Symmetry and Limb Dominance in Able-bodied Gait a Review
Interlimb symmetry of traumatic unilateral transtibial amputees wearing two different prosthetic anxiety in the early on rehabilitation phase
George Northward. South. Marinakis, PhD
Centre for Biomedical Engineering/School of Engineering and European Plant of Health and Medical Sciences,
University of Surrey, Guildford, United kingdom
Abstract — This study evaluated the SACH and the Greissinger Plus prosthetic anxiety, in terms of the symmetry provided betwixt the lower limbs, in the case of unilateral transtibial amputees 16.3 weeks from the time of limb fitting and 38.9 weeks from surgery. Sagittal plane gait assay was carried out for nine right-limb traumatic amputees. In all examined cases, the spatial and temporal parameters measured were significantly improved. When the symmetry indexes of the same parameters calculated with three unlike methods were considered, significant comeback was observed for the hip and talocrural joint ranges of movement and the opinion phase menses. All the same, no significant differences were found for the symmetry indexes of the articulatio genus range of motion, cadence, and walking speed. In addition, for near spatial parameters, the statistical significance varied considerably amongst the three methods used for the assay of symmetry.
Key words: gait symmetry, prosthetic feet, transtibial amputees, traumatic amputees.
Abbreviations: PTB = patellar-tendon-bearing, ROM = range of motion, SACH = solid talocrural joint absorber heel, SD = standard deviation.
This fabric was based on work supported by the Middle for Biomedical Applied science/School of Engineering and European Constitute of Health and Medical Sciences, Academy of Surrey, Guildford, U.k..
Address all correspondence to George Northward. Southward. Marinakis, PhD; School of Engineering (Brown-L3), University of Surrey, Guildford, Surrey, United kingdom GU2 7XH; +44-1483-682986; fax: +44-1483-689385; email: email: yard.marinakis@surrey.ac.uk.
INTRODUCTION
Normal human walking tin be divers equally "a method of locomotion involving the apply of the ii legs, alternately, to provide both support and propulsion" [one]. Past relying on coordinated muscle action and intact foot and ankle structures, normal individuals control the acceleration and deceleration of the foot and shank, thereby achieving weight-begetting stability while preserving forwards progression [2]. On the other hand, amputees depend on an bogus limb for back up of body weight and joint mobility during gait. In many cases, individuals with transtibial prostheses demonstrate walking difficulties, accompanied by asymmetry betwixt the involved and uninvolved limbs. These problems tin can be partly attributed to the behavior of their prostheses. In a survey of veterans and nonveterans with lower-limb amputation, fit and comfort were reported as two of the almost important functional characteristics of their prostheses [3]. The choice of appropriate prosthetic components as part of the prosthetic prescription is critical to user condolement [4].
Prosthetic pes components have a pregnant impact on several variables that depict lower-limb move [v]. The solid ankle cushion heel (SACH) pes historically has been the nigh ordinarily prescribed conventional prosthetic foot, despite its disadvantages. To overcome the limitations of the conventional types, developers have introduced new prosthetic feet during the last decade. While the range of prosthetic feet available has broadened, the selection of the almost appropriate pes for each patient has go more difficult. The goals of any prosthetic treatment include support of body weight, effective command of the motion of joints, and provision of stability. New prosthetic feet should provide increased range of motion of the joints, improve shock absorption, and lower metabolic energy cost.
Several studies have examined the effect of dissimilar prosthetic feet past measuring spatial and temporal parameters during gait. When the SACH foot is used in transtibial amputees, its kinematic beliefs has been compared with and so-called "dynamic elastic response" feet. The SACH human foot exhibits reduced range of move of the ankle joint, decreased single back up time, lower self-selected walking speed, and increased late stance duration disproportion [6-12]. In addition, the SACH pes is reportedly appropriate for low-activeness-level amputees requiring limited dorsiflexion [13], and the walking disability, classified past the patients, was not significantly unlike betwixt SACH and dynamic elastic response feet users, when indoor walking was considered [fourteen]. Furthermore, several studies have investigated the free energy cost of transtibial amputees wearing dissimilar types of prosthetic anxiety [7,13,15-17]. All the same, to the best of my knowledge, no literature currently exists that compares the behavior of the SACH foot and the Greissinger Plus foot for traumatic unilateral transtibial amputees in the early on rehabilitation stage, in terms of the interlimb symmetry provided during gait, by indexes calculated with iii different methods.
The present report attempts to provide useful data that will help the professionals involved in the rehabilitation of amputees to choose amongst dissimilar prosthetic feet by plumbing equipment the same individuals with two types of anxiety and analyzing their spatial and temporal gait parameters symmetry via an off-line video analysis system.
METHODS
Design
The independent variable used in this written report was the type of prosthetic foot. Two types of prosthetic anxiety were used, the SACH foot and the Greissinger Plus foot. Both prosthetic feet were manufactured by Otto Bock Orthopaedic Industry, Inc. (Duderstadt, Germany). The SACH foot was composed of a rigid longitudinal keel, a compressive wedge-shaped heel absorber (to provide energy absorption at impact), and a foot adapter (Figure 1). The Greissinger Plus foot was composed of a rigid longitudinal keel and a multiaxial ankle. The keel was longer than that of the SACH foot, due to the extra motion the ankle unit affords. The function of the ankle joint was based on a ring-shaped rubber (rocking rubber) and a cone-shaped bumper (joint retainer) that were compressed to control plantar flexion following heel strike and to provide a dorsiflexion limit in the late stance stage (Figure ane). The dependent variables were spatial (hip, knee, and ankle joint range of motion) and temporal (walking speed, cadence, and stance phase period) gait parameters and the correspondent symmetry indexes.
The gait data for both the disabled and nondisabled subjects were collected in the Biomedical and Rehabilitation Applied science Unit based at the National Constitute for the Rehabilitation of Handicapped in Attica (Greece). The disabled subjects completed two sessions, one with each foot. The outset testing session with the SACH foot was completed on the commencement day in the laboratory. The 2nd testing session with the Greissinger Plus human foot was held 1 week later, to ensure acclimation to the prosthetic foot. The reduction and statistical analysis of the data were carried out at the Middle for Biomedical Engineering based at the University of Surrey in Guildford (UK).
Participants
The ix male subjects who participated in this written report had unilateral (right) transtibial amputation due to trauma. All amputees were wearing a patellar-tendon-bearing (PTB) prosthesis with a soft removable liner. Inclusion criteria were (1) fitted with definitive prosthesis at least 4 months from amputation surgery (early in their postoperative stage), (ii) fitted with and continuously wearing the prosthesis at least three months prior to gait analysis, (3) residual limb with no current complications, (four) intact limb with no current complications, (v) independent airing