An exploratory study of righting reactions from a supine to a standing position in adults with Down syndrome.

[Unrau K, Hanraban SM, Pitetti KH. An exploratory study of righting reactions from a supine to a standing position in adults with Down syndrome. Phys Tber. 1994;741116-1124.!

Key Words: Down syndrome, Mental retardion, Motor development, Righting tasks.

Moving from a supine position to erect bipedal stance is considered a righting task.[1] Righting tasks utilize body movements that move an individual from a supine position to erect bipedal stance.[1] VanSant and other researchers have studied the righting tasks in rising from a supine to a standing position in children, adolescents, young adults, and adults in their fourth through eighth decades of life and found age-related changes in their righting behaviors.[2-7] Based on studies of nondisabled individuals, VanSant and colleagues[5-9] and Lawrence and Hopkins[10] proposed, developed, and validated a developmental sequence of movements for the task of standing and accounted for age-related variability.

The work by VanSant and others[7,9 12] contributed to a theory concerning motor development that differs from the classical theory. The classical theory states that motor development is primarily caused by the process of maturation of the central nervous system and that when maturation is complete, the developmental process terminates.[10] VanSant and others[11] have expanded this traditional theory into what they have termed a "life-span" concept of motor development, This concept explains change in motor behavior as a consequence of both intrinsic (eg, physical growth, body topography, body weight, limb lengths, body proportions, neural maturation) and extrinsic (eg, environmental) factors. Thus, motor development is seen as a continuum, beginning in early childhood with asymmetrical movements that become symmetrical in young adulthood and that regress to less symmetry with age. VanSant,[7] based on her study of the task of moving from a supine to a standing position, argued that motor development is a lifelong phenomenon.

One way to explore the utility of VanSant's proposed developmental sequence is to determine whether that sequence can be used to characterize the movements of persons with developmental disabilities. Our goal was to compare VanSant's established developmental sequence for the task of moving from a supine to a standing position with the movements observed in our study of persons with Down syndrome (DS).

Down syndrome is a condition caused by a whole or partial trisomal defect of chromosome 21 and is the most common cause of mental retardation in the United States.[12] There exists circumstantial evidence that persons with DS possess intrinsic factors (ie, poor muscle strength, small stature, hypotonicity) that may affect their developmental level of movement. Intrinsic developmental factors along with cenain intrinsic physiological factors have been identified.

Investigators[13-16] have determined that infants with DS demonstrate delays in achieving gross motor milestones such as sitting and walking. Furthermore, a positive association has been identified between delays in achieving gross motor milestones and delays in the development of postural reactions (eg, righting, equilibrium, and protective reactions) in infants with DS.[16] Whether these delays seen in infants and children with DS are associated with deficits in righting tasks in adults with DS is not known.

Physiological factors that could affect the developmental level of movement have been suggested by investigations demonstrating that children and adults with DS display (1) poorer cardiovascular fitness and decrcased muscle strength when compared with sedentary, nondisabled children and adults[17-19]; (2) small stature, short arms and legs, and a propensity to be overweight due to excess fat stores[19-22]; and (3) hypotonicity (a defect in tone), which can affect joint range of motion because of diminished resistance to passive movements and thus may result in unusual postures (eg, froglike position of the legs adopted in the supine position).[22,23]

There exists, therefore, sufficient circumstantial evidence to warrant an exploratory study to determine the level of movement development in persons with DS. The purpose of this study was to determine the level of development of movement in the righting task of adults with DS. Rising from a supine to a standing position was selected as the movement task for evaluating the level of movement development because it is a movement of the whole body that has been described across the age span by VanSant.[4]

Method

Subjects

A sample of convenience was recruited from a community-based sheltered workshop/training center for persons with developmental disabilities in a midwestem city with a population of over 300,000 individuals. Fifteen adults with DS (10 male and 5 female), who routinely participated in an exercise/recreation program (on site) and were considered in good health, participated in this study. Subjects' ages ranged from 22 to 65 years, with a mean age of 37.6 years (SD=18). The subjects' Iqs were within a range considered representative of individuals with mild to moderate retardation (IQ=45-70). All subjects' medical records indicated that they had been diagnosed with DS.

Protocol

Each subject was videotaped with a single video camera(*) positioned at a right angle to the long axis of the subject and located so that all of the subject's movements were included within the video frame. This protocol was based on the protocol described by VanSant.[4] An exercise mat was provided for subject's comfort and safety while performing movement tasks. Informed consent was obtained from the subjects or their legal guardian.

