Lower limb coordination during walking in subjects with post stroke hemiplegia vs. healthy control subjects.
The purpose of this study was to compare bilateral intralimb coordination of people with hemiparesis to that of age-matched healthy individuals during walking. Angle-angle analysis of hip/knee intralimb coordination indicated disrupted movement patterns existed bilaterally in the stroke subjects when compared with healthy individuals. Angle-angle analysis of knee/ankle intralimb coordination indicated disrupted movement patterns in only the hemiplegic limb of the stroke subjects. The contralateral limb of the stroke subjects was found to be similar to the healthy individuals. Analysis of the area within the curve of the hip/knee angle-angle diagrams of the involved limb (average [+ or -] standard deviation: 48.0 [+ or -] 46.1 [mm.sup.2]) was significantly less than that of the contralateral limb (158.0 [+ or -] 64.8 [mm.sup.2]) (p < 0.05). The area within the knee/ankle angle-angle curves for the involved limb (20.7 [+ or -] 12.3 [mm.sup.2]) was significantly less than that of the contralateral limb (52.0 [+ or -] 19.9 [mm.sup.2]) (p < 0.05). Individuals with a stroke walked significantly slower (39.4 [+ or -] 32.2 cm/s) than healthy individuals (128.5 [+ or -] 15.9 cm/s) (p < 0.01) contributing to the differences seen in area within the curve comparisons between the subjects with a stroke and the healthy subjects. The results of this study suggest that the contralateral limb range of motion limitation is a compensation for the reduced gait speed dictated by the involved limb.
Key Words: biomechanics; stroke; gait; kinematics
People with hemiparesis as a result of stroke or cerebrovascular accident (CVA) tend to have impaired lower limb function affecting ambulation (8). Extensive study in this population has focused on gait abnormalities affecting the involved limb. Most studies focus on the time course graphs of each joint of the involved limb compared to normal gait. Occasionally, joints of individual limbs of those with CVA are compared bilaterally. A unique perspective of evaluating within limb and between limb comparisons is the use of angle-angle diagrams. Symmetry between limbs can be demonstrated through the evaluation of the shape and size of the cyclic loop with angle-angle diagrams (1, 20, 21). Utilization of angle-angle diagrams has significant clinical value for the clinician in regard to viewing gait abnormalities of persons with CVA.
Individuals with hemiparesis demonstrate several deviations from normal gait kinematics (2, 4, 9,10). During the stance phase, the deviations include a forward tilt of the trunk and knee hyperextension (2, 8, 9). Deviations during the swing phase include a decreased foot-floor clearance, abnormal foot-floor contact after swing with the foot flat on the floor, and circumduction of the hip with the knee in extension resulting in the dragging of the toes (2, 3, 8, 9, 10).
Gait speed is a key variable reflecting the severity of the stroke (11, 13). Both stride length and cadence in individuals with a stroke are decreased relative to those parameters in normal individuals resulting in the decreased gait speed associated with hemiparetic gait (11, 13). The stance phase bilaterally occupies a greater proportion of the gait cycle for individuals with a stroke as compared to normal individuals. Consequently, the swing phase bilaterally is reduced in those with a stroke compared to normal individuals (11, 14). The increased stance phase results in slower walking speeds and is attributed to balance and muscular weakness problems (11, 14).
While the swing phase bilaterally is shortened in individuals with a stroke, the contralateral limb swing phase is reduced further in comparison to the involved limb as a result of muscular weakness on the involved limb preventing significant weight bearing from occurring during the stance phase of the involved limb. This results in a measurable asymmetry between the involved limb and contralateral limb (11, 14). Symmetry in gait reeducation following stroke is unquestionably valued as a goal by rehabilitation professionals (6, 11). Griffen, Olney, and McBride (6) have suggested two reasons for advocating symmetry in gait as an objective for rehabilitation in hemiparetic patients. The first reason suggests that subjects may wish to walk in a manner similar to their peers. This includes symmetry of spatio-temporal and kinematic variables. The second reason suggests that there may be a good rationale for the encouragement of symmetry in spatio-temporal and kinematic patterns in a changing biomechanical system like that found directly following stroke. Patients receiving early rehabilitation may benefit from setting symmetry as a goal to remedy altered motor function resulting from the stroke. Therapy focusing on achievement of normal spatio-temporal and kinematic performance may carry with it the consequence of a symmetric gait (6).
