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ORIGINAL ARTICLE
The Effects of Foot Position on the Performance of the
Sit-To-Stand Movement With Chronic Stroke Subjects
Ana Cristina R. Camargos, PT, MSc, Fátima Rodrigues-de-Paula-Goulart, PT, PhD,
Luci F. Teixeira-Salmela, PT, PhD
ABSTRACT. Camargos AC, Rodrigues-de-Paula-Goulart F,
Teixeira-Salmela LF. The effects of foot position on the performance of the sit-to-stand movement with chronic stroke
subjects. Arch Phys Med Rehabil 2009;90:314-9.
Objective: To investigate the effects of different foot positions during the sit-to-stand (STS) movements with stroke
subjects.
Design: Cross-sectional.
Setting: Research laboratory.
Participants: Twelve chronic stroke subjects (N⫽12).
Interventions: Not applicable.
Main Outcome Measures: Differential latency and electromyography (EMG) activity of the tibialis anterior, soleus,
quadriceps, and hamstring muscles of the affected leg as well
as the movement time, time of seat-off, weight symmetry, and
rising index were obtained while the subjects performed the
STS movements by using 4 different strategies: spontaneous;
symmetric; asymmetric-1, with the affected foot behind; and
asymmetric-2, with the unaffected foot behind.
Results: Compared with the spontaneous strategy, the soleus
showed the greatest differential latency in the asymmetric-2
strategy, the hamstrings had lower EMG activity in the symmetric strategy, and the movement time was greater in the
asymmetric strategies.
Conclusions: The asymmetric 2 strategy appeared to be the
least favorable, whereas the spontaneous and the symmetric
strategies appeared to be more favorable in improving the STS
performance. Based on these findings, allowing the subjects to
adopt the spontaneous strategy or training of the symmetric
strategy could result in greater benefits for subjects with higher
chronicity and higher functional levels, such as those evaluated
in the present study.
Key Words: Electromyography; Hemiparesis; Rehabilitation; Stroke.
© 2009 by the American Congress of Rehabilitation
Medicine
performing activities of daily living, such as rising from a chair
without assistance.3,4
The STS movement is one of the most common functional
activities, and it is essential for the maintenance of an individual’s
independence.4-9 During the period of recovery from a stroke, the
loading on the affected leg tends to be spontaneously avoided,
leading to difficulties in accomplishing the STS tasks.8-12 If the
affected side is neglected during functional activities, this will
become a habit and will stimulate disuse, leading to the development of the learned nonuse phenomenon.4,13
The incapacity to bear weight on the affected leg can occur
because of pain, spasticity, balance deficits, sensorial problems,
neglect, muscular weaknesses, and changes in postural control.14,15 Thus, subjects with hemiparesis after a stroke may
develop compensatory mechanisms that can affect the components related to dynamic balance and muscular activation patterns to perform the STS movement.4
The STS task is often stimulated and trained earlier during
rehabilitation programs.16,17 The practice of this movement,
through strategies that promote the weight bearing on the
affected leg, can provide benefits for the return of more functional movements and prevention of falls and the learned
nonuse of the limb.8,14,16
The learned nonuse of the limb can be reversed by the forced
use of the affected leg,8 In accordance with Engardt and Olsson,10 subjects with hemiparesis, during the acute phase, when
requested, are able to load more weight on the affected leg.
Some strategies can be used to favor the load on the affected
leg during the STS movements. The change in position of the
affected leg backwards, for example, is a common strategy
used for training in clinical practice; however, its effects in
subjects with chronic hemiparesis are still not well documented.
Therefore, the aim of the present study was to investigate the
effects of different positions of the lower limbs during the STS
movement with chronic stroke subjects by using 4 distinct strategies on the temporal and EMG measurements.
METHODS
TROKE IS DEFINED AS a neurologic deficit in the brain
S
after vascular injuries. Muscular weaknesses contralateral
to the injury side are the most common problems of subjects
1
who have suffered a stroke2 and may lead to difficulties in
From the Department of Physical Therapy, Universidade Federal de Minas Gerais,
Belo Horizonte, Brazil.