One testing session was required of each subject. Subjects were asked to lie on their backs and stand up using any movements of their choice. Reaching full standing posture constituted one trial. Subjecls were asked to perform 10 consecutive trials at any comfortable rate of their choice. No time constraints were imposed. The 10 trials were routinely completed within 5 minutes per subject. Generic affirmation such as "OK" or "alright" was given to signal the completion of a trial. No criticism or critique of performance was offered. Subjects were videotaped at the same workshop/training site.

The videotapes were viewed using slow-motion and stop-action techniques to identify the component movements present in each of the three body regions: upper extremity (UE; hands and arms), axial region AX; head, thorax, and pelvis), and lower extremity (LE; feet and legs) fir each trial. Movement components were tabulated according to categories developed and described by VanSant[4] (Tab. 1-3).

A total of 150 trials were analyzed for individual movement components. In the system of categorization used by VanSant,[4] low numbers indicated less advanced movement development (ie, movements that would be seen in children) and sequentially higher numbers represented increasingly advanced movement development (ie, movements that would be seen in young adults) (Tabs. 1-3). The frequencies of movements not described by VanSant were tabulated and are designated with an asterisk (*) in Figures 1 through 3. Although this was not a comparative study, the percentage of occurrence of each category of movement as reported by VanSant[4] for young adults is shown alongside that of the subjects of our study in Figures 1 through 3 for contrasting purposes.

[TABULAR DATA 1-3 OMITTED]

Results

Percentages of occurrence for the UE components for 150 trials are presented in Figure 1 along with the percentages of occurrence found by VanSant4 in young adults (mean age=28.6 years). In 64% of the 150 trials, the subjects with DS displayed UE movements not described by VanSant, making that the most frequently used type of movement. Additionally, only 4.6% of the trials involved the highest-level movements (ie, movements 4 and 5).

Figure 2 shows the percentages of occurrence of 150 trials for movements in the AX region. For the AX movements, 14.6% of the trials involved movements not described by VanSant4 and 40.6% of the trials involved the most advanced movements (ie, movements 3 and 4).

The percentages of occurrence for the LE movements are shown in Figure 3. For the subjects in this study, 33.8% of the LE movements were not described by VanSant.[4] Of the movements that were described by VanSant,[4] over 55% were at the lowest developmental level (ie, movement 1). No subjects used the second most advanced movement pattern (ie, movement 3), and LE patterns described as the highest level of development (ie, movement 4) were observed in 6% of the trials.

Table 4 shows the most frequent movement seen in the 10 trials for each subject. The movement was considered "most frequent" if the subject displayed it at least 50% of the time (ie, at least in 5 of the 10 trials). Three of the subjects consistently used movements that were not described by VanSant.[4] Four subjects consistently used movements for the UE component that were not previously described, and they used mostly low-level developmental movements for the AX and LE components. Eight subjects displayed described movements, but there was no consistent frequency.

Table 4. Most Frequent Movement Patterns Seen for Each Component(a)

Component                            No. of
UE           AX           LE         Subjects

ND            ND          ND           3
ND             3           1           2
ND             1           1           2
D-NF         D-NF        D-NF          8

(a) ND=movement not described by VanSant[4]; D-NF=movement described by VanSant,[4] but no consistent (ie, at least 50% of time) frequencies demonstrated; 1, 2, 3 = movement number as described by VanSant[4]; UE = upperextremity region, AX=axial region, LE=low-erextremity region.

Discussion and Conclusions

In VanSant's descriptions of movements,[4] symmetric movement is the most developmentally advanced. The results of our study suggest that adults with DS predominantly use either less developmentally advanced asyrnmetrical movements or movements that were not observed by VanSant.[4] Furthermore, the tendency to use movements not described by VanSant[4] was most evident in both the UE and LE regions (Figs. 1 and 3) and the subjects displayed more movements described for young adults[4] in the AX region (Fig. 2), although the movements tended to be skewed toward the less developed levels.

The subjects in this study used a wide variety of movement patterns during their 10 trials. For example, when considering the most consistent movement displayed in the 10 trials for each subject, 3 subjects consistently displayed nondescribed movements for all components (ie, UE, AX, LE), 4 subjects consistently showed nondescribed movements for the UE component and mostly low levels of movement development in the AX and LE components, and 8 subjects did not demonstrate a consistent movement for all three components (Tab. 4).