The asymmetry associated with hemiplegic gait also results in issues of interlimb and intralimb coordination (9). Interlimb coordination is addressed through time course graphs evaluating individual joints bilaterally (e.g. ankle of each limb). However, intralimb coordination (i.e. coordination of joints within a limb) has clinical value for understanding how a limb achieves movement through the gait cycle and how the joints work together to achieve the overall movement pattern (21). This type of analysis can be done through the use of angle-angle diagrams which plot one joint against another within a limb. The area contained within the curve of the diagram can be utilized to compare intralimb coordination bilaterally, as well (7, 20, 21).
Kinematic intralimb deviations from normal gait are readily viewed via angle-angle diagrams. These diagrams plot joint angles against each other to create characteristic walking cycles in cyclic loops (1, 7, 20, 21). Previous studies of hemiparetic gait involving records of angle-angle diagrams show markedly disrupted intersegmental coordination between joints, out-of-phase synchronization in the pre-swing phase, and alternating vertical and horizontal segments indicating a loss of simultaneous movement in both joints (2, 20, 21). These studies used analysis of both limbs of the stroke subjects, however, they did not point out the specific differences that are found in the contralateral limb, and why those differences may exist. The focus has been primarily on the differences that exist between the healthy and involved limb of the stroke subjects. The purpose of this study was to compare bilateral intralimb coordination of people with hemiparesis bilaterally and to age-matched healthy individuals during walking.
Eleven (eight men and three women) community-dwelling subjects with hemiplegia due to cerebrovascular accident and ten healthy communitydwelling men voluntarily agreed to participate and signed informed consent forms approved by the VA Greater Los Angeles Healthcare System Institution Review Board. Subjects with hemiplegia were recruited from the Physical Medicine and Rehabilitation Department Continuity of Care Outpatient Clinic of the VA Greater Los Angeles Healthcare System. Healthy control subjects were recruited from the general outpatient clinics and staff of the VA Greater LA Healthcare System--West Los Angeles Healthcare Center. Subjects with hemiplegia (2 right CVA, 9 left CVA) were at least six months post stroke (range: 0.5 -13 years, median time post CVA was 2 years). The median age for the subjects with hemiplegia was 64.5 years (range: 56-77 years old). The median age for the control subjects was 68 years (52-83 years). The assistive devices used by the subjects with hemiplegia were: single point cane (3 individuals), quad cane (2 individuals), walker (2 individuals) and ankle-foot orthoses (6 individuals). None of the control subjects used assistive devices.
Exclusion criteria for both groups included 1) inability to stand and locomote (with or without assistive device) independently, 2) inability to understand verbal instructions 3) severe cardiac problems which limited physical activity, 4) other neurologic disease (e.g. multiple sclerosis, Parkinson's disease), and 5) pain or trauma of the lower extremity, which limited range of motion or physical activity (e.g. amputation, rheumatoid arthritis, symptomatic arthritis).
A high resolution computer based six camera motion analysis system (Motion Analysis Corp., Santa Rosa, CA) was used to collect kinematics data (60 Hz) during walking. Three-dimensional coordinates of walking were obtained using a frame-by-frame trajectory tracking system (EVA v. 5.0--Motion Analysis Corp., Santa Rosa, CA). Interpolation algorithms for resolving gaps in the tracking trajectories due to marker obstruction are included in the software.
Subjects had retroreflective hypo-allergenic markers with adhesive backing placed bilaterally on the acromial processes, lateral humeral epicondyles, ulnar styloids, anterior superior iliac crests, superior border of the greater trochanters, lateral femoral epicondyles, inferior tip of the lateral malleous, posterior tip of the calcaneus and dorsum of the feet in line with the calcaneal markers (standard Helen Hayes marker system--Figure 1) (Motion Analysis Corp., Santa Rosa, CA).
[FIGURE 1 OMITTED]
Data Collection Protocol
Retroreflective markers were placed on each subject in the appropriate anatomical positions. Each subject was then instructed to walk along a 30ft. walkway at a comfortable pace. Several minutes of practice time were provided to allow the subjects to acclimate themselves to the testing environment. Each subject was instructed to walk wearing a comfortable pair of their own shoes and assistive devices necessary, allowing them to walk as normally as possible.
