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 tech-
niques. 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 meth-
ods. 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 compre-
hensive and experimentally proven neu-
rophysiological basis.1-3 Furthermore,
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.
some stroke rehabilitation methods used
by physical therapists have been criti-
cized for their lack of evidence demon-
strating a specific therapeutic benefit.4,5
The conventional approach to the
treatment of stroke patients involves
training such patients to use their re-
maining motor capabilities to com-
pensate for those that were lost.6,7
Neurophysiological approaches, how-
ever, focus on rejuvenation of the lost
motor capacities.8-10 In that sense,
Knott and Voss referred to "hidden po-
tentials" for recovery,9 and Bobath re-
ferred to "some untapped potential for
more highly organized activity."10 This
theoretical difference between the con-
ventional 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 con-
ventional 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 be-
cause a higher level of improvement is
expected, and it is a slow, step-by-step
process. The developers of both the pro-
prioceptive neuromuscular facilitation
(PNF) and Bobath methods claim their
methods have greater therapeutic effects
than the conventional approach. Be-
cause Bobath rejected some of the main
principles on which the PNF method is
based,10 however, more than one alter-
native to the conventional treatment ap-
proach may exist.
The need to compare the effectiveness
of the main neurophysiological treat-
ment 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 associ-
ates 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-

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 ac-
knowledged as the major goal of physi-
cal rehabilitation.
The purpose of our study was to com-
pare the effectiveness of the conven-
tional, PNF, and Bobath approaches by
applying separately treatments based on
these methods to three groups of pa-
tients who were hospitalized in the same
institution. We considered improve-
ment 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 im-
provement 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 re-
ferred to the physical therapy depart-
ment 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 ther-
apy 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 combi-
nations 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 re-
quired of the physical therapists partic-
1234
TABLE 1
other week. These updated variables re-
Subject Characteristics lated to two groups of functions: 1) sen-
sory functions of touch, pressure, pro-
Variable N % prioception, stereognosis, hemianopia,
Side of hemiplegia and unilateral neglect, which was ex-
Right 66 50.5 amined by the tests of Oxbury et al,15
Left 62 47.5 and 2) values of the criterion variables,
Bilateral 3 2.0 which will be described separately in the
Sensory deficiencies following section. Each physical thera-
Present 89 70.0 pist treated her first five patients with
Absent 42 30.0
the conventional method, the next five
Aphasia in right hemi-
plegics
with the PNF method, and the last five
Present 36 54.5 with the Bobath method. All patients
Absent 30 45.5 were treated at least five days a week,
Unilateral neglect in and each treatment session lasted 30 to
left hemiplegics 45 minutes.
with sensory defi-
cits Criterion Measurements
Present 28 49.0
Absent 29 51.0 The following criterion variables were
Territory of cerebro- measured for each patient on admission
vascular accident to the program and every other week
Internal carotid ar-
thereafter:
tery 107 89.0 1. Functional independence was deter-
Posterior cerebral or
vertebrobasilar ar-
mined with the Barthel index (BI)16
tery 13 11.0
(Tab. 2). We used this index because
of its simplicity, validity, and relia-
bility.17,18 The BI also has been used
ipating in the study. All of the therapists as a criterion measurement in a com-
were experienced in applying these parable study.13
methods, and each therapist was re- 2. Muscle tone of the involved extrem-
quired to be familiar with the profes- ities was checked by passive move-
sional textbooks used as guidelines for ments of the extremities while the
the correct application of the neuro- patient was in the supine position. It
physiological methods.9,10 In addition, was graded using an ordinal scale
during the study period two refresher composed of five points: a) flaccid,
courses in each of the two neurophysi- b) low, c) normal, d) high, and e)
ological approaches were conducted, en- spastic. Similar scales are used in
suring a review of these methods before other clinical settings for comparable
shifting from one treatment method to purposes.19
another. Weekly meetings during the 3. Isolated motor control over the in-
study period provided the physical ther- volved ankle and wrist joints was
apists with further opportunities for dis- determined with the following tests:
cussion of problematic issues. Treat- a) Active range of motion of these
ment with any of the three methods joints was measured while the patient
involved regular patient assessments, was in the supine position and was
which were an integral part of the ap- compared with that of the same
proach practiced. An outline of the most joints on the sound side (for patients
prominent features of each treatment with limited ROM, the exact range
was measured with a goniometer)
procedure is provided in the Appendix.
and b) strength of the ankle and wrist
dorsiflexor muscles was measured
Procedure
twice in a pattern-free isolated move-
ment,firstby manual muscle testing
The data collection form for each pa-
and second by the patient pulling a
tient consisted of two main parts. The
gauged spring. This second measure-
first part was used to record basic infor-
ment was obtained from patients in
mation regarding the patient's medical
history, such as age, sex, body side af- the supine position with the limb
fected, and location of the damaged ar- placed straight on the tabletop and
tery, and was completed on admission with the measured joint at the table's
to the program. The second part was edge; the patient was instructed to
used to record variable data and was pull the spring from extreme plantar
updated by the physical therapist every flexion or palmar flexion.
PHYSICAL THERAPY