VanSant[4] found that young adults, who showed the highest preference for symmetric movements, also tended to stand in one motion, with no interruption. In our study, both old and young subjects tended to use interrupted styles of movement.5 The most common movement variations seen in our study involved separating the righting task into the following parts: (1) flexing and moving to a sitting position; (2) a repositioning transitional movement; (3) side-sitting on the right to kneeling in a fowpoint posture (ie, on hands and mees); and (4) rising to a standing position using movement I for the UE, AX, and LE components, respectively.

Because of the limited descriptive information (ie, height, weight, percentage of body fat, fitness and motor evaluations) we collected, insight into the reason(s) for the variability of body movements by the subjects is restricted. Additionally, the environment in which these subjects live may shape or influence the development of motor behaviors that are uncharacteristic of those of the general population. Several subjects performed striking, but irrelevant or nonproductive, movements that appeared more suited to public perforrnance than a testing setting. That is, on some occasions, the subjects would bow as if gesturing to a crowd their approval of their actions. This performance posturing suggests that persons with DS are sensitive to motor learning but may not be particularly discriminating about the appropriate context in which to use their available motor skills. Care should be taken to consider the functional implications of motor skills taught to persons with DS and to make clear the appropriate context for these movements.

Although this was not a comparative study, the data from our study are presented side-by-side with data reported by VanSant.[4] Although such a comparison is indeed valuable, there are several differences between the two studies that should be addressed. First, the subjects in our studv were asked to stand at their own pace, whereas those in the study of VanSant[4] were asked to "stand up as quickly as possible." This methodological difference might have contributed to the differences in results between the two studies. Perhaps the subjects in VanSant's study[4] would have demonstrated some of the movement patterns that we classified as not previously described had they been permitted to stand at their own pace.

Second, the ages of the subjects differed dramatically between our study and that of VanSant.[4] In the study by VanSant," the subjects ranged from 20 to 35 years, whereas the subjects in our study ranged between 22 and 65 years, with 40% of our subjects being over 40 years of age. Our subjects had a larger range of ages because of the difficulty in obtaining a sample, resulting in a sample of convenience. Nevertheless, because older people demonstrate less developmentally advanced movement patterns than younger people,[4,7] the apparent trend of the subjects in our study to use less advanced movement patterns may be a consequence of their age rather than the presence of DS.

A third factor that restricts a comparison between our study and that of VanSant[4] concerns the reliability of judgments made by a single rater. Prior to our study, we performed a pilot study involving young adults (ages 24-35 years) with no disabilities to allow the rater (KLJ) to familiarize himself with recognizing the movement patterns described by VanSant.[4] Although the rater in the pilot study felt proficient in recognizing the patterns described by VanSant,[4] the question of reliability and competency still exists. The differences between our study and that of VanSant[4] (ie, experimental instruction, age of subjects, rater competency) mean that conclusions must be made cautiously as to the impact of DS on the developmental level used to move from a supine to a standing position.

Another possible factor that restricts comparisons between our study and the studies by VanSant and colleagues is the number of cameras used. VanSant and colleagues used two cameras to record movements of children[5] and adults[24] rising from a bed. However, in their 1986[9] and 1988[4] studies, on which we based our study protocol, VanSant and colleagues used only one camera. Furthermore, in a recent study evaluating the movement patterns of middle-aged adults coming from a supine position to erect stance, Green and Williams[11] used two cameras, yet they used the same descriptive categories for the movement of their subjects that were used in our study, categories that were based on the 1988 study by VanSant[4] with only slight modifications. Those modifications were made because of the ages of the subjects (ie, middle age to elderly) in the study by Green and Williams." The majority of the subjects chosen for our study would not be considered elderly; therefore, we utilized the protocol (ie, one camera) and movement-pattern descriptions reported in VanSant's 1988 article.[4]

Even when considering the limitations of our study, the fact that the subjects consistently displayed a preference for less developed movement components and a large percentage of the movements chosen were not described by VanSant and colleagues must be addressed. Closer scrutiny of the factors that may cause the atypical righting behavior may lead to greater awareness of the possible interplay of intrinsic and extrinsic factors in this population. Possible confounding factors may be muscle strength and endurance, motor control and balance, developmental age as opposed to chronological age, body weight, percentage of body fat, body topography, and education. Substantial research remains to be done on the movement skills of persons with DS.

