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Evidence In Practice |
Lisa Riolo, PT, PhD,NCS, is Associate Professor, Departments of Rehabilitation Science and Geriatric Medicine and Jill Pitman Jones Professor of Physical Therapy at University of Oklahoma Health Sciences Center, Oklahoma City, Okla
Kimberly Fisher is an MPT student in the Department of Rehabilitation Science at University of Oklahoma Health Sciences Center
| The purpose of "Evidence in Practice" is to illustrate the literature search process to obtain evidence that can guide clinical decision making. This article is not a case report. The examination, evaluation, and intervention sections are purposely abbreviated.
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A 72-year-old man was admitted to the inpatient rehabilitation facility where I was completing the clinical education requirement for my Master's of Physical Therapy degree. The patient had had a left cerebral vascular accident 10 days prior to his admission. Magnetic resonance imaging confirmed an infarct consistent with a thrombosis in the area of the middle cerebral artery. The patient, a retired attorney, lived with his wife in a 2-story house that requires climbing 2 stairs to enter. His goals were to walk independently and to return to his hobbies of gardening and golfing. The patient's medical history included a 15-year history of hypertension, for which he has been treated with a cardioselective beta-blocker (metoprolol [Lopressor]).* Because his cardiac status was stable on admission to the rehabilitation facility, his physician cleared him to begin an exercise program.
During my initial examination, I determined that the patient's right extremities were hemiparetic. He was able to hold his right shoulder in flexion, abduction, adduction, and extension and hold his right elbow in flexion and extension against gravity without using compensatory movements; however, he could not accept resistance without using compensatory movement at the scapulae and distal joints (3/5 muscle grade using manual muscle testing as described by Kendall et al1). He held his right wrist in flexion and extension against moderate resistance without recruiting compensatory movement patterns (4/5 muscle grade). He was able to hold his right hip in flexion, extension, abduction, and adduction and hold his right knee in flexion and extension against gravity without using compensatory movements; however, he could not accept resistance without using compensatory movement at the pelvis and distal joints (3/5 muscle grade). He demonstrated no active movement of his right ankle into dorsiflexion (0/5 muscle grade) and was able to move into plantar flexion only by using extension in his hip and knee.
According to Frese et al,2 the reliability and validity of manual muscle testing is relatively low (50%–60% agreement). However, because grades of 3/5 and 0/5 do not require a judgment about the amount of resistance applied by the tester, the reliability of the measurements may be better. Despite questionable reliability and validity, I believe that this test was the best I had available.
The patient demonstrated a mild increase in reflex activity (spasticity) in his right shoulder adductor, elbow flexor, wrist flexor, hip adductor, quadriceps femoris, and ankle dorsiflexor muscles (grade 1 using the Modified Ashworth Scale as described by Bohannon and Smith3).
The patient was able to walk 6 m (20 ft) in the hospital hallway with "moderate" assistance (he performed 50% to 75% of the activity) and a quad cane. He could perform stand-pivot transfers from the wheelchair to his hospital bed with "minimal" assistance (he performed 75% of the activity).
My evaluation of the examination data indicated that the patient was weak in his right extremities. I consulted the Guide to Physical Therapist Practice4 to aid my clinical decision making. I classified the patient under Preferred Physical Therapist Practice PatternSM 5D ("Impaired Motor Function and Sensory Integrity Associated With Nonprogressive Disorders of the Central Nervous System—Acquired in Adolescence or Adulthood"). Interventions listed for this practice pattern include muscle strengthening and endurance training. My clinical instructor, however, did not agree with my decision to include strength training as an intervention to address the patient's weak muscle groups. My clinical instructor loaned me a book by Bobath,5 who argued that traditional treatment approaches do not recommend strength training for people with central nervous system disorders. The premise of the traditional model of managing patients with stroke is that challenging muscles with resistance would increase reflex activity and reinforce abnormal movement patterns.5 Rather than strengthen weak muscles, the aim of traditional treatment is to reduce abnormal movement patterns.
