| | Effects of Ankle Joint Mobilizations in Adults Poststroke: A Pilot StudyPresented in part as a poster to the Combined Sections Meeting, American Physical Therapy Association, February 1−4, 2006, San Diego, CA, and as a platform to the Kansas Physical Therapy Association, April 1, 2006, Wichita, KS. Abstract Kluding PM, Santos M. Effects of ankle joint mobilizations in adults poststroke: a pilot study. ObjectiveTo compare the effect of 2 interventions on ankle mobility, ankle kinematics, and weight-bearing symmetry during functional activities in subjects with hemiparesis after a stroke. SettingAcademic medical center. ParticipantsA convenience sample of 16 subjects with hemiparesis after stroke (mean age, 55.2y; mean time since stroke, 21.4mo). InterventionSubjects received 8 sessions over 4 weeks of either functional task practice combined with ankle joint mobilizations, or functional task practice only. Main Outcome MeasuresChanges in ankle range of motion (ROM) (not blinded), ankle kinematics during sit-to-stand (STS) and gait, and lower-extremity weight-bearing symmetry during STS and static standing. ResultsThe combined intervention group gained 5.7°±3.1° in passive ankle ROM compared with 0.2°±2.6° in the functional practice only group (95% confidence interval [CI], 2.5–8.6; P<.01). No significant changes in ankle kinematics or weight bearing during static standing were noted in either group. The functional practice group decreased differences in weight bearing during STS by 9.5%±6.47%, whereas the combined intervention group increased this difference by 3.37%±5.29% (95% CI, 3.26–19.46; P=.01). ConclusionsThe increase in ankle motion did not improve joint kinematics and may have prevented improvement in weight-bearing symmetry. LIMITATIONS IN PASSIVE and active ankle movement are common impairments for people with chronic hemiparesis secondary to a stroke.1, 2, 3 Subjects with stroke have been found to have only half of dorsiflexion range of motion (ROM) compared with healthy controls.4 Researchers using careful laboratory measures to distinguish contracture from spasticity in a small sample found that 7 of 16 subjects had a true ankle plantarflexion contracture.5 Limited motion at the ankle may contribute to functional limitations, which are likely caused by the interaction of several complex factors such as spasticity, immobility, and structural adaptations. Central nervous system pathology may result in spasticity, or a velocity-dependent increase in stretch reflexes, which contributes significantly to calf muscle hypertonia or stiffness.6, 7 Non-neural factors, such as immobilization- and aging-induced changes in mechanical properties of muscle and connective tissue,8, 9, 10, 11, 12 are known to increase resistance of joint movement and contribute to the loss of passive movement independent of reflex activity.2, 3, 13, 14 In the upper extremity, lack of functional limb movement appears to increase the likelihood that wrist flexion contractures develop within 6 to 8 weeks after stroke.15 Thus, a component of the increased resistance to passive stretch that is commonly attributed to spasticity may be secondary to adaptive muscle changes or passive joint stiffness caused by non-neural factors, and these changes may begin soon after sustaining a stroke. Approximately 30° of ankle ROM is required for normal performance of sit-to-stand (STS) transfers,16 walking,17 and climbing stairs.18 Limited ankle mobility may not only affect the performance of these important functional tasks, but it may also affect the initial foot position for STS, which has been specifically identified as a key determinant in STS performance.19 Moderate correlations have been found between ankle ROM and balance scores in elderly women,20 and elderly fallers have been found to have significantly less dorsiflexion than elderly nonfallers.21 Adults with hemiparesis have an asymmetric distribution of body weight away from their hemiparetic leg during STS,22, 23 static standing,24 and while walking.25 Limited ankle mobility on the hemiparetic leg may contribute to this asymmetry in weight-bearing positions because of difficulty with placing the foot firmly on the floor. Joint mobilizations, or passive movement of the articular surfaces, are a technique commonly used by physical therapists to help restore normal accessory motion when there is a ROM limitation.26 Although ankle joint mobilizations are most often used for patients with a primary musculoskeletal pathology such as ankle sprains,27 mobilizations have been recommended as an appropriate treatment for joint hypomobility in children with cerebral palsy,28, 29 and have been found to effectively increase passive ankle ROM in subjects with diabetic neuropathy.30 However, specific functional practice that targets active use of the newly gained motion may be necessary for a change in motor strategy. This randomized controlled pilot study compared the effects of a combined intervention (ankle joint mobilizations and structured practice of functional skills) with structured practice alone. The purpose of this project was to compare the effect of these 2 interventions on ankle ROM, ankle kinematics, and weight-bearing symmetry during functional activities in subjects with hemiparesis after a stroke. Because this was a pilot study, we were interested in exploring the feasibility of the intervention and the sensitivity of our