(*) Omnivision PV645, Panasonic Industrial Co, Audio-Visual Systems Division Executive Office, One Panasonic Way, Secaucus, NJ 07094.

[Figures 1-3 ILLUSTRATION OMITTED]

References

[1] McGraw MB. Veuromuscular Maturation of the Human Infant. New York, NY: Hafner Press; 1945 [2] Leuhring SK. Component Movement Pattern of Two Groups of Older Adults in the Task of Rising to Standing From the Floor Fachmond, Va: Virginia Commonwealth University; 1989. Master's thesis. [3] Sabourin PT, Rising From a Supine to a Standing Position: A Study of adolescents, Richmond, Va: Virginia Commonwealth University; 1989. Master's thesis. [4] VanSant AF. Rising from a supine position to erect stance: description of adult movement and a developmental hypothesis. Phys Ther 1988;68:185-192. [5] VanSant AF. Age differences in movement patterns used by children to rise from a supine position to erect stance. Phys Ther 1988; 68:1333-1338. [6] VanSant AF, Cromwell S, Deo A, et al. Rising from a supine to a standing position: a study across middle adulthood, Presented at the joint Congress of the American Physical Therapy Association and the Canadian Physiotherapy Association; June 12-16, 1988; Las Vegas, Nev. [7] VanSant AF. Life-span development in functional tasks. Phys Ther. 1990;70:788-796. [8] VanSant AF. A life-span perspective of age difference in righting movements, In: Roberton MA, ed. Advances in Motor Development Research, Volume 4 New York, NY: AMS Press Inc. In press. [9] Nuzik S, Lamb R, VanSant AF, Hirt S. Sit-to-stand movement patterns: a kinematic study. Phys Ther. 1986;66:1708-1713. [10] Lawrence DG, Hopkins DA. The development of motor control in the rhesus monkey: evidence concerning the role of corticomotorneuronal connections. Brain, 1979;99:235-254. [11] Green LN, Williams K, Differences in developmental movement patterns used by active versus sedentary middle-aged adults coming from a supine position to erect stance. Phys Ther. 1992;72:560-568. [12] Kirk SA. Educating Exceptional Children. Boston, Mass: Houghton Mifflin Co; 1972. [13] Carr J. Mental and motor development in young mongol children. J Ment Defic Res. 1970;14:205-220 [14] Hanson MJ. A Longitudinal Descriptive Study of the Behaviors of Down's Syndrome Infants in an Early Intevention Program. Eugene, Ore: University of Oregon Books; 1981: 1-49. [15] Kopp CB. Perspectives on infant motor development. In: Borstein MH, Kessen W, eds. Psychological Development From Infancy: Image to Intention. Hilisdale,. NJ: Lawrence Erlbaum Associates Inc; 1979:9-35, [16] Haley SM. Postural reactions in infants with Down syndrome. Phys Ther. 1986;66:17-22. [17] Pitetti KH, Climstein M, Mays MJ, Barrett PJ. Isokinetic arm and leg strength of adults with Down syndrome: a comparative study. Arch Phys Med Rebabit 1992;73:847-850. [18] Pitetti KH, Climstein M, Campbell KD, et al. The cardiovascular capacities of adults with Down syndrome: a comparative study. Med Sci Sports Fierc. 1992;24:13-19. [19] Dichter CG, Darbee JC, Effgen SK, Palisano RJ. Assessment of pulmonary function and physical fitness in children with Down syndrome. Pediatric Physical Therapy. 1993;5(1): 3-8. [20] Cooney TP, Thurbleck WM. Pulmonary hypoplasia in Down syndrome. N Engl J Fed. 1982;307:170-173. [21] Thelander HE, Pryor HB. Abnormal patterns of growth and development in mongolism: an anthropometric study. Clin Pediatr Phila). 1966;5:493-501. [22] Block ME. Motor development in children with Down syndrome, Adapted Physical Therapy Activily Quarterly. 1991;8:179-209. [23] Morris AF, Vaughan SE, Vaccaro P. Measurement of neuromuscular tone and strength in Down's syndrome children. J Ment Defic Res. 1982;26:41-46.

Invited Commentary

I congratulate the authors for undertaking the task of using component movement pattern descriptions to examine a sample of adults with developmental disability performing the rising task. The description of the movements used by individuals with disabilities has been a long-term goal of the research program from which the descriptive categories arose. The need to describe and understand motor behavior of individuals with developmental disabilities is important to validating physical therapy.

