolution of the analysis, patients in each group were subdivided into four categories according to their BI scores: 1) score of 0, 2) scores of 1 to 20, 3) scores of 21 to 60, and 4) scores of 61 to 100. A chi-square test was applied to

a table constructed by these four cate­gories according to the three treatment groups. We found no significant be­tween-group difference, either on ad­mission to the program or after six weeks of treatment. The treatment ef­fects of the three methods also were compared in subgroups of patients char­acterized by each of the variables listed in Table 1. In none of these subgroups did we find any significant advantage to one of the approaches over the others (Kruskal-Wallis one-way ANOVA). We also did not detect any differential influ­ence of the compared approaches on the patients' improvement in ADL on the basis of a multiple regression analysis.

Extremity Muscle Tone Comparison of the muscle tone of the

lower extremities in the three groups after six weeks of treatment yielded no significant results (chi-square test); the muscle tone increased by a comparable magnitude in all patients. By observing the nature of that increase (Fig. 1), how­ever, we found that after six weeks of treatment the percentage of patients at­taining normal muscle tone in the PNF-treatment group was smaller than in the other two groups. Concurrently, the per­centage of patients with high muscle tone in the PNF-treatment group sur­passed their proportion in the rest of the patients. This pattern of muscle tone change, which was not statistically sig­nificant, also was observed to a lesser extent in the upper extremities.

Active Range of Motion and Strength of the Ankle and Wrist Dorsiflexor Muscles

The results of the chi-square analysis and the Kruskal-Wallis one-way AN­OVA for the six-week data of these var­iables showed no significant difference

Fig. 1. Lower extremity muscle tone before (blank) and after (shaded) six weeks of treatment. (F = flaccid, L = low, N = normal, H = high, S = spastic.)

Volume 66 / Number 8, August 1986 1235

between any of the treatment ap­proaches. Because these measurements required some cooperation from the pa­tients, the findings are based on a smaller sample. That is, only 91 patients (69.5%) cooperated in pulling the gauged spring using their ankle dorsi-flexor muscles. The six-week improve­ment in the strength of the dorsiflexor muscles and the active ROM of these distal joints was minimal for all patients. For example, in 65% of the patients who on admission to the program were lim­ited in active ankle ROM and in 71.6% of those with limited ROM in the wrist joint, no change in these variables was recorded at the end of six weeks (Figs. 2,3).

Walking Ability

The walking ability of the patients in the three treatment groups was not sig­nificantly different at the end of the six weeks. Table 3 shows the changes in ambulation after two, four, and six weeks of treatment. We found signifi­cant between-group differences after two and four weeks of treatment. These differences (p < .003 and p < .04, re­spectively) resulted from the high per­centage of nonwalking patients in the Bobath-treatment group and the con­current high proportion of patients walking with an assistive device and the aid of another person in the conven­tional-treatment group. These differ­ences stabilized, however, after six weeks of treatment. Sensory deficiency and limited ROM of the ankle joint were found to affect walking ability ad­

versely in the three groups; however, none of the tested approaches had an advantageous treatment effect on pa­tients with these limitations. The side of hemiplegia was not found to be associ­ated significantly with the ambulation of patients in the PNF-treatment and Bobath-treatment groups. In the con­ventional-treatment group, the six-week difference between the ambulation of right versus left hemiplegic patients was significant (x2 = 8.64, df= 2, p = .03). We found a higher percentage (23%) of independently walking patients with right hemiplegia compared with those with left hemiplegia (0%). At the same time, 55.2% of the left hemiplegic pa­tients walked with an assistive device compared with 30.8% of the right hem­iplegic patients.

DISCUSSION

The results of this study, similar to those of others,12,13 did not demonstrate significant between-group differences in the improvement of the patients' per­formance of ADL. Because functional independence is the overall goal of each of these methods, this finding may have practical implications for the physical rehabilitation of aged hemiplegic pa­tients. Because functional and motor improvement are closely related,21 the lack of significant differences in isolated limb functions among the treatment groups after the six-week treatment pe­riod may explain the lack of differences in the BI scores.

We measured isolated control over the involved ankle and wrist joints be-

TABLE 3 Patient Gait in the Three Groups

Time from Admission

(wk)

2

4

6

Therapeutic Approach

Conventional PNF Bobath

Conventional PNF Bobath

Conventional PNF Bobath

Nonwalking

45.0 60.0 64.9

22.7 28.6 42.1

20.2 20.0 28.9

Ambulatory

With Walking Aid and

Assistance

37.3 14.3 2.7

41.8 28.6 10.5

34.0 31,4 10.5

Statusa

With Walking

Aid

13.9 25.7 27.0

31.2 42.9 42.1

39.1 45.7 52.6

Independent

3.8 0.0 5.4

4.2 0.0 5.3

6.7 2.9 7.9

Test Results

(n = 129) x2 = 19.73, df = 6, p = .003 (n = 130) x2 = 13.32, d f = 6 , p = .04 (n = 130) X2 = 7.88, d f = 6 , p = NS

cause these joints are the first to become involved and are among the last to re­cover after a CVA.22 Despite the imme­diate beneficial treatment effects of the neurophysiological approaches, the re­sults of our study did not demonstrate that either the PNF or the Bobath ap­proaches are superior to the conven­tional approach in enhancing the recov­ery of lost isolated distal movements or improving control over involved limbs.