measures, defining an appropriate sample size for future projects, and gathering data that might support our hypotheses. The research hypotheses were that: (1) joint mobilizations would be effective at increasing ankle ROM in subjects with chronic stroke, (2) increased ankle ROM with structured practice of functional skills would result in a larger increase of ankle dorsiflexion motion during STS and gait than practice alone, and (3) increased ankle ROM with structured practice of functional skills would result in improved weight-bearing symmetry during STS and static standing than practice alone. Methods  Participants We recruited a convenience sample of subjects with hemiparesis resulting from a stroke 6 months to 5 years prior from the University of Kansas Medical Center (KUMC) Stroke Registry Database and via flyers given to local stroke support groups. Inclusion criteria included: (1) the presence of hemiparesis confirmed by physical examination, (2) able to transfer from a sitting to a standing position and walk approximately 10m without the assistance of another person, and (3) less than 8° of passive ankle dorsiflexion ROM on the hemiparetic side. Normative dorsiflexion ROM values are 22.75° in people aged 40 to 49 and 15.39° in people aged 60 to 84,12 so it was assumed that subjects who had less than 8° on the hemiparetic leg had a contracture due to stroke. Subjects were excluded from the study if they presented with contraindications for ankle joint mobilization (ie, ankle joint hypermobility, trauma, or inflammation), with language or cognitive deficits that would impair ability to give informed consent, or were simultaneously receiving physical therapy intervention outside of this study. Subjects who were participating in an exercise program (home-based or at a gym) were instructed to continue their participation throughout the duration of this study. Design This pilot study was a randomized trial with 2 intervention groups (fig 1). This study was conducted in accord with the ethical standards of the KUMC human subjects committee. Testing Procedures After obtaining informed consent from willing participants who met the above requirements, we randomly divided the subjects by choosing a piece of paper (numbered 1–17) out of a box. Subjects who selected an even number were assigned to the structured functional practice intervention (FP control), and subjects who selected an odd number were assigned to a combined intervention consisting of structured functional practice and ankle joint mobilizations (M/FP). Testing sessions were completed before and after the 4-week intervention, and included measurements of ankle passive ROM, ankle kinematics, and weight-bearing measurements during functional tasks. Subjects provided demographic information and completed the Rivermead Mobility Index (RMI), a self-reported measure of function.31 This index has 15 items ranging in difficulty from bed mobility to running. Subjects are given 1 point for each task they are able to perform, with a maximal score of 15. Rasch analysis has shown that this scale is sensitive to change and is a valid measure of function for stroke survivors both during and after rehabilitation.32 Ankle ROM Subjects were seated on an elevated plinth to measure ankle ROM on the hemiplegic side. The hip and knee were maintained at a constant 90° of flexion during the measurements. The subject was instructed to relax while the ankle was passively moved in the plantarflexion and dorsiflexion directions to the end of the available ROM with the subtalar joint in a neutral position, and a measurement was taken with a standard goniometer with alignments as described by Clarkson.33 Active ankle ROM was also measured with a goniometer in a similar way, asking the subject to volitionally move their foot into the plantarflexion and dorsiflexion directions. Maximal passive dorsiflexion and total active motion (full plantarflexion to full dorsiflexion) values were recorded twice, and the average of these was used in data analysis. The investigator who took the goniometric measurements (PMK) was not blinded to subject group assignment, and reliability for this investigator has been previously reported (intraclass correlation coefficient, model 3,1 [ICC3,1]=.95) for subjects with stroke using this procedure.34 The passive resistance in the ankle plantarflexors was characterized using the Modified Ashworth Scale (MAS).35, 36 Apparatus We monitored 3-dimensional motion of the ankle during functional activities with the Optotrak 3020a motion measurement system, in which light from infrared emitting diode (IRED) markers is directed onto a series of 3 charge-coupled devices and lens cells mounted on a 1.10m long stabilizer bar. As the subject moves, 3-dimensional data are reported for each marker position. Ground reaction forces were simultaneously measured with 2 AMTI OR6-5 biomechanics force platformsb embedded in an extended walkway. The 2 forceplates are positioned adjacent to one another along the walkway. For STS and static standing activities, 1 leg was positioned on each forceplate. For gait, the subjects were instructed to walk normally across the walkway. Procedure The 3-dimensional angles of the ankle joint during the experiment were determined using a previously established procedure.37 Briefly, a total of 6 active markers were placed on the lateral aspect of the lower extremity, 3 on the calcaneus, and 3 on the