This study clearly illustrates the fundamental assumptions that must be examined before using the sets of movement pattern descriptions to answer questions regarding the developmental status of any population.

The first assumption concerns the methods used to gather the data. The authors' methods seem well within the limits that would permit comparison of data between their study and my original study of young adults.[1] A single camera was used to collect the data in my original study of adults, although in subsequent studies, including a study of children,[2] two cameras were used. The instructions to the subjects in this study, although possibly a bit more complex than we have used, are not decidedly different.

In this study, the subjects were allowed to rise at their own pace. Our experience with subjects of other ages and with different motor disabilities suggests that many will stand at their own pace regardless of the instruction. This difference in methodology could contribute to the greater variability of movement patterns observed, but I do not believe it explains fully the relatively high incidence of upper and lower-extremity movement patterns that could not be classified.

I would first ask, How reliable was the rater in using the categories? I am concerned that reliability statistics were not reported. In a study of adults' rising movements conducted by Green et al,[3] reliability was attained prior to reducing the data. When using the component method, my colleagues and I have consistently reported reliability statistics between raters and the percentage of exact agreement on repeat classifications for the primary rater.[1,2,4-6]

Although one cannot assume consistency of the ratings reported in this study, if reliability were within acceptable limits, two fundamental questions must be addressed before describing the developmental status of this group of adults. These questions are: (1) Do the categorical descriptions accurately describe movements of the population under study? and (2) Are the categorical descriptions comprehensive of the movements of the new population?7

The results reported by Unrau and colleagues indicate that the movement pattern descriptions[1] developed to portray the rising action of young adults without disabilities are not accurate or comprehensive descriptors of movements used by adults with Down syndrome to perform the rising task.

Since the time of my original study of adults,[1] we have worked to further define anti refine movement pattern categories for this task.[8] We have revised the categories to incorporate movements that seem to differ in minor ways from the original categorical descriptions but that are clearly within the defining criteria for the pattern. We also describe movements that are substantially different from those previously described. bur work with younger and older subjects with and without disabilities has led to the identification of additional movement patterns. The sets of categories[9] we have used since the initial study of young adults are both more accurate and more comprehensive than the original set. I suspect that if these more comprehensive sets of movement pattern descriptions were used, a larger proportion of the movements could have been classified.

Did the movements that were "undescribed" involve pushing on the thighs with the upper limbs, an action seen among both elderly and middle-aged adults?[10] Did the jump-to-squat pattern appear? It appears from the description of the most common form of rising that a kneeling pattern was observed. Both of the kneeling and the jump-to-squat patterns of lower-limb action were defined in my study of young children,[2] and have been subsequently seen in a variety of age groups. The action of flexing and rotating the trunk until the abdomen contacts the support surface was also defined as a category of action in my study of young children.[2] Did that action appear in this sample?

Unrau and colleagues stated that the most common movement pattern variations involved an interrupted style of moving in which the postures of sitting, side-sitting, and then four-point kneeling were observed. Interrupted forms of movement during this rising task have been noted previously among younger children and older adults,[3] as well as among adults who sustained traumatic brain injury.[11] In the latter study, interrupted movements were classified using the set of component categorical descriptions refined through studies of young children, older adults, middle-aged adults, and teen-aged subjects. Whether our decision to categorize interrupted movements in the existing categories or whether different categories should be developed that specifically note pauses in transitional postures is an important issue, but it does not obviate the component method.

Descriptions of the most common forms of movement provided by Unrau and colleagues seem to abandon the component approach in favor of description of whole body action. They describe body action up to time when the hands-and-knees posture was assumed and then refer to the component pattern descriptions to characterize the latter part of the movement. It is not always easy to focus on component actions when whole body action is easily anchored to recognizable postures such as sitting and four-point kneeling. However, one of the assumptions of the component approach is that movement patterns may be varying in different ways and for different reasons across the three body regions. The component method should lead to more detailed and comprehensive characterization of movements than can be expected from a whole body action descriptive method. At present, the "undescribed" patterns dearly illustrate the additional work that needs to be done to comprehensively describe the rising movements of these subjects.