Coordinates of the endpoint markers were analyzed in three-dimensional (3D) space through the use of 3D trajectory tracking system software (EVA HiRes, Motion Analysis, Santa Rosa, CA). Kinematics data were used within ORTHOTRAK[R] software to calculate joint angles for the ankle, knee and hip over three steps per limb and averaged joint angles were used to produce angle-angle plots. The locations of the hip joint centers were predicted as displacements along the pelvic X axis (anterior/posterior), Y axis (medial/lateral), and the Z axis (inferior). These distances were expressed as fixed percentages (22% in the X direction (posterior), 32% in the Y direction (lateral), and 34% in the Z direction (inferior)) of the anterior superior iliac spine distances within ORTHOTRAK software (Motion Analysis Corp., Santa Rosa, CA, USA). Angle-angle analyses consisted of plotting the time-series of joint angles on the x- and y-axes. Comparisons were made between the ankle (x-axis) and knee (y-axis) for the knee-ankle angle-angle diagram and between the hip (x-axis) and knee (y-axis) for the hip-knee angle-angle diagram.
Quantitative results were obtained through the calculation of the area within the curve in the phase-plane diagrams. Printing the diagrams onto graph paper, determining the area of one square, and multiplying that area by the number of squares within the curve calculated area. A greater area indicates greater motion at the joint(s), while smaller areas represent less movement.
The area within the curve for each phase-plane diagram (knee-ankle; hip-knee) was compared separately. For the subjects with hemiplegia, the hemiplegic limb refers to the limb on the opposite side of the lesion (I = involved), while the contralateral limb is on the same side as the lesion (C = contralateral). These data were compared using a paired t-test. For healthy subjects, data from right (R) and left (L) limbs were compared using a paired t-test and averaged together measured no statistical differences found. The average of the right and left limbs for the healthy group was compared to each limb of the stroke group using an analysis of covariance with gait speed as the covariant. The ratios between limbs (I/C; R/L) were calculated and expressed as a percentage and compared between groups using an analysis of covariance, where gait speed was the covariant. Power analyses were performed to determine statistical power for the comparison between limbs in the stroke group and between groups (19). Comparisons between limbs in the stroke group yielded a power of greater than 90%. Comparisons between groups yielded a power of approximately 80%.
Exemplar patterns for the involved and contralateral limb hip/knee angle-angle diagrams are shown in Figure 2. The involved limb patterns were smaller than the contralateral limb patterns for all subjects and demonstrated shorter horizontal lines representing a smaller range of hip movement. Eight of the eleven subjects showed less than a [30.sup.0] horizontal change throughout the gait cycle. Subject 4 was an extreme example of shortened horizontal displacement, as the hip movement of this subject resulted in less than a [18.sup.0] range of motion. Subject 3 demonstrated the maximum value for horizontal displacement moving through [38.sup.0] of hip range of motion. The vertical lines were also shortened indicating a decrease in knee motion. Six of the eleven subjects showed less than a [20.sup.0] vertical change throughout the gait cycle. Subject 5 had a vertical displacement of less than [5.sup.0], which was an extreme example of decreased knee movement. Subject 1 demonstrated the maximum value for vertical displacement moving through 400 of knee range of motion. Common amongst all subjects were regions of diagonal lines bilaterally indicating movement in both joints simultaneously.
[FIGURE 2 OMITTED]
The area within the hip/knee angle-angle curves for the involved limb (average [+ or -] standard deviation: 48.0 [+ or -] 46.1 [mm.sup.2]) was significantly less compared to that of the contralateral limb (158.0 [+ or -] 64.8 [mm.sup.2]) (p < 0.0001). Thus, a measure of symmetry (involved limb expressed as a percentage of the contralateral limb (% I/C)) averaged less than 30% (26.7 [+ or -] 15.4%). (Table 1)
Both the right and left limbs showed a similar distribution of ranges of motion throughout the gait cycle. Consequently, only the right limb pattern is presented in Figure 2 as exemplar data. Hip range of motion was at least [35.sup.0] for all subjects (range: 35 - [60.sup.0]). Knee joint range of motion was between [40.sup.0] - [65.sup.0] for all subjects. Diagonal lines indicating simultaneous movement in both the hip and knee joints were present bilaterally in all the subjects. The curves of the diagrams bilaterally followed a characteristic loop indicating similar movement in all subjects.