The between-group differences in am­bulatory status after two and four weeks of treatment (Tab. 3) may reflect the different principles of each approach. We encouraged the patients treated with the conventional approach to walk as early as possible, whereas ambulation of those patients treated with the PNF ap­proach and especially with the Bobath approach was delayed. Because the dif­ference in ambulation between the treat­ment groups stabilized after six weeks, we believe that the two-week and four-week differences were temporary and that none of the approaches contributed more than the others to ambulation. The difference in walking ability be­tween the left and right hemiplegic pa­tients in the conventional-treatment group may have been because left hem­iplegic patients suffer more often from sensory impairment and spatial agnosia than do right hemiplegic patients. For the left hemiplegic patients, the lack of sufficient sensory input through the left side of the body may have adversely affected their ability to walk. Further research is warranted to clarify this re­lationship.

The increase over time in muscle tone of the extremities was expected. The large increase in high muscle tone in the PNF-treated patients (Fig. 1) may be related to the use of facilitation tech­niques.10 This interpretation, however, does not explain the high percentage of PNF-treated patients who maintained lower muscle tone when compared with the subjects of the other groups. The similar patterns of muscle tone change in the conventional-treatment and Bo­bath-treatment groups (Fig. 1) do not support Bobath's claims that her tech­niques exert a special influence on mus­cle tone. Although our findings did not support the superiority of the Bobath approach in improving muscle tone when compared with the other ap­proaches after the six-week treatment a Figures indicate percentages of the row in each category.

1236 PHYSICAL THERAPY

RESEARCH

Fig. 2. Percentage of patients with limited active ankle ROM on admission (blank) and at the end of six weeks (shaded) in the three treatment groups.

period, they neither refuted nor substan­tiated the short-term benefits (during treatment or even several hours later) reported by Bobath.10

The shortcomings of our study derive from several sources. First, because the pace of improvement is individual, our choice of the treatment period as an equalizing variable or, alternatively, our decision to limit the treatment period arbitrarily to six weeks may be criticized. Second, the criterion variables almost always were measured using ordinal and nominal scales. Such measurement scales, although prevalent in clinical set­tings, lack fine discriminative power and introduce subjectivity into assessments. The BI, for example, discriminates only between major levels of performance and provides no information on the quality of that performance. Third, be­cause changes in CVA patients are influ­enced by numerous variables, to discuss the effects of more than only a few of these variables in one study is practically impossible. Because of these shortcom­ings, additional evaluative studies are needed. Such studies should be based on large groups of patients and use a variety of objective measurement tools and time frames. We hope that through many such projects physical therapists

Fig. 3. Percentage of patients with limited active wrist ROM on admission (blank) and at the end of six weeks (shaded) in the three treatment groups.

APPENDIX Exercise Therapy Approaches

Conventional Approach 1. Assessment was based on measurements of active and passive ROM of the affected joints,

evaluation of muscle strength by manual muscle testing, assessment of muscle tone by passive movement of the limbs, and evaluation of performance of functional activities.

2. Exercises were performed in anatomical planes. Progress was encouraged either by gradual increase in the number of joints involved or by increasing resistance to a requested movement. Passive movements were administered to immobile joints.

3. The use of exercise gadgets such as pulleys, suspensions, or weights was a permissible option.

4. Practice of ADL began as early as possible. Rapid acquisition of independence was given higher priority than the quality of movements by which it was achieved. Gait training usually was started near a horizontal rail that supported the patient at his sound side.

PNF Approach 1. Assessment was based on the format suggested by Knott and Voss.9

2. During treatment, reflexes (most commonly the stretch reflex) frequently were used to elicit movements.

3. Mass-movement patterns formed an integral part of the exercises. These patterns included the diagonal and spiral patterns and the total patterns of the developmental sequence.

4. Appropriate basic procedures and specific techniques of the approach were incorporated into each treatment.

Bobath Approach 1. Assessment was made according to the published guidelines of that method.10

2. During each treatment session, the first step was geared toward the inhibition of abnormal muscle tone, usually through the application of appropriate reflex-inhibiting patterns. This process was performed concurrently with an effort to initiate normal movements (automatic and voluntary) through "key points of control" in the patients' bodies.

3. Imposition of activity on the patients was accompanied by efforts to impose normal sensations of posture and movements in which weight-bearing exercises played an impor­tant role.