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
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 measure-
ments were included in the data analy-
sis. 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 uni-
formity of the evaluations was tested.
The interrater reliability for measure-
ments of all criterion variables was
found to be greater than .90.
Data Analysis
Descriptive statistics were used to re-
port patient characteristics. The chi-
square test was used to study associa-
tions between the treatments and
changes in the criterion measurements.
The Kruskal-Wallis one-way analysis of
variance (ANOVA) was used to com-
pare average changes among the three
groups. We used a multiple regression
technique to study the relative contri-
bution 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,
Volume 66 / Number 8, August 1986
Possible Score
With Help Independent
5 10
5,10 15
0 5
5 10
0 5
10 15
0 5
5 10
5 10
5 10
5 10
36 (27.5%) with the PNF approach, and
38 (29%) with the Bobath approach.
The variables that constituted the crite-
rion measurements were checked for
randomization on admission to the pro-
gram (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 sepa-
rately 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 dif-
ferent 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
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.)
RESEARCH
a table constructed by these four cate-
gories according to the three treatment
groups. We found no significant be-
tween-group difference, either on ad-
mission to the program or after six
weeks of treatment. The treatment ef-
fects of the three methods also were
compared in subgroups of patients char-
acterized by each of the variables listed
in Table 1. In none of these subgroups
did wefindany significant advantage to
one of the approaches over the others
(Kruskal-Wallis one-way ANOVA). We
also did not detect any differential influ-
ence 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), how-
ever, we found that after six weeks of
treatment the percentage of patients at-
taining normal muscle tone in the PNF-
treatment group was smaller than in the
other two groups. Concurrently, the per-
centage of patients with high muscle
tone in the PNF-treatment group sur-
passed their proportion in the rest of the
patients. This pattern of muscle tone
change, which was not statistically sig-
nificant, 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 AN-
OVA for the six-week data of these var-
iables showed no significant difference
1235
between any of the treatment ap-
proaches. Because these measurements
required some cooperation from the pa-
tients, 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 improve-
ment 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 lim-
ited 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 sig-
nificantly 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 signifi-
cant between-group differences after
two and four weeks of treatment. These
differences (p < .003 and p < .04, re-
spectively) resulted from the high per-
centage of nonwalking patients in the
Bobath-treatment group and the con-
current high proportion of patients
walking with an assistive device and the
aid of another person in the conven-
tional-treatment group. These differ-
ences 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 pa-
tients with these limitations. The side of
hemiplegia was not found to be associ-
ated significantly with the ambulation
of patients in the PNF-treatment and
Bobath-treatment groups. In the con-
ventional-treatment group, the six-week
difference between the ambulation of
right versus left hemiplegic patients was
significant (x 2 = 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 pa-
tients walked with an assistive device
compared with 30.8% of the right hem-
iplegic 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' per-
formance of ADL. Because functional
independence is the overall goal of each
of these methods, thisfindingmay have
practical implications for the physical
rehabilitation of aged hemiplegic pa-
tients. 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 pe-
riod may explain the lack of differences
in the BI scores.
We measured isolated control over
the involved ankle and wrist joints be-
cause these joints are the first to become
involved and are among the last to re-
cover after a CVA.22 Despite the imme-
diate beneficial treatment effects of the
neurophysiological approaches, the re-
sults of our study did not demonstrate
that either the PNF or the Bobath ap-
proaches are superior to the conven-
tional approach in enhancing the recov-
ery of lost isolated distal movements or
improving control over involved limbs.
The between-group differences in am-
bulatory 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 ap-
proach and especially with the Bobath
approach was delayed. Because the dif-
ference in ambulation between the treat-
ment 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 be-
tween the left and right hemiplegic pa-
tients in the conventional-treatment
group may have been because left hem-
iplegic 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 re-
lationship.