The area within the hip/knee angle-angle curves for the right limb (average [+ or -] standard deviation: 351.3.0 [+ or -] 76.9 [mm.sup.2]) was similar to that of the left limb (338.2 [+ or -] 63.8 [mm.sup.2]) (p > 0.05). Thus, a measure of symmetry (right limb expressed as a percentage of the left limb (% R/L)) averaged approximately 100% (105.4 [+ or -] 20.9%). (Table 1) Consequently, comparison with the involved and contralateral limbs of individuals with a stroke were made using the average of right and left limb values for healthy individuals.
Exemplar patterns for the involved and contralateral limb knee/ankle angle-angle diagrams are shown in Figure 3. The knee/ankle angle-angle patterns of the involved limb contained more horizontal lines compared to the contralateral limb patterns. The horizontal lines represent knee movement in the absence of ankle movement. The displacement of the horizontal lines were also much shorter compared to the contralateral limb patterns. The shorter horizontal lines represented a smaller range of motion about the knee. Seven of the eleven subjects showed less than a [25.sup.0] horizontal change throughout the gait cycle. Subject 5 was an extreme example of shortened horizontal displacement, as the knee/ankle angle-angle diagram showed less than an [8.sup.0] horizontal change. Subject 1 demonstrated the maximum value for horizontal displacement moving through [40.sup.0] of knee range of motion. The vertical lines of the involved limb curves were exceptionally small, indicating very little ankle movement. Six of the eleven subjects showed less than a [20.sup.0] vertical change. An extreme example, subject 5, had less than a [10.sup.0] displacement in the vertical frame. Subject 12 demonstrated the maximum value for vertical displacement moving through [28.sup.0] of ankle range of motion. Diagonal lines indicating movement in both joints simultaneously were present in all involved limb curves with the exception of subject 8.
[FIGURE 3 OMITTED]
Similarly to the hip/knee comparison, the area within the knee/ankle angle-angle curves for the involved limb (20.7 [+ or -] 12.3 [mm.sup.2]) was significantly less compared to that of the contralateral limb (52.0 [+ or -] 19.9 [mm.sup.2]) (p < 0.0001). Thus, a measure of symmetry (involved limb expressed as a percentage of the contralateral limb (% I/C)) averaged less than 40% (39.1 [+ or -] 14.0%). (Table 1)
Both the right and left limbs showed a relatively even distribution of ranges throughout the gait cycle. Consequently, only the right limb pattern is presented in Figure 3 as exemplar data. Knee joint range of motion was between 40- [65.sup.0] for all subjects. Ankle range of motion was at least [28.sup.0] (range: 28 - [35.sup.0]) for all subjects. Diagonal lines indicating simultaneous movement in both the knee and ankle joints were present bilaterally for all subjects. The curves bilaterally followed a characteristic loop indicating similar movement in all subjects.
Similarly to the hip/knee comparison, the area within the knee/ankle angle-angle curves for the right limb (128.5 [+ or -] 38.4 [mm.sup.2]) was similar compared to that of the left limb (130.0 [+ or -] 23.9 [mm.sup.2]) (p > 0.05). Thus, a measure of symmetry (right limb expressed as a percentage of the left limb (% R/L)) averaged approximately 100% (100.1 [+ or -] 27.9%). (Table 1) Consequently, comparison with the involved and contralateral limbs of individuals with a stroke were made using the average of right and left limb values for healthy individuals.
Stroke vs. Healthy Comparison
Individuals with a stroke walked significantly slower (average [+ or -] standard deviation: 39.4 [+ or -] 32.2 cm/s) than healthy individuals (128.5 [+ or -] 15.9 cm/s) (p < 0.0001). As a result, when comparing the area within the curve for either limb of the subjects with a stroke versus the bilateral average of the healthy subjects, the analysis of covariance demonstrated that comparisons were significantly different due to differences in gait speed for both the hip/knee and knee/ankle angle-angle patterns. The measure of symmetry (% I/C versus % R/L) was significantly less in the subjects with a stroke relative to the healthy individuals for both the hip/knee comparison (Stroke group: 26.7 [+ or -] 15.4%; Healthy group: 105.4 [+ or -] 20.9%) and the knee/ankle comparison (Stroke group: 39.1 [+ or -] 14.0%; Healthy group: 100.1 [+ or -] 27.9%) (p < 0.0001).