I decided to perform a literature search to help solve my dilemma. I wanted to find the evidence on whether strength training exaggerates abnormal movement patterns or leads to increased reflex activity or whether it is associated with functional improvements when included as a component of a rehabilitation program for people who have had a stroke.
 | Database used for search: MEDLINE |
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(www.ovid.com). MEDLINE was created by the National Library of Medicine and contains citations from more than 4,600 journals in medicine and health care, including physical therapy. The database contains more than 11.8 million records dating back to 1966. MEDLINE is updated weekly, and 520,000 citations are added each year. Because MEDLINE is so extensive, I decided this database would be the most useful one for my search. Ovid is a collection of more than 90 databases, including MEDLINE. Full-text articles from some journals are available directly from Ovid. I performed this search on January 15, 2003. | Initial keywords: cerebrovascular accident |
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 TopDatabase used for search:... Initial keywords:... Additional keyword: strength...Selection of articles for...Clinical decision:References |
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The search produced 7,224 results. I clicked on the Limit button at the top of the main search page to narrow the search. I am able to read only English, so I clicked the box that would limit my search to articles published in English. I decided not to use the other options (including evidence-based medicine reviews, article review, full text available, male, female) because I wanted my search to include all of these options. Using this limit brought the number of results to 6,476.
| Additional keyword: strength training |
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TopDatabase used for search:...Initial keywords:...Additional keyword: strength...Selection of articles for...Clinical decision:References |
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I combined my two searches by typing 2 and 4 in the keyword box, which corresponded to the lines in my search history for: (1) cerebrovascular accident limited to English citations and (2) the subheadings of strength training—exercise therapy or weight lifting or exercise—limited to English citations. This combination of terms resulted in 80 hits.
The 80 citations produced were a rather large number to review; therefore, I attempted to narrow my search. I revised my search on the keyword strength training by retyping it in the keyword entry box. This time I selected only weight lifting and exercise therapy from the list of subject headings, eliminating exercise. I limited this search to English as I had before. This search resulted in 8,991 citations.
Next, I typed 2 and 7 in the keyword entry box to combine: (1) my search on cerebrovascular accident and (2) my revised search of the keyword strength training. This combination of terms resulted in 45 citations. I clicked on Display to review a list of these citations. Many of the titles contained interventions that were not related to strength training (eg, supported treadmill ambulation training, interventions to treat shoulder-hand syndrome, and constraint-induced therapy); however, 11 of the titles appeared to be possible answers to my question. I wanted to at least read the abstracts of these papers. I clicked on the checkboxes located to the left of the citations that most interested me. When I finished scrolling down the entire list, I clicked on the icon titled Main Search Page. This action saved these 11 citations. Part A of the Figure depicts my final search as it appeared on the main search page, and part B of the Figure lists the 11 citations.
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| Selection of articles for review: |
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TopDatabase used for search:...Initial keywords:...Additional keyword: strength...Selection of articles for...Clinical decision:References |
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After reading the abstract, I chose to read the Badics et al article first because it evaluated strength training as the sole intervention. I obtained this article through interlibrary loan.
Badics E, Wittmann A, Rupp M, Stabauer B, Zifko UA. Systematic muscle building exercises in the rehabilitation of stroke patients. NeuroRehabilitation; 17(3): 211–4, 2002.The effects of targeted strength training in patients with muscle weakness of central origin following cerebrovascular accidents has hardly been investigated to date. This prospective non-randomized study of 56 patients was designed to shed light on the effects of strength building exercises on muscle tone and on the gain in muscle strength achieved with them. All patients underwent a full residential neurologic rehabilitation program for 4 weeks, which included an exercise program for restoring the extensor strength of the legs and the supporting strength of the arms by leg and arm presses. Throughout the rehabilitation program muscle spasticity was evaluated clinically and maximal muscle strength on completion of the exercise program was compared to baseline. The extensor strength of the legs increased by 31.0 (+/– 26.7)% by 40.2 (+/– 15)%. significant for both variables. The extent of strength gain was positively correlated with the intensity and the number of exercising units. Muscle tone, which was abnormally high at baseline, did not further increase in any one case. The results of this study showed that targeted strength training significantly increased muscle power in patients with muscle weakness of central origin without any negative effects on spasticity.
[© 2002 IOS Press. Abstract reprinted with permission of IOS Press.]