tibia bone (fig 2). Bony landmarks were digitized using a digitization probe to establish the calcaneus and tibia anatomic coordinates for 3-dimensional calculation of the ankle joint angles.38, 39 Subjects performed these tasks while barefoot in the following order: (1) stand up from a chair (ie, STS), (2) stand still for 30 seconds, and (3) walk across a 6-m (20-ft) walkway. Their instructions for the STS and walking tasks were to perform the task “as fast as possible while still being safe,” and they were permitted to practice these activities twice. The instruction for the standing trial was to “stand normally” while focusing on a point at eye level. One standing trial, 3 STS, and 3 gait trials were performed with ankle kinematic and forceplate data collection. Rest was provided between trials if requested by the subject. Subjects were permitted to use their arms to push off the seat when standing up and to use their typical assistive device while standing and walking if necessary. The chair height, knee joint angle, foot position, and use of armrests and assistive devices were documented for each subject and replicated for the post-test measurements. Subjects were guarded during these activities for safety by a physical therapist. Data processing Kinematic data were sampled at a frequency of 100Hz and forceplate data were sampled at a frequency of 200Hz. The kinematic and forceplate systems were synchronized using a trigger stimulus pressed as the “go” command was given to the subject. Three-dimensional coordinates of the markers recorded during the experiment were processed using a custom-made computer program developed in Matlabc to reconstruct 3-dimensional joint motions of the ankle including dorsiflexion and plantarflexion. The vertical forces of the stronger lower limb were used to identify the onset and end of STS. Onset of STS was identified as the first deflection from baseline in the vertical force after the trigger stimulus. This deflection indicates movement of the trunk in preparation for standing before any movement occurs at the ankle.40 To identify the end of the STS movement (steady standing), the amount of vertical force deflection during steady stand was used as a reference point for each subject to identify the transition point between greater variation during STS and steady stand (fig 3). The peak of ankle dorsiflexion of the hemiparetic limb was identified during STS and the stance phase of gait for each trial (Fig 4, Fig 5). Forceplate data were processed to determine the amount of weight placed on each leg during STS and static standing. The force difference between the 2 legs (calculated in newton meters) was normalized to total force in quiet standing (representing total body weight). Intervention Subjects in both groups attended physical therapy sessions twice each week for 4 weeks. Two physical therapists (PMK, MS) with several years of experience using joint mobilizations carried out the interventions. All subjects participated in functional task practice, and the amount and type of practice opportunities were based on a standardized protocol to maintain similarities between subjects in both groups. The first 5 minutes of the 30 minute sessions differed between the FP control and M/FP groups. The subjects in the FP control group began each session with 5 minutes of breathing exercises and sitting active ROM exercise for the upper and lower extremities. The subjects in the M/FP group began each session with 5 minutes of ankle joint mobilization on the hemiplegic leg. The subjects were seated in a chair with both feet resting on the floor. The joint mobilizations were performed to the proximal tibia-fibula, the distal tibia-fibula, and the talocrural articulations of the hemiplegic lower leg. The proximal and distal tibiofibular joints were mobilized first in an anterior and posterior direction with the knee flexed slightly. The talocrural joint was mobilized next in a loose packed position, with an emphasis on gliding the talus posteriorly on the tibia. All joint mobilizations were applied with grade I or II manual traction and gliding during the first session, and grade III movements for the remainder of the sessions, as described by Kaltenborn.26 For all subjects, the next 15 minutes were spent on functional training, providing multiple opportunities to practice STS, walking, and climbing stairs. The final 10 minutes were spent on activities to challenge sitting and standing balance. The specific functional and balance activities practiced were varied based on each subject’s individual ability and progressed to provide a continual challenge. These practice sessions were designed using motor learning principles as described by Schmidt and Lee41 with multiple repeated practice opportunities, use of variability in practice sequences, progression from blocked to randomized schedules, and the gradual weaning of augmented feedback. The use of manual guidance was minimized, and was provided only as a form of initial feedback and when needed for safety. The activities were designed to encourage subjects to maximize their available ankle motion during functional tasks and to bear weight through their involved limb, including activities such as standing up from a chair with the stronger leg either extended or elevated. Data Analysis The required sample size was estimated by a power analysis that used data collected in a previous study