Supported by the Brazilian Government Funding Agencies Conselho Nacional de
Pesquisa (CNPq) and Fundação de Amparo à Pesqusia de Minas Gerais (FAPEMIG).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Correspondence to Fátima Rodrigues-de-Paula-Goulart, PT, PhD, Departamento de
Fisioterapia, Universidade Federal de Minas Gerais, Avenida Antonio Carlos, 6627
Campus Pampulha, 31270-910 Belo Horizonte, Minas Gerais, Brazil, e-mail:
[email protected].
0003-9993/09/9002-00343$36.00/0
doi:10.1016/j.apmr.2008.06.023
Arch Phys Med Rehabil Vol 90, February 2009
Subjects
Community-dwelling stroke subjects participated in the
study according to the following inclusion criteria: having had
only 1 episode of stroke, having had the stroke at least 6
months before the study to ensure chronicity,18 being over 60
years of age, having weakness and/or spasticity on the affected
List of Abbreviations
EMG
QUAD
ROM
SOL
STS
TA
electromyography
quadriceps
range of motion
soleus
sit to stand
tibialis anterior
SIT-TO-STAND WITH HEMIPARETIC SUBJECTS, Camargos
side, being able to rise from a chair without aid of their hands,
and showing no receptive aphasia. Subjects were excluded if
they had any musculoskeletal problems or any other neurologic
disease as well as any auditory or visual deficits that could
prevent data collection.
Outcome Measures
Measures of EMG activity (latencies and quantity), time to
perform the STS (movement time), time of the seat-off, rising
index, and weight symmetry were obtained while the subjects
performed the STS in spontaneous, symmetric, and asymmetric
conditions. These measures were selected because they were
used to evaluate the STS tasks with healthy subjects and
subjects with chronic disabilities.7,10,19,20
Instrumentation
The EMG activities of the TA, SOL, QUAD, and hamstring
muscles during the STS movements were assessed with an
EMG apparatus (MP150WSWa). This device had 2 amplifiers
connected to a computer, which had an input impedance of 2
M⍀ and CMRR of 1000 M⍀ and allowed data acquisition at
frequencies from 10 to 1000Hz. Data were collected at a
frequency of 1000Hz. Surface, active, bipolar, TSD 150 electrodesa with diameters of 13.5, and impedance of 100 M⍀ were
used for data collection.
The triaxial accelerometera was used to determine the movement time to perform the STS and was placed on the participants’ forehead,19 which described the vertical (Z), horizontal
(Y), and lateral (X) acceleration. Its 3 channels were connected
to the electromyography interface, and only the information of
the horizontal and vertical axes, in the sagittal plane, were
considered for analyses. The time when the seat-off occurred
was obtained with 2 force sensors whose signals ranged between ⫺1V to ⫹1V and were placed on the laboratory stool
surface used for the tests. The time of the seat-off was determined by the baseline changes in the voltage signals.
The Balance Master System version 8.3b was used to evaluate the rising index and the left/right weight symmetries. The
rising index registered the percentage of body weight exerted
by the lower limbs during the rising phase. The affected/
nonaffected weight symmetry indicated the amount of weight
born by each leg during the rising phase for 5 subsequent
seconds.20 The accelerometer, force sensors, and Balance Master System were all connected through an interface of the
Biopac System for synchronization with electromyography,
which allowed all of the records to be simultaneously collected.
Procedures
Before the initiation of data collection, subjects were informed about the objectives of the study and invited to sign a
consent form, which was previously approved by the University Ethical Review Board. After this, demographic and anthropometric data were collected on all subjects to document their
age and other clinically relevant information. In addition, for
characterization purposes, data were obtained regarding the
ROM for ankle dorsiflexion, self-paced walking velocity, muscle tone, and isokinetic torque measures of the flexor and
extensor muscles of the hip, knee, and ankle bilaterally at a
speed of 60° a second. The measures of peak torque were
described as the ratios between the affected and nonaffected
sides.
After skin preparation, which included shaving, rubbing, and
cleansing with alcohol, the participants were instructed to assume a standing position on the Balance Master System platform. Surface electrodes were placed in pairs and parallel to the
315
muscle fibers following previously described procedures.19,21
For the TA, the electrodes were placed on the anterior, lateral,
and superior aspects of the tibia at approximately one third of
the distance between the knee and the ankle; for the SOL, on
the inferior and lateral aspects of the leg, below the belly of the
gastrocnemius; for the QUAD, at middistance between the
anterior-superior iliac spine and the superior patellar edge; and
for the hamstrings, medially at the middistance point between
the gluteal fold and knee joint. The reference electrode was
placed over the patella of the unaffected leg. The participants
were then seated on a backless wooden stool, which was
adjusted to 100% of the height of the subjects’ knees determined by the distance from the lateral knee joint line to the
floor, but the amount of thigh loading was not monitored.