The purpose of this prospective study was to evaluate the effects of a 4-week strength-training program on increased reflex activity and muscle force in people who have had a stroke. The mean age of the 56 subjects was 61 years; they had had strokes between 3 weeks and 10 years prior to the study. People who had muscle testing scores below 2 and Ashworth Spasticity Scale scores greater than 4 were excluded from participating in the study. This study was particularly useful because they used a measurement for reflex activity that was similar to the measurement I was using. The intervention consisted of closed-chain exercises (presumably with the distal limb segment fixed), including extensor leg presses for the hip and knee and arm presses to strengthen the triceps. Exercise intensity ranged from 30% to 50% of maximum muscle strength. The subjects performed 20 repetitions for 3 to 5 sets. All 56 subjects performed the lower-limb exercises, but only 36 performed the upper-limb exercises. The remaining 20 had shoulder-hand syndrome related to their stroke. The authors did not specify how many days a week the patients exercised; however, in the discussion section, they recommended that exercise sessions should occur at intervals of at least 2 to 3 days.
All 56 subjects exhibited increases in muscle force produced in the lower limb, and all 36 of the subjects who performed the upper-limb exercises exhibited significant increases in muscle force in the upper limb, regardless of age, sex, or time since the onset of stroke. None of the subjects demonstrated increased reflex activity. All of the subjects reported improvements, but these improvements were not measured in a standardized way.
Badics et al concluded that closed-chain strengthening exercises result in significant strength gain measured as muscle force without increased reflex activity. My patient met the inclusion criteria for age, reflex activity, and muscle strength at all joints with the exception of right ankle dorsiflexion, which had a 0/5 grade. Although the article stated that all subjects improved regardless of the time since onset of stroke, the time since onset of stroke ranged from 3 weeks to 10 years, and the authors did not list a group mean time since onset. Because only 10 days had elapsed since my patient had a stroke, I was unable to generalize these findings to my patient. The level of evidence of this article was also a concern. This study was not randomized and did not have a control group, which weakens the strength of this evidence.
After reading this article, I had some evidence that strength training could improve muscle force without increasing reflex activity, but I wanted to find stronger evidence and to investigate the effects of strength training on function. The following abstract addresses this subject in addition other outcome measures. After reading this abstract, I chose to read the entire article, which I obtained from my university library.
Teixeira-Salmela LF, Olney SJ, Nadeau S, Brouwer B. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Archives of Physical Medicine & Rehabilitation; 80(10):1211–8, 1999 Oct.OBJECTIVE: To evaluate the impact of a program of muscle strengthening and physical conditioning on impairment and disability in chronic stroke subjects. DESIGN: A randomized pretest and posttest control group, followed by a single-group pretest and posttest design. SUBJECTS: Thirteen community-dwelling stroke survivors of at least 9 months. INTERVENTION: A 10-week (3 days/week) program consisting of a warm-up, aerobic exercises, lower extremity muscle strengthening, and a cool-down. MAIN OUTCOME MEASURES: Peak isokinetic torque of the major muscle groups of the affected lower limb, quadriceps and ankle plantarflexor spasticity, gait speed, rate of stair climbing, the Human Activity Profile (HAP), and the Nottingham Health Profile (NHP) were recorded twice for the treatment group and three times for the control group. RESULTS: Significant improvements were found for all the selected outcome measures (HAP, NHP, and gait speed) for the treatment group (p < .001). In terms of overall training effects, the 13 subjects demonstrated increases in strength of the affected major muscle groups, in HAP and NHP profiles, and in gait speed and rate of stair climbing without concomitant increases in either quadriceps or ankle plantarflexor spasticity. CONCLUSIONS: The 10-week combined program of muscle strengthening and physical conditioning resulted in gains in all measures of impairment and disability. These gains were not associated with measurable changes of spasticity in either quadriceps or ankle plantarflexors.
[© 1999 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Abstract reprinted with permission from American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.]
The authors recruited 13 subjects who had weakness, increased reflex activity, or both in the affected lower extremity. The mean age of the participants was 67.73±9.2 years, and the time since the onset of stroke was at least 9 months. Subjects were randomly assigned to either a treatment group (n=6) or a control group (n=7). The 6 subjects in the treatment group participated in a 10-week training session, 3 mornings a week. Each 60- to 90-minute training session consisted of a 5- to 10-minute warm-up and aerobic exercise, such as walking, stepping, and cycling. The intervention also included strength training using progressive-resistive exercise (isometric, concentric, and eccentric muscle contractions) of the hip flexors, extensors, and abductors; knee flexors and extensors; and ankle dorsiflexors and plantar flexors for 30 minutes per session. Each weight-training program was individually prescribed based on the subject's ability and used only body weight, sandbag weights, or elastic tubing for resistance. Subjects began lifting a load of 50% of a single maximum repetition and increased their tolerance to 80% of a single maximum repetition.