Walking is a multijoint task in which each joint contributes to the overall response within a lower limb and one limb affects the movement of the other (17). The results of this study suggested that the contralateral limb range of motion limitations during walking are a compensation for the reduced gait speed dictated by the involved limb. The walking speed of the subjects with stroke was a key issue affecting range of motion viewed as the decreased size and altered shape of the area within the angle-angle diagrams bilaterally.
Diminished muscular strength is characteristic of hemiplegic gait (2, 10, 13, 14). One of the most affected joints is the ankle of the involved limb. The weakened ankle tends to be remedied by the use of ankle foot orthoses (AFO) which restricts the joint range of motion. When the ankle is constrained, there is a tendency to reduce stride length resulting in a quicker cadence and less of a loading response about the knee. Consistent with reduced stride length, the stance phase occupies a greater portion of the gait cycle bilaterally (13). Furthermore, a greater proportion of the stance phase is spent in double support compared to healthy individuals (13). The longer stance time during gait is often associated with an attempt toward greater stability, as can be seen in abnormal walking populations (5). The bilateral difference can be attributed to the lack of balance and muscular control within the involved limb (13). Consequently, the reduced stride length and increased stance phase require less range of motion bilaterally. Thus, the problem manifests itself as a slower gait speed.
The asymmetry associated with hemiplegic gait resulted in bilateral limitations. While these limitations were seen in both limbs, the limitation in the contralateral limb was more of a compensation due to the limitation in the involved limb. By reason of gait speeds dictated by the involved limb, there was not a necessity for the contralateral limb to go through full range of motion. Ostrosky, Vanswearingen, Burdett, and Gee (15) have suggested that longer stride lengths and greater range of motion produced by the hip, knee, and ankle occur with faster gait speeds. Also, Goble, Marino, and Potvin (5) suggested that greater asymmetries in walking are associated with decreased speeds. Consequently, we see symmetry in healthy subjects walking at "normal" speeds and drastic asymmetry in stroke subjects. The asymmetry of the stroke subjects were magnified due to the slower gait speeds. If healthy individuals were forced to walk at the same speed as those with a stroke, range of motion may decrease and the magnitude of the difference between the contralateral limb and healthy individuals may decrease.
The use angle-angle diagrams achieves particular value clinically when applied to an activity such as walking where the main components of the action consist of cyclical angular movements at multiple joints in the same plane (20). Angle-angle diagrams were particularly facilitative to this study due to inferences that can be drawn regarding how each joint within a limb work together simultaneously. While time course graphs are a way to evaluate data, they only provide data from one joint at a time and focus only on the magnitude of the movement. Angle-angle diagrams plot one joint against another and focus on the magnitude and coordination of the movement within a limb. The angle-angle diagrams presented in this study indicated similar results compared to studies completed by Winstein and Garfinkel (21), Charteris (1), and Steiner, Capildeo, and Rose (20). The involved limb diagrams showed disturbed intralimb coordination, out-of-phase synchronization throughout the gait cycle, and alternating vertical and horizontal segments indicating a loss of simultaneous movement in both joints. The contralateral limb diagrams showed normal aspects including diagonal segments indicating simultaneous movement in both joints, and appropriate synchronization of each joint segment throughout the gait cycle. The results of previous investigations and of our study support the notion that limitations in the contralateral limb are a compensation for the involved limb rather than an alteration.
Clinically, the results of this study can be used by rehabilitation specialists to understand the limitations that may exist bilaterally in the involved and contralateral limbs of individuals with a stroke. The use of these diagrams can also be used to evaluate the effectiveness of different modes of therapy. Along with gait abnormality measurement, methods of therapy that focus on regaining strength and motor function of the involved limb are recommended (16). Early rehabilitation that focus on these issues may benefit the patient as the recovery of motor function is commonly believed to occur only in the first 6 to 12 months after stroke (16). One potential therapy that can be used to increase the function of the involved limb is constraint therapy.
Constraint therapy encourages the use of the weaker limbs by the deliberate restricted use of better functioning limbs. Page, Sisto, Levine, and Mcgrath (16) have suggested that short periods of concentrated, task-specific training have induced cortical reorganization. It is possible to apply constraint therapy to the lower limbs. A stationary bicycle may be used to force the use of the involved limb and could be considered therapeutically efficacious. Use of a stationary bicycle can also encourage reciprocal usage of the ankle extensor and flexor muscle groups (18). The motion produced by movement on the bicycle is very similar to walking which may help to balance out the vast differences between the involved and contralateral limbs.