I would also like to point out that there is a subtle difference between the stated purpose of the authors' work and the manner in which I would now phrase a question from a life-span developmental framework. That difference lies in the use of the term "developmental level." I use purposefully the term "step," instead of "level." In my thinking, "developmental level" implies a hierarchical relationship between patterns and suggests that early-appearing steps are prerequisite foundations to later-appearing steps. I have tried to strip the remnants of hierarchical theory from my work. I view the steps as age-related differences in performance. The hierarchical concept is deeply rooted in traditional concepts of neurodevelopmental processes.[12] Using terms such as "early-appearing steps" and "later-appearing steps" also eliminates the set of values associated with terms such as "advanced" or primitive." I wholeheartedly agree with Unrau and colleagues' suggestion that movement-pattern differences seen among these subjects might be constrained by a variety of intrinsic and extrinsic factors other than the nervous system.

I applaud the authors' work to this point and challenge them to continue to describe the movements used by adults with Down syndrome to rise to a standing position. I anxiously await the time when the "undescribed" movements are described so that a more valid comparison can be made to determine the developmental status of these subjects' performance in this task. I also would encourage the authors to collect data related to their subjects' body configuration and composition. These factors appear to be important constraints to rising movements among children[13] and adults[14] without disabilities and may account for some of the variation seen in this sample.

Ann F Vansant, PhD, PT Associate Professor Department of Physical Therapy College of Allied Health Professions Temple University 3307 N Broad St Philadelphia, PA 19140

References

[1] VanSant AF. Rising from a supine position to erect stance: description of adult movement and a developmental hypothesis. Phys Ther. 1988;68:185-192. [2] VanSant AF. Age differences in movement patterns used by children to rise from a supine position to erect stance. Phys Ther. 1988; 68:1333-1338. [3] Green LN, Williams K. Differences in developmental movement patterns used by active versus sedentary middle-aged adults coming from a supine position to erect stance. Phys Ther. 1992;72:560-568. [4] Richter RR, VanSant AF, Newton RA. Description of adult rolling movements and hypothesis of developmental sequences. Phys Ther. 1989;69:63-71. [5] McCoy JO, Vansant AF. Movement patterns of adolescents rising from a bed. Phys Ther, 1993;73:182-193. [6] Ford-Smith C, VanSant AF. Age differences in movement patterns used to rise from a bed: a study of middle adulthood. Phys Ther. 1993;73: 300-309. [7] Roberton MA, Dirocca PL. Validating a motor skill sequence for mentally retarded children. American Corrective Therapy Journal 1981;35:148-152. [8] VanSant AF. Life-span development in functional tasks. Phys Ther, 1990;70:788-798. [9] VanSant AF, Cromwell S, Deo A, et al. Rising from supine to standing: a study across middle adulthood. Poster presentation at the joint Congress of the American Physical Therapy Association and the Canadian Physiotherapy Association; June 13, 1988; Las Vegas, Nev. [10] VanSant AF. Life-span motor development. In: Lister M, ed. Contemporary Management of Motor Control Problems Proceedings of the Il Step Conference Alexandria, Va: Foundation for Physical Therapy Inc; 1991:77-83. [11] Vansant AF. Recovery of movement patterns following traumatic head injury. In: Proceedings of the World Confederation for Physical Therapy 11th International Congress, Book II. London, England: World Confederation for Physical Therapy; 1991:992-994. [12] VanSant AF. Concepts of neural organization and movement. In: Connolly BH, Montgomery PC, eds. Therapeutic Exercise in Developmental Disabilities. 2nd ed. Hixson, Tenn: Chattanooga Group Inc; 1993:1-12. [13] Brown L, Marasheski R, Phillips B, et al. Effects of body dimensions on the movement patterns used by children to rise from supine to standing. Poster presentation at the American Physical Therapy Association Annual Conference; June 13, 1993; Cincinnati, Ohio. [14] Vansant AF, Sabourin P, Luehring S, et al. Relationships among age, gender, body dimensions, and movement patterns in a righting task. Poster presentation at the American Physical Therapy Association Annual Conference; June 12, 1989; Nashville, Tenn.

K Unrau, PT, is Physical Therapist, St. Joseph Medical Center, 3600, Wichita, KS 67218.

SM Hanrahan, PhD, PT,is Program Director, Department of Physical Therapy, College of Health

KH Pitetti, PhD, FACSM, is Associate Professor, Department of Physical Therapy, College of Health Professions, The Wichita State University, Campus Box 43, Wichita, KS 67260-0043 (USA). Address all correspondence to Dr Pitetti.

This study was approved by the Institutional Review Board at The Wichita State University

This article was submitted June 24, 1993, and was accepted June 23, 1994.