The authors assessed stair climbing, gait speed, functional performance using the Human Activity Profile, quality of life using the Nottingham Health Profile, lower-extremity muscle torque using the Cybex II isokinetic dynamometer,
and increased lower-extremity reflex activity using a corrected relaxation index and controlled resistance to passive stretch. The 7 subjects in the control group did not receive intervention during the first 10 weeks of the study. The outcome measurements of the control group were compared with those of the experimental group. The treatment group improved in all outcome measurements after training, but the control group's scores did not change from baseline. The authors then performed the 10-week intervention program with the control group and pooled the data for all subjects in a single group pretest/posttest design. All 13 subjects showed improvements in all outcome measures with no change in reflex activity after receiving the intervention.
This study illustrates that aerobic exercise combined with strength training can result in improvements in muscle torque, function, and quality of life for patients with chronic stroke conditions with no increase in reflex activity. This study used a randomized controlled study design but included a weak, pretest/posttest research design for their main results to increase the total sample size. My patient had a stroke only 10 days before being referred, whereas, for the patients in this study, between 1 and 34 years had elapsed since the onset of stroke. This study also evaluated strength training in combination with aerobic exercise, which does not directly answer my clinical question concerning the effects of strength training alone. These factors, along with the small sample size, limited my ability to generalize the findings of this article to my patient.
I chose to read another article to further evaluate the effects of a strength training program on patients who had had a stroke. Another article I found in my search appeared to be useful and was available at my university library.
Teixeira-Salmela LF, Nadeau S, Mcbride I, Olney SJ. Effects of muscle strengthening and physical conditioning training on temporal, kinematic and kinetic variables during gait in chronic stroke survivors. Journal of Rehabilitation Medicine; 33(2):53–60, 2001.The purpose of this study was to evaluate the impact of a combined program of muscle strengthening and physical conditioning on gait performance in subjects with chronic stroke, using a single group pre- and post-test design. Thirteen subjects were recruited for the 10-week program (3 days/week), which consisted of warm-up, aerobic exercises, lower extremity muscle strengthening and cool-down. Data from cinematographic film and a force plate obtained during multiple walking trials were used in a four-segment kinetic model to yield spatiotemporal, kinematic and kinetic variables. Gait analysis revealed that the 10 week training resulted in significant increases in gait speed associated with improvements in walking patterns as determined by increases in selected kinematic and kinetic measures. After training, subjects were able to generate higher levels of powers and demonstrated increases in positive work performed by the ankle plantar flexor and hip flexor/extensor muscles.
[© 2001 Taylor & Francis Ltd. Abstract reprinted with permission of Taylor & Francis Ltd (www.tandf.co.uk).
This study involved the same authors, subjects, and intervention as the second article I reviewed, but it used different outcome measures. The purpose of this article was to analyze the effects of the same intervention on the kinetics and kinematics of gait. The authors found improvements between pretest and posttest measurements in gait velocity, cadence, and stride length. Changes in joint profiles occurred, but the authors described the changes rather than analyzing them statistically, making the significance of the data difficult to determine. This article suggests that aerobic exercise and strength training can enhance gait performance; but because it used only a single group and a pretest and posttest design, the strength of the evidence is poor.6
A systematic review is considered to have the highest level of evidence.6 I read the review of the article by van der Lee and colleagues that is available online because I was unable to receive the original article through interlibrary loan in time to make my clinical decision. I was able to access the review using the Article Review link on the citations page. The article review was published by the Database of Abstracts of Reviews of Effectiveness. It is an outline of the original article, including the type of interventions and participants included in the review, the number of studies included, and the results of the review. The abstract of the original article is listed below.