4. For patients with low or flaccid muscle tone, postural activity was facilitated by touch and proprioceptive stimuli.

5. Progress in treatment generally followed the normal developmental sequence, although some latitude was allowed.

6. Resistive exercises, mass movements, and use of simple and abnormal reflexes were forbidden.

Volume 66 / Number 8, August 1986 1237

will be able to learn the relative thera­peutic effects of the procedures they ap­ply to CVA patients. Because some of the theoretical principles of the neuro-physiological approaches have been questioned recently,23 objective evalua­tion of the effects of these treatments is required.

CONCLUSIONS

Despite the differences in theory and practice among the conventional, the PNF, and the Bobath approaches, we found no treatment-related variances in the outcomes of the patients after six weeks of treatment. We, thus, found no important differences in improvements in ADL, in isolated motor control over the involved ankle and wrist joints, and in gait among the three groups of sub­jects. The only outstanding result was the pattern of muscle tone improvement in the PNF-treatment group. Although this result may be related to the use of facilitation techniques, additional evi­dence is needed. Further studies are needed of the effects of exercise therapy procedures on hemiplegic patients.

REFERENCES 1. Hewer RL: Stroke rehabilitation. In Russell

RWR (ed): Cerebral Arterial Disease. Edin­burgh, Scotland, Churchill Livingstone, 1976, pp 262-280

2. Basmajian JV: Research or retrench: The re­habilitation professions challenged. Phys Ther 55:607-610, 1975

3. Basmajian JV: Neuromuscular facilitation tech­niques. Arch Phys Med Rehabil 52:40-42, 1971

4. Brocklehurst JC, Andrews K, Richards B, et al: How much physical therapy for patients with stroke? Br Med J 1:1307-1310, 1978

5. Mayo MG: The evaluation of physical therapy in treatment of stroke: A preliminary investiga­tion. The Australian Journal of Physiotherapy 23:28-33, 1977

6. Friedland F: Physical therapy. In Licht S (ed): Stroke and Its Rehabilitation. Baltimore, MD, Williams & Wilkins, 1975, chap 10

7. Mcdowell FJ: Rehabilitation of patients with stroke. Postgrad Med 59:145-153, 1976

8. Kabat H: Studies on neuromuscular dysfunc­tion. Arch Phys Med 33:521-533, 1952

9. Knott M, Voss DE: Proprioceptive Neuromus­cular Facilitation: Patterns and Techniques, ed 2. New York, NY, Harper & Row, Publishers Inc, 1968

10. Bobath B: Adult Hemiplegia: Evaluation and Treatment, rev ed 2. London, England, William Heinemann Medical Books Ltd, 1978

11. Rusk HA: Rehabilitation of patients with stroke. In Rusk HA (ed): Rehabilitation Medicine, ed 4. St. Louis, MO, C V Mosby Co, 1977, pp 601-620

12. Stern PH, Mcdowell FJ, Miller JM, et al: Effects of facilitation-exercise techniques in stroke re­habilitation. Arch Phys Med Rehabil 51:526-531,1970

13. Logigian MK, Samuels MA, Falconer J, et al: Clinical exercise trial for stroke patients. Arch Phys Med Rehabil 64:364-367, 1983

14. Gordon EE, Drenth V, Jarvis L, et al: Neuro­physiology syndromes in stroke as predictors of outcome. Arch Phys Med Rehabil 59:399-403, 1978

15. Oxbury JM, Campbell DC, Oxbury SM: Unilat­eral spatial neglect and impairment of spatial analysis and visual perception. Brain 97:551-564, 1974

16. Mahoney Fl, Barthel DW: Functional evalua­tion: The Barthel index. Md State Med J 14:61 -65,1965

17. Wylie CM: Measuring end results of rehabilita­tion of patients with stroke. Public Health Rep 82:893-898, 1967

18. Granger CV, Greer DS, User RN, et al: Meas­urement of outcomes of care for stroke pa­tients. Stroke 6:34-41, 1975

19. Keenan MA, Perry J, Jordan C: Factors affect­ing balance and ambulation following stroke. Clin Orthop 182:165-171, 1984

20. Nie NJ, Hull CK, Jenkins JG, et al: Statistical Package for the Social Sciences. New York, NY, McGraw-Hill Inc, 1975

21. Gresham GE, Fitzpatrick TE, Wolf PA, et al: Stroke: The relationship of neurological deficit and co-morbid disease to dependence in AOL and mobility among survivors of the Framing-ham study. Arch Phys Med Rehabil 56:540, 1975

22. Twitchell TE: Restoration of motor function following hemiplegia in man. Brain 74:443-480, 1951

23. Keshner EA: Reevaluating the theoretical model underlying the neurodevelopmental the­ory: A literature review. Phys Ther 61:1035-1040,1981

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