The increase over time in muscle tone

TABLE 3
of the extremities was expected. The
Patient Gait in the Three Groups
large increase in high muscle tone in the
Ambulatory Statusa PNF-treated patients (Fig. 1) may be
Time from related to the use of facilitation tech-
Therapeutic With Walking With Test
Admission
Approach Nonwalking Aid and Walking Independent Results niques.10 This interpretation, however,
(wk)
Assistance Aid does not explain the high percentage of
PNF-treated patients who maintained
2 Conventional 45.0 37.3 13.9 3.8 (n = 129)
lower muscle tone when compared with
PNF 60.0 14.3 25.7 0.0 x2 = 19.73,
Bobath 64.9 2.7 27.0 5.4 df = 6, the subjects of the other groups. The
p = .003 similar patterns of muscle tone change
4 Conventional 22.7 41.8 31.2 4.2 (n = 130) in the conventional-treatment and Bo-
PNF 28.6 28.6 42.9 0.0 x 2 = 13.32, bath-treatment groups (Fig. 1) do not
Bobath 42.1 10.5 42.1 5.3 df=6, support Bobath's claims that her tech-
p = .04 niques exert a special influence on mus-
6 Conventional 20.2 34.0 39.1 6.7 (n = 130) cle tone. Although our findings did not
PNF 20.0 31,4 45.7 2.9 X2 = 7.88, support the superiority of the Bobath
Bobath 28.9 10.5 52.6 7.9 df=6,
approach in improving muscle tone
p = NS
when compared with the other ap-
a
Figures indicate percentages of the row in each category. proaches after the six-week treatment

1236 PHYSICAL THERAPY


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 substan-
tiated 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 set-
tings, lackfinediscriminative 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, be-
cause changes in CVA patients are influ-
enced 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 shortcom-
ings, 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
Volume 66 / Number 8, August 1986
RESEARCH
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 impor-
tant 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.
1237
will be able to learn the relative thera-
peutic effects of the procedures they ap-
ply to CVA patients. Because some of
the theoretical principles of the neuro-
physiological approaches have been
questioned recently,23 objective evalua-
tion 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 sub-
jects. 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 evi-
dence is needed. Further studies are
needed of the effects of exercise therapy
procedures on hemiplegic patients.
1238
REFERENCES
1. Hewer RL: Stroke rehabilitation. In Russell
RWR (ed): Cerebral Arterial Disease. Edin-
burgh, Scotland, Churchill Livingstone, 1976,
pp 262-280
2. Basmajian JV: Research or retrench: The re-
habilitation professions challenged. Phys Ther
55:607-610, 1975
3. Basmajian JV: Neuromuscular facilitation tech-
niques. 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 investiga-
tion. 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 dysfunc-
tion. Arch Phys Med 33:521-533, 1952
9. Knott M, Voss DE: Proprioceptive Neuromus-
cular 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 6 0 1 -
620
12. Stern PH, Mcdowell FJ, Miller JM, et al: Effects
of facilitation-exercise techniques in stroke re-
habilitation. 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: Neuro-
physiology syndromes in stroke as predictors
of outcome. Arch Phys Med Rehabil 59:399-
403, 1978
15. Oxbury JM, Campbell DC, Oxbury SM: Unilat-
eral spatial neglect and impairment of spatial
analysis and visual perception. Brain 97:551-
564, 1974
16. Mahoney Fl, Barthel DW: Functional evalua-
tion: The Barthel index. Md State Med J 14:61 -
65,1965
17. Wylie CM: Measuring end results of rehabilita-
tion of patients with stroke. Public Health Rep
82:893-898, 1967
18. Granger CV, Greer DS, User RN, et al: Meas-
urement of outcomes of care for stroke pa-
tients. Stroke 6:34-41, 1975
19. Keenan MA, Perry J, Jordan C: Factors affect-
ing 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 the-
ory: A literature review. Phys Ther 61:1035-
1040,1981
PHYSICAL THERAPY