Four strategies were investigated during the STS movements: spontaneous, without instructions on the initial foot
position; symmetric, with both ankles placed backwards at the
same level with a dorsiflexion angle of the unaffected leg
ranging between 10° and 15°; asymmetric-1, with the affected
leg placed behind the unaffected leg; and asymmetric-2, with
the unaffected leg placed behind the affected leg.
To guarantee adequate positioning of the lower limbs for the
symmetric and asymmetric strategies, subjects were requested
to sit on a wooden stool and to move the unaffected ankle
backwards as much as possible to measure the angle of the
ankle with a universal goniometer. From this measure, which
ranged between 10° and 15°, a mark aligned with the calcaneus
was placed on the floor to position the lower limbs backwards.
With a measuring tape, the anterior distance, equivalent to half
of the length of the foot, was obtained from the previous line
and was also marked from the anterior position of the calcaneus, which was used during the performance of the asymmetric strategies.
The STS task was performed with the subjects’ feet supported on the Balance Master System platform and their arms
across the chest to prevent the use of the upper limbs during the
execution of the task. The participants were instructed not to
move their feet and to stand as fast as possible from the initial
instructions of the Balance Master System. When the standing
position was attained, they were asked to maintain this position
for 5 seconds. After familiarization, 3 trials were obtained for
each strategy, and the mean values were considered for analyses. Before each trial, the positioning of the feet was ensured,
and a brief rest interval was allowed between trials. The strategies were randomly assigned, except for the spontaneous
strategy, which was always performed first.
Data Reduction and Analysis
EMG data processing was performed by using the Acknowledge software. The EMG signals were full wave rectified and
low-pass and high-pass filtered with cutoff frequencies of 500
and 10Hz, respectively. The muscular latencies were determined by the time between the visual Balance Master System
signal and the EMG onset for each muscle. The onset of
muscular activity was considered when the values exceeded 2
SDs from the mean values observed at baseline for a 50-ms
duration.22
To compare the muscular latency between the conditions, a
value of 0 was considered for the time instance of the seat-off
of each trial, and the differential latencies were calculated
between the EMG onset for each muscle and the time instance
of the seat-off. In this manner, muscles that initiated their
activities before the seat-off showed negative latencies. The
quantification of EMG activity was expressed by root mean
squares,21 which were normalized by the maximum signal
amplitude and described in percentages23 during intervals of
Arch Phys Med Rehabil Vol 90, February 2009
316
SIT-TO-STAND WITH HEMIPARETIC SUBJECTS, Camargos
Table 1: Participants’ Characteristics
Variable
Age (y)
Time since onset of
stroke (y)
Body mass (kg)
Height (m)
BMI (kg/m2)
Knee height (m)
Affected DF ankle
ROM (degrees)
Nonaffected DF ankle
ROM (degrees)
Self-paced walking
velocity (m/s)
Muscle tone (Modified
Ashworth scale)
Statistical Analyses
Descriptive statistics, tests for normality (Shapiro-Wilk) and
homogeneity of variance were calculated for all outcome variables by using the software SPSS 13.0 for Windows.c Repeated-measure analysis of variance followed by planned contrasts
were used to investigate differences between the symmetric
and asymmetric strategies in relation to the spontaneous strategy with a significance level of ␣ less than 0.05.
Range
(minimum–maximum)
Mean ⫾ SD
68.00⫾7.14
60–80
7.67⫾3.99
66.73⫾11.07
1.62⫾0.09
25.35⫾2.89
0.47⫾0.03
1–14
53.50–86.90
1.51–1.76
21.72–30.43
0.43–0.53
8.83⫾6.62
0–15
14.83⫾2.76
10–20
0.68⫾0.25
0.34–1.08
NA
0–3
Abbreviations: BMI, body mass index; DF, dorsiflexion; NA, not
applicable.