Limitations do exist in acquiring angle-angle diagrams when evaluating gait abnormalities of those with a stroke. Obtaining these diagrams may be time consuming for the clinician. However, use of angle-angle diagrams assists the clinician in the full understanding of intralimb and interlimb coordination and gait patterns. Also, future research should be conducted addressing the difference in gait speeds between individuals with a stroke and healthy individuals. Further studies involving a control group in which the walking speeds are constrained may be suggested.
Issues of symmetry and differences from healthy older adults can be explained due to the bilateral range of motion limitations. However, in those with stroke, they are a result of different factors. In the involved limb, range of motion limitations are a consequence of decreased stride length resulting from lack of strength and motor control. These limitations are expressed as a slower gait speed. The results of this study suggest that the limitations seen in the contralateral limb are present as a compensation for the slower gait speed dictated by the involved limb. Overall, the improvement of gait speed of individuals with a stroke is a key issue. In order to address this issue, rehabilitation specialists should focus on improvement of muscular strength and range of motion of the involved limb.
This research was supported in part by an American Heart Association Greater Los Angeles Affiliate Grant 1116-G11 awarded to Karen L. Perell.
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R.C. Giannini (a) and K.L. Perell (a,b)
(a) California State University, Fullerton, Departments of Kinesiology and Health Science, Fullerton, CA and (b) VA Greater Los Angeles Healthcare System--West Los Angeles Healthcare Center, Los Angeles, CA.
ADDRESS CORRESPONDENCE TO:
Karen L. Perell
Departments of Kinesiology and Health Science
California State University, Fullerton
800 N. State College, Fullerton, CA 92834
Tel.: (714) 278-4384
fax: (714) 278-5317
E-mail address: email@example.com (K.L. Perell).
Table 1: Mean, standard deviation, and range of the area within the angle-angle diagram loop for each limb (I = involved; C = contralateral) (R = right; L = left) for each group. The ratios of between limbs are compared across groups. Stroke Gait Hip/Knee-I Group Speed (cm/s) ([mm.sup.2]) Mean [+ or -] Standard 39.4 [+ or -] 32.2 48.0 [+ or -] 46.1 Deviation Range 8.6-110.5 10.9-156.3 p value (I vs. C) 0.0000 Healthy Gait Hip/Knee-R Group Speed (cm/s) ([mm.sup.2]) Mean [+ or -] Standard 128.5 [+ or -] 15.9 351.3 [+ or -] 76.9 Deviation Range 105.0-159.0 256.3-506.3 p value (R vs. L) 0.5793 p value 0.0000 (S vs. H) Stroke Hip/Knee-C I/C Group ([mm.sup.2]) (%) Mean [+ or -] Standard 158.5 [+ or -] 64.8 26.7 [+ or -] 15.4 Deviation Range 93.8-287.5 9.0-54.3 p value (I vs. C) 0.0000 Healthy Hip/Knee-L R/L Group ([mm.sup.2]) (%) Mean [+ or -] Standard 338.2 [+ or -] 63.8 105.4 [+ or -] 20.9 Deviation Range 243.8-406.3 75.4-135.5 p value (R vs. L) 0.5793 p value 0.0000 (S vs. H) Stroke Knee/Ankle-I Knee/Ankle-C Group ([mm.sup.2]) ([mm.sup.2]) Mean [+ or -] Standard 20.7 [+ or -] 12.3 52.0 [+ or -] 19.9 Deviation Range 7.8-43.8 26.6-84.4 p value (I vs. C) 0.0000 Healthy Knee/Ankle-R Knee/Ankle-L Group ([mm.sup.2]) ([mm.sup.2]) Mean [+ or -] Standard 128.5 [+ or -] 38.4 130.0 [+ or -] 23.9 Deviation Range 81.3-193.8 87.5-168.8 p value (R vs. L) 0.9022 p value (S vs. H) Stroke I/C Group (%) Mean [+ or -] Standard 39.1 [+ or -] 14.0 Deviation Range 19.4-64.7 p value (I vs. C) Healthy R/L Group (%) Mean [+ or -] Standard 100.1 [+ or -] 27.9 Deviation Range 56.5-147.3 p value (R vs. L) p value 0.0000 (S vs. H)
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|Author:||Giannini, R.C.; Perell, K.L.|
|Publication:||Clinical Kinesiology: Journal of the American Kinesiotherapy Association|
|Date:||Dec 22, 2005|
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