of ankle joint mobilizations on people with hemiplegia.34 The following formula was used to calculate the effect size42: The effect size of 2.63 indicated that a study with 8 subjects in each group would have 99% power to detect differences in passive dorsiflexion ROM.42 The primary dependent variables in this study included passive ankle ROM, peak dorsiflexion angle during the functional tasks of STS and gait, and weight-bearing differences during STS and static standing. Other variables were analyzed for potential differences in change between the groups, including other measures of ankle ROM, time to perform STS, and the RMI. All data were analyzed using SPSSd for Windows. For each subject, the means of the 2 trials for the ROM data and the 3 trials for each kinematic and forceplate-dependent variables were calculated. Baseline comparisons were made to examine differences between groups prior to the intervention using an independent t test. After the intervention, the mean change values for the M/FP and FP control group subjects were compared with an independent t test. A .05 level of significance was used for all statistical tests. Results We initially recruited 17 subjects for this study, but 1 subject dropped out after 4 intervention sessions because she experienced a seizure and a fall at home. The remaining 16 subjects (9 men, 7 women; mean age ± standard deviation [SD], 55.2±11.9y; mean time since stroke, 21.4±13.8mo) completed testing after 8 intervention sessions. No adverse complications were reported as a result of the intervention. The time between the final treatment session and the testing session varied from the same day to 9 days later (average, 3.6d). Subject characteristics are presented in table 1. There were no differences between the 2 groups in age, time since stroke, baseline measures of function (RMI), active or passive dorsiflexion of the hemiplegic ankle. | | |  | Group | Age (y) | Sex | Affected Side of Body | Time Since Stroke (mo) | RMI Score | MAS Score | DF PROM (deg) | |
|---|
| M/FP | 57 | Male | Left | 10 | 14 | 1+ | 1.5 | | | M/FP | 33 | Female | Left | 14 | 14 | 1+ | 7.5 | | | M/FP | 50 | Female | Left | 21 | 8 | 1+ | 0.5 | | | M/FP | 54 | Male | Left | 31 | 2 | 1 | −13.5 | | | M/FP | 61 | Female | Right | 6 | 12 | 2 | 4.5 | | | M/FP | 69 | Male | Right | 40 | 12 | 3 | −1.5 | | | M/FP | 63 | Female | Right | 15 | 11 | 2 | 0.0 | | | M/FP | 57 | Male | Right | 9 | 14 | 0 | 4.5 | | | FP | 55 | Male | Left | 8 | 12 | 1 | −7.0 | | | FP | 58 | Male | Left | 36 | 13 | 2 | 4.5 | | | FP | 35 | Female | Left | 42 | 13 | 2 | 3.5 | | | FP | 47 | Female | Left | 14 | 11 | 1+ | −11.5 | | | FP | 73 | Male | Left | 25 | 13 | 0 | 1.5 | | | FP | 64 | Male | Right | 48 | 12 | 1+ | −5.0 | | | FP | 44 | Male | Left | 7 | 14 | 1 | 5.5 | | | FP | 73 | Female | Left | 17 | 7 | 1+ | 0.0 | | | Mean ± SD | 55.8±11.9 | | | 21.4±13.8 | 11.4±3.2 | | 0.3±6.1 | | | | |
Ankle ROM The pretreatment, post-treatment, and change scores are presented in table 2 with the results of the t test comparing the 2 groups. Subjects who received the joint mobilizations in addition to the functional training (M/FP group) had increased ROM in comparison with the group that only received functional training (FP control group). The effect size for the change in passive dorsiflexion ROM was .88, and the effect size for the change in total active ROM was .72. Ankle Kinematics and Weight-Bearing Symmetry During Functional Activities The pretreatment and post-treatment measurements of kinematic and other selected functional variables are presented in table 2, with the results of statistical analysis comparing the groups. In spite of the increase in passive ROM noted above, no significant changes in ankle kinematics or weight bearing during static standing were noted in either group. The FP control group significantly decreased differences in weight bearing during STS in comparison with the M/FP group. The effect size for the change in peak weight bearing was −.85, and the effect size for the change in average weight-bearing difference was −.65 for the subjects in the FP control group. Subjects in the M/FP group did have a significant decrease in total STS time in comparison with the FP control group (the effect size was 0.6 for this change). Other measurements of function did not differ between groups. When the data for all subjects from both groups were pooled in a paired t test, the RMI score did show marginally significant improvements (t=3.15, P=.07). Discussion The purpose of this pilot study was to compare the effects of a combined intervention (ankle joint mobilizations and structured practice of functional skills) with structured practice alone on ankle mobility and functional performance in subjects with hemiparesis after a stroke. We found that the testing and intervention procedures were feasible, because only 1 subject out of 17 did not complete the project. The average age of our sample was 55.2 years, which indicates a relatively younger group of stroke survivors. It is possible that younger subjects are more willing to participate in a study that requires attendance at multiple testing and intervention sessions. The first hypothesis was that joint mobilizations will be effective in increasing ankle ROM, and this hypothesis was supported by the results of this study. All subjects who received mobilizations increased passive dorsiflexion ROM, despite the presence of