van der Lee JH, Snels IA, Beckerman H, Lankhorst GJ, Wagenaar RC, Bouter LM. Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials. Clinical Rehabilitation; 15(1):20–31, 2001.OBJECTIVE: Assessment of the available evidence for the effectiveness of exercise therapy to improve arm function in patients who have suffered from a stroke. METHODS: A systematic search of bibliographical databases and reference checking were performed to identify publications on randomized controlled trials (RCTs) which evaluated the effect of exercise therapy on arm function in stroke patients. The methodological quality was assessed systematically by two raters, based on a standardized list of methodological criteria. Study characteristics, such as the chronicity and severity of impairment of the patient population, the amount and duration of interventions, and specific methodological criteria, were related to reported effects. RESULTS: Thirteen RCTs were identified, six of which reported positive results on an arm function test. In five of these six studies there was a contrast in amount or duration of exercise therapy between groups. Methodological scores ranged from 5 to 15 (maximum possible score: 19 points). CONCLUSION: Insufficient evidence made it impossible to draw definitive conclusions about the effectiveness of exercise therapy on arm function in stroke patients. The difference in results between studies with and without contrast in the amount or duration of exercise therapy between groups suggests that more exercise therapy may be beneficial.
[© 2001 Arnold Journals. Abstract reprinted with permission of Arnold Journals.]
The purpose of this systematic review was to assess the effectiveness of exercise programs in improving the arm function of patients who have had a stroke. Although I was not specifically interested in arm function for my patient, the results are applicable to his rehabilitation. The age of subjects reported in the 13 randomized control trials included in the review ranged from 53 to 73.8 years. The outcomes included the Barthel Index of Activities of Daily Living, Action Research Arm Test, and Fugl-Meyer Assessment Scale. Each study was assigned a "positive" score if P was less than .05 or a "no difference" score if P was greater than .05.
Six of the 13 studies reported positive results in arm function. The intensity and duration of intervention affected the outcomes in 5 of these 6 studies. Three of these studies reported that intervention continued to have a positive effect after 6 weeks, 1 year, or 2 years of follow-up. Two studies reported positive results in activities of daily living at follow-up. The authors reported that the evidence suggests that more exercise may be more beneficial but that the evidence is insufficient to draw strong conclusions about the benefit of exercise on arm function.
After exhausting my MEDLINE search, I decided to read the following article, which was cited and described by Badics and colleagues. I obtained the article from my university library. It did not, however, appear in my MEDLINE search.
Sharp SA, Brouwer BJ. Isokinetic strength training of the hemiparetic knee: effects on function and spasticity. Archives of Physical Medicine & Rehabilitation; 78(11):1231–6, 1997 Nov.PURPOSE: To determine whether isokinetic training can improve the strength of the hemiparetic knee musculature, functional mobility, and physical activity and to evaluate its effect on spasticity in long-term stroke survivors. DESIGN: Nonrandomized self-controlled trial. SUBJECTS: A volunteer sample of 15 community-dwelling stroke survivors of at least 6 months. INTERVENTION: A 6-week (3 days/week, 40 minutes/day) program consisting of warm-up, stretches, reciprocal knee extension and flexion isokinetic strengthening, and cool-down for the paretic limb. MAIN OUTCOME MEASURES: Peak isokinetic hamstring and quadriceps torque, quadriceps spasticity, gait velocity, timed Up and Go, timed stair climb, and the Human Activity Profile (HAP) scores were recorded at baseline, after training, and 4 weeks after training cessation (follow-up). RESULTS: Paretic muscle strength improved after training (p < .05) while tone remained consistent (p > .87). Gait velocity increased after training (p < .05) and at follow-up (p < .05). Changes in stair climbing and timed Up and Go were not significant (p > .37; p > .91), although subjects perceived gains in their physical abilities at follow-up (p < .01). CONCLUSIONS: Gains in strength and gait velocity without concomitant increases in muscle tone are possible after a short-term strengthening program for stroke survivors. The psychological benefit associated with physical activity is significant.
[© 1997 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Abstract reprinted with permission from American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.]