0.8s, which were between 0.4s before and 0.4s after the time of
the seat-off. The seat-off is considered to be the time of the
highest muscular activation during the STS5,6 and, therefore,
has been recommended for quantifying EMG.18,22
The beginning of the movements was detected from the
initial changes of the y and z axes of the accelerometer and the
end of the movements to the return to the baseline values. To
determine the mean values at baseline, the mean values during
1 second were calculated before the Balance Master System
signals with the subjects at rest. A threshold of the baseline was
determined by adding 2 SDs to the mean values. The beginning or
the end of the movements was determined as the time when the
values were over or under the baseline for at least 0.1 seconds.
Body weight was used to normalize the rising index based on the
following formula: (rising index/body mass) ⫻ 100%. The
weight-bearing symmetry values were expressed as the ratios
between the affected and nonaffected sides, with the value of 1 as
an indication of perfect symmetry.
RESULTS
Twelve stroke subjects, 6 men and 6 women with a mean age
of 68.00⫾7.14 years, a body mass index of 25.25⫾2.89 kg/m2,
and a mean time since onset of stroke of 7.67⫾3.99 years
completed all tests (table 1). Seven subjects were classified as
fast, 3 as medium, and 2 as slow gait speed in accordance with
the criteria proposed by Olney et al.24 Some patients were not
able to generate sufficient torque at the hip and ankle joints.
Therefore, the isokinetic strength data related to the peak
torque ratios of the affected and nonaffected legs were obtained
for 12 subjects who completed the knee tests, 11 for the hip,
and 6 for the ankle. The ratio values were 0.89 and 0.70,
respectively, for the hip flexors and extensors, 0.56 and 0.68 for
the knee flexors and extensors, and 0.81 and 0.56 for the ankle
dorsiflexors and plantar flexors.
Descriptive data and the significant differences for all outcome variables are presented in table 2. As shown in figure 1,
the differential latency of the SOL muscle was higher in the
asymmetric 2 strategy when compared with the spontaneous
strategy (P⫽0.01). No significant differences were found for
the differential latency of the other investigated muscles. As
shown in figure 2, the hamstrings muscle showed less activation in the symmetric strategy in comparison to the spontaneous strategy (P⫽0.03), but no significant differences were
observed for the other investigated muscles.
Compared with the spontaneous strategy, the movement
time was significantly greater in the asymmetric-1 (P⫽0.002)
and asymmetric-2 (P⫽0.02) strategies, but no differences were
found between the spontaneous and symmetric strategies.
Compared with the spontaneous strategy, no differences were
found for the times between the beginning of the movement
and the seat-off for all strategies (fig 3) or for the symmetry
Table 2: Descriptive Data of the Outcome Measures for the Investigated Strategies
Strategy
Variable
Spontaneous
Symmetric
Asymmetric 1
Asymmetric 2
DIFLAT TA (s)
DIFLAT SOL (s)
DIFLAT QUA (s)
DIFLAT HMS (s)
EMG TA (mV)
EMG SOL (mV)
EMG QUA (mV)
EMG HMS (mV)
MT (s)
SEAT-OFF (s)
RISING INDEX (%)
SYMMETRY (ratio)
⫺0.36⫾0.20
⫺0.15⫾0.15*
⫺0.21⫾0.30
⫺0.27⫾0.13
0.17⫾0.04
0.09⫾0.03
0.21⫾0.03
0.16⫾0.04*
1.93⫾0.29*†
0.91⫾0.13
11.63⫾4.32
0.59⫾0.30
⫺0.27⫾0.21
⫺0.10⫾0.08†
⫺0.31⫾0.20
⫺0.20⫾0.17
0.26⫾0.23
0.10⫾0.03
0.22⫾0.04
0.13⫾0.02*
1.94⫾0.25‡
0.90⫾0.13
10.07⫾4.00
0.64⫾0.35
⫺0.31⫾0.16
⫺0.10⫾0.12‡
⫺0.27⫾0.25
⫺0.18⫾0.09
0.18⫾0.04
0.09⫾0.04
0.21⫾0.03
0.15⫾0.03†
2.16⫾0.34*
0.89⫾0.12
10.77⫾4.61
0.74⫾0.73
⫺0.26⫾0.20
⫺0.03⫾0.13*
⫺0.34⫾0.22
⫺0.20⫾0.08
0.17⫾0.04
0.08⫾0.04
0.19⫾0.03
0.16⫾0.03‡
2.16⫾0.46†
0.92⫾0.13
10.10⫾3.45
0.47⫾0.30
NOTE. Values are mean ⫾ SD.