hypertonicity of the plantarflexor muscles in several of the subjects. Prior to the intervention, subjects in this study showed significant limitations in ankle motion compared with normative dorsiflexion ROM values of 22.75° in people aged 40 to 49 and 15.39° in people aged 60 to 84.12 Although the average increase of 5.7° after the intervention in the M/FP group did not return the subjects to normal, it is a large change for subjects with chronic stroke who would not be expected to otherwise improve. The intensity of the joint mobilization intervention (5min per session for 8 sessions) was based on the clinical experience of the investigators, and is similar to that reported for the use of mobilization to treat ankle joint sprains and peripheral neuropathy.27, 30 Our previous study using a similar intensity of ankle joint mobilization found a mean passive ROM increase of 13.4° in subjects who were an average of 8.8 months poststroke.34 Subjects in the present study (mean time poststroke, 21.4mo) may have been more resistant to the stretching of articular tissues because decreased connective tissue extensibility is associated with prolonged immobility.8, 9 Joint mobilizations are intended to increase the accessory movements at the joint that contribute to passive mobility.43 The subjects in the M/FP group showed increases in total active ROM in addition to increases in passive dorsiflexion ROM. It is possible that the increased joint flexibility allowed the muscles to increase their action, or that functional training in combination with passive stretching had an effect on active ROM at the ankle joint. The second hypothesis was that increased ankle ROM with structured practice of functional skills will result in a larger increase of ankle dorsiflexion motion during STS and gait than practice alone. This hypothesis was based on the assumption that practice of functional skills would encourage subjects to use their newly gained ROM. However, this hypothesis was not supported by the findings of this study because neither group showed change in this variable despite gains in passive and active ankle mobility in the M/FP group. These findings illustrate the complex and nonlinear relationship between multiple impairments in body structures and functional activities. The relationship between a single impairment (ankle joint ROM) and performance of functional tasks is likely complicated by the presence of multiple other impairments in people with hemiparesis after stroke. Few studies have investigated whether changes in passive ankle motion translate into improved function in people with stroke or the elderly,44, 45 and none of the studies that we found evaluated changes in kinematics. A recent study evaluated whether combining neuromuscular electric stimulation to the ankle dorsiflexors with conventional stroke rehabilitation would be more effective than conventional rehabilitation alone.46 Both groups (combined treatment and rehabilitation only) improved in general measures of lower-extremity motor recovery, but no significant change in the kinematic characteristics of gait were found in either group, which is in agreement with the results of the present study. There are several possible reasons for the lack of improvement in the kinetic and kinematics patterns in patients with stroke in this study. First, proximal compensations at the hip and pelvis have been found to vary in people with stroke depending on the level of lower-extremity motor control, and selective motor control of the proximal lower limb may be more important than distal limb control in determining gait velocity.47 Proximal kinematics were not evaluated in the present study, but would be an important area of future investigation because subjects may have changed the kinematics in proximal joints to compensate for the deficits in the distal limb, and proximal kinematics may have affected the amount of dorsiflexion measured during STS and gait. Second, the subjects in this study may have had inadequate time for practice of the functional skills integrating the newly acquired ROM. The subjects in the M/FP group were simultaneously gaining ROM and practicing functional skills during the 4-week intervention period. In our previous study of ankle joint mobilizations in stroke using repeated measures, we found that the ROM increase was gradual over time and that the subjects showed a highly variable pattern of change in ankle kinematics during STS.34 Perhaps the gains in ROM by the end of the 4 weeks in this study had not yet been incorporated into everyday skills. Immediate learning was not measured, only long-term retention, because the testing sessions were conducted several days after the final intervention and practice session. Finally, the comparison was made between ankle ROM measured in the seated position with the knee flexed, and ankle motion during functional tasks (with the knee extended or moving from a flexed to an extended position during STS). Joint mobilizations are intended to stretch local structures such as the joint capsule, ligaments, and intrinsic muscles, and no additional extrinsic muscle stretching was provided. Because of this, the gain in ankle motion may have been overcome by gastrocnemius tightness shown in the standing position during functional activities. It may be beneficial to include passive muscle stretching with the knee extended after the mobilization as part of