This nonrandomized, self-controlled study measured the effects of an isokinetic strength-training program for the quadriceps femoris and hamstring muscles of the affected knee on peak torque production, reflex activity, mobility, and physical activity levels. The 15 subjects that participated had strokes between 0.9 and 18 years before the study. The training program included 3 sessions per week for 6 weeks. Each session consisted of a warm-up on a stationary bicycle, stretching of the quadriceps femoris and hamstring muscles of the involved leg, strength training of knee extension and flexion using a Orthotron isokinetic machine, and a cool-down consisting of the same hamstring and quadriceps muscle stretches. The subjects performed 3 sets of 6 to 8 repetitions using the affected leg at speeds of 30, 60, and 120 degrees per second.
The authors measured peak knee flexor and extensor torques using the Cybex II isokinetic dynamometer and reflex activity of the knee extensors using the pendulum test. The authors also evaluated changes in gait velocity, stair climbing ability, the ability to transfer from sitting to standing using the Timed Up & Go Test, and levels of physical activity using the Human Activity Profile. Immediately following training, subjects exhibited improvements in peak torque production of the affected hamstring and quadriceps muscles at all 3 speeds. Although scores still indicated improvement 4 weeks later, the scores were no longer higher than baseline measurements. There was no change in reflex activity. Gait velocity improved after training and 4 weeks later, but there was no change in scores on the Timed Up & Go Test or in stair climbing ability. Subjects improved their scores on the Human Activity Profile after training, and their scores continued to improve when measured 4 weeks after the intervention. All participants subjectively perceived improvements in their functional ability after training.
This study offered further evidence that strength training can improve muscle torque and functional ability without affecting reflex activity. However, it was a nonrandomized study and therefore provides weaker evidence than a randomized controlled trial.6 This study evaluates the effects of strength training on patients with chronic stroke conditions rather than acute stroke, which further limits its application to my patient.
| Clinical decision: |
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TopDatabase used for search:...Initial keywords:...Additional keyword: strength...Selection of articles for...Clinical decision:References |
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My original search included exercise as a subject heading and resulted in 80 citations. Rather than review what seemed to be an excessive number of articles, I decided to narrow the search by excluding the term exercise from my final search. I recognize that in making this decision I may have missed some relevant studies. Given the time frame I had to make my clinical decision, however, I decided that this limitation was necessary.
My patient differs from the subject population only in chronicity. His Modified Ashworth Scale scores and demographic information otherwise match the population of the subjects in the studies I read. I found no research studies that evaluated the effect of strength training on people with acute stroke. Perhaps the authors of these studies did not recruit people with acute stroke because they wanted to control for confounding variables. Spontaneous recovery varies from individual to individual, and it therefore is difficult to attribute improvements in function to an intervention program when this variable is not controlled. However, I am not conducting a research study; instead, I am interested in providing an intervention to help improve the functional ability of my patient.
I decided to proceed cautiously with a strength training program and closely monitor my patient's status. I will begin each session with a warm-up and end each session with a cool-down, and I will focus on strengthening the weak muscles of his upper and lower extremities that I identified in my examination. I chose to begin at an intensity of 30% of a one-repetition maximum using closed-chain exercises as recommended by Badics et al. I chose this conservative intensity because of my concern about the chronicity of my patient's stroke condition and the moderate strength of the evidence. Close monitoring of my patient will allow me to (1) alter the program should any increase in reflex activity occur and negatively affect his ability to function and (2) to increase the intensity when he demonstrates improvement.
Although my patient differed in chronicity from subjects in the studies I read, I justified my decision to perform strength training on the positive effects on strength, quality of life, and function for all subjects described in the articles. Based on the literature I reviewed, I do not anticipate any changes in reflex activity that would negatively affect my patient's functional ability. I believe that strength training will be a beneficial component of my patient's rehabilitation program.
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This work was funded in part by VA Rehabilitation Research and Development Merit Review grant #E2121R.
* Novartis Pharmaceuticals Corp, One Health Plaza, East Hanover, NJ 07936. 
Ovid Technologies, 333 Seventh Ave, 4th Fl, New York, NY 10001.
Cybex International Inc, 10 Trotter Dr, Medway, MA 02053.
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  S. J. Olney, J. Nymark, B. Brouwer, E. Culham, A. Day, J. Heard, M. Henderson, and K. Parvataneni A Randomized Controlled Trial of Supervised Versus Unsupervised Exercise Programs for Ambulatory Stroke Survivors Stroke, February 1, 2006; 37(2): 476 - 481. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