Abbreviations: DIFLAT, differential latency; EMG, electromyographic activity (% peak of the maximum activity); HMS, hamstrings;
MT, movement time; QUA, quadríceps; SOL, soleus; TA, tibialis anterior.
*Differ significantly (P⬍.05).
†
Differ significantly (P⬍.05).
‡
Differ significantly (P⬍.05).
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317
Fig 1. Differential latency (seconds) of the soleus muscle for the 4
strategies.
Fig 3. Movement time and the time of seat-off (seconds) for the 4
strategies.
values. Finally, no significant differences were found between
the strategies for the rising indices, although the greatest values
were observed for the spontaneous strategy.
DISCUSSION
Movement Time and Seat-Off
The time to perform the STS is one of the main indicators of
functional ability.25,26 Hemiparetic subjects require more time to
perform this movement compared with healthy subjects,9,12,27 and
Cheng et al7 reported that a greater duration to perform this
activity can be indicative of falls.
Subjects with hemiparesis were slower to perform the STS
movements when they used the asymmetric strategies. Because
no differences were found for the durations of the movements
between the strategies until the time instance of the seat-off, it
can be concluded that the increases of the total movement time
occurred because of a prolongation of the postseat-off phase or
its extension,6 which requires greater control and work to
generate more force to raise the body.28 This indicates poorer
performance of the hemiparetic subjects when performing the
movements using these asymmetric strategies. Such strategies
are not routinely used by these subjects and could have caused
greater complexity of the movements, thus increasing their
duration. On the other hand, the subjects were faster when they
used the spontaneous and symmetric strategies, and these strategies appeared to have contributed to better performance during the accomplishment of the task.
Symmetry and Rising Index
In accordance with Cheng et al,16,27 the maintenance of
postural symmetry during the STS movement may improve the
Fig 2. Electromyographic activity (mV) of the hamstrings for the 4
strategies.
performance of this task and also reduce the incidence of falls
in subjects with hemiparesis. Although gains in postural symmetry are one of the main goals of the rehabilitation programs
with these subjects, evidence that symmetry exerts an important role for functional performance is lacking. TeixeiraSalmela et al29 did not find differences in weight symmetry
measures of hemiparetic subjects during STS movements after
a program of muscle strengthening and physical conditioning.
This suggested that this postural asymmetry was a typical
feature of hemiparetic subjects and seemed not to affect the
functional performance of chronic stroke subjects.
Similarly, the subjects in this study did not show differences
in the weight symmetry values, independent of the used strategies. Thus, to maintain weight-bearing symmetry while performing the STS movements might not be relevant for the
functional performance of this task by these subjects. In the
present study, the spontaneous strategy was shown to be more
favorable for the subjects with hemiparesis to perform the STS
movements because the rising index was maximal during this
strategy.
EMG Parameters During the STS Movement
In accordance with Cheng,7 the TA, SOL, QUAD, and
hamstring muscles played essential roles in the anterior-posterior stabilization of the ankle and knee joints during the STS
tasks with healthy subjects. The activity of these muscles was
compromised regarding the activation intensity and the onset
latency in subjects with hemiparesis.
In the present study, the beginning of the SOL muscle
activation was delayed when the unaffected foot was placed
behind, in comparison to the spontaneous strategy. However,
the differential latencies of the SOL muscle showed that this
muscle was activated before the seat-off during all investigated
strategies. It is well documented that, in healthy subjects, the
SOL is the last muscle to be activated and its activation occurs
after the seat-off during the performance of the STS movements.6,19,22 In healthy subjects, the function of the SOL is
related to the deceleration and stabilization at the end of the
movement once in the standing position.19 The fact that the
subjects with hemiparesis activated the SOL earlier, independent of the lower-limb positions, suggests that there are possible changes of the motor control mechanisms of the ankle
inherent to these subjects. These findings may be justified by
the presence of the spasticity and weaknesses of this muscle,
which have been shown to be the most affected of all investigated muscles.
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No differences in the differential latencies of the TA,
QUAD, and hamstring muscles were found between the strategies, and these muscles were also activated before the initiation of the seat-off and the same behaviors were observed with
healthy subjects.6,19,22 In the latter situation, however, the
changes of the initial lower-limb positions during the STS
movements changed the TA latency because this muscle was
considered to be responsible for the necessary preparatory
postural adjustments.19 The absence of changes in the TA
latencies observed in the subjects in the present study suggests
that they showed a lack of adaptation of the preparatory postural adjustments to the various demands for the same task.
This reinforced the previously cited hypotheses of the modified
motor control at the ankle level.
The amount of muscular activity showed that hamstring was
less activated in the symmetric strategy. In agreement with Lee
et al,4 subjects with hemiparesis showed greater amounts of
activation of this muscle during the last stage of STS to
stabilize the knee in the standing position. The present results
indicated that the positioning of both the lower limbs backwards have decreased the necessity of the stabilization of these
joints. This idea was reinforced by the results of Schultz et al30
who suggested that the backward positioning of the feet can
improve the anterior-posterior stability and lead to a safer
accomplishment of the STS movements.
Contrary to the present results, Brunt et al8 found higher
activation of the TA and QUAD muscles when the affected
foot was positioned behind the nonaffected one. This positioning is often used in clinical practice for reducing the learned
nonuse of the limb, although it has not been very well studied.
Because the QUAD was considered one of the main generating
muscles of the STS movement5,19,31 and the TA is considered
to be essential for ankle stabilization,7 it would be expected that
the use of such a strategy would increase the weight bearing on
the affected leg, leading to increases in motor unit recruitment
and more activation of the paretic muscles. This would lead to
better performance of STS movements. However, differences
between the study of Brunt et al8 and the present study should
be considered because they evaluated a sample of chronic
stroke subjects with a mean time after stroke of 3.6 years,
which was less than the 7.7 years observed in the present study.
It is possible that because of the fact that the present subjects
were more chronic, they could have been better adapted to
spontaneously perform the STS movements by using different
motor-control strategies as functional compensations. Other
differences could also have been related to the methods used
for the backward positioning of the affected leg. Brunt et al8
used 100° of flexion of the affected knee, whereas, in this
study, the ankle was the reference joint that showed the variability in ROM of the affected leg (0o–15°) because of the difficulty
to make heel contact of the affected leg with the ground. This
also may explain the differences between the studies for the
asymmetric strategy with the affected foot positioned behind
the nonaffected one. Therefore, the present findings do not
support the use of this strategy for subjects with the characteristics of the present study.
Study Limitations
The EMG parameters investigated in the present study failed
to find relevant differences between the strategies of lowerlimb positioning. Other studies already pointed out the great
variability in muscular latencies during the accomplishment of
the STS movements in subjects with hemiparesis,7,17 and this
variability was also observed in the present study. Moreover,
these subjects were also instructed to perform the movement as
fast as possible following the Balance Master System instrucArch Phys Med Rehabil Vol 90, February 2009
tions. On the other hand, other studies used the natural speed
for the accomplishment of the task and the speed of the movements, which could interfere with both the EMG variables4 and
the movement patterns.
Another factor that needs to be discussed refers to the
specific characteristics of the subjects in the present study.
Although they were chronic, most of them were classified as
fast in relation to the gait speed. This classification, proposed
by Olney et al,24 suggests that the majority of these subjects
could be considered minimally affected. Within this context, it
is possible that the spontaneous and symmetric strategies were
more natural and well known, and favored their performance of
the STS movement.
CONCLUSIONS
The asymmetric strategy with the unaffected foot placed
behind appeared to be least favorable for the accomplishment
of the STS movements because it increased the movement time
and delayed the activation of the soleus muscle. The asymmetric strategy with the affected foot placed behind did not show
advantages for the studied subjects. The symmetric strategy
revealed little need of stabilization of the affected knee, and the
movement time was similar to that of the spontaneous strategy.
Based on these findings, allowing the subjects to adopt the
spontaneous strategy or training of the symmetric strategy
could result in greater benefits for subjects with higher chronicity and higher functional levels, such as those evaluated in
the present study.
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Suppliers
a. EMG apparatus MP150WSW; Biopac System Inc, 42 Aeor
Camino, Santa Barbara, CA 93117-3133.
b. Balance Master System version 8.3; Neurocom, International Inc,
95970 SE Lawnfield Rd., Clackamas, OR 97015.
c. SPSS 13.0 for Windows; SPSS Inc, 233 S Wacker Dr, 11th Fl,
Chicago, IL 60606.
Arch Phys Med Rehabil Vol 90, February 2009