the intervention in future studies. Other findings did not support our third hypothesis that increased ankle ROM with structured practice of functional skills will result in improved weight-bearing symmetry during STS and static standing than practice alone. In an unexpected finding, the FP control group decreased the difference in weight bearing between the 2 lower extremities, whereas the M/FP group did not. Previous studies have found that the use of specific feedback on weight-bearing force is effective at decreasing the weight-bearing difference between legs in people with stroke48; 1 study found that subjects who participated in a 3-week intervention decreased this difference by 10.9%.49 A study that used a 4-week rehabilitation program based on principles of neurodevelopmental treatment did not find a change in weight-bearing difference, although subjects with left hemiparesis decreased the difference between limbs by 21.9% and subjects without sensory impairment decreased the difference by 32.8%.50 Our intervention did not specifically include feedback on weight bearing, although we did encourage subjects in both groups to increase use of their hemiparetic leg during functional tasks. Subjects who only received functional practice may have been more willing to increase weight bearing on their weak side without the concurrent change in ROM at the ankle. The subjects in this study had been functioning for months or years after their stroke, and the chronic adaptations to motor strategies may be challenging to overcome, similar to the learned nonuse phenomenon that has been described in the upper extremity of people after stroke.51 Another theory postulates that the central nervous system “knows best” in trying to solve motor problems given certain impairments,52 so perhaps changing ROM would not necessarily be beneficial for people who have already found a solution that is allowing them to function adequately in their environment. Subjects in the M/FP group did show decreased time for the STS task after the intervention in comparison with the FP only group, and the change of .82 seconds represents a 20% decrease in time. It is possible that the increase in passive motion at the ankle helped to facilitate increased speed of momentum transfer during STS. Time to stand up from a chair has been found to distinguish between stroke survivors who have experienced a fall at home and those who have not,22 so this may be an important aspect of improvement. Study Limitations This study included a small group size, and therefore there is increased risk of a type II error.42 However, a moderate to large effect size was noted for each variable that did show a significant change. There were other limitations to this study that must be considered. The investigator who measured passive ROM was not blinded to group assignment, although she was blinded to previous ROM measurements for each subject. We did not collect information on sensory or perceptual function for each subject; deficits in proprioception may have interfered with subjects’ ability to use their newly gained ROM during functional activities. We also did not distinguish between ankle stiffness caused by hypertonicity and that caused by purely mechanical limitations, although the intervention was directed primarily at mechanical limitations. A large amount of time and effort is currently directed at correcting ankle joint contractures in people who have had a stroke, both in the clinic and in research.45, 53 However, this study found that increasing ankle joint motion did not change STS or gait kinematics, and in fact may have prevented the improvement in weight-bearing symmetry seen in the subjects who did not receive the stretching component of the intervention. This outcome calls into question the relevance of treating decreased ankle motion in people with functional limitations after stroke. Conclusions This preliminary work shows that joint mobilizations may be effective at increasing ankle ROM and improving speed for STS when combined with functional task practice in subjects with chronic hemiparesis after stroke. However, there were no changes in joint kinematics during STS or gait, and no improvements in weight bearing were shown. The relationship between passive ankle motion, the functional use of ankle motion, and lower-extremity weight-bearing symmetry are important areas for future investigation. Suppliers Acknowledgment We thank Richard Condray, DPT, for his contributions to the technical aspects of data processing and data analysis for this project. References 1. 1Yarkony GM, Sahgal V. Contractures: a major complication of craniocerebral trauma. Clin Orthop Related Res. 1987;(219):93–96. 2. 2Given JD, Dewald JP, Rymer WZ. Joint dependent passive stiffness in paretic and contralateral limbs of spastic patients with hemiparetic stroke. J Neurol Neurosurg Psychiatry. 1995;59:271–279. MEDLINE |
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Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS.  Reprint requests to Patricia M. Kluding, PT, PhD, Mailstop 3051, 3901 Rainbow Blvd, Kansas City, KS 66160
Supported by the School of Allied Health Research Committee, University of Kansas Medical Center. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(07)01853-9 doi:10.1016/j.apmr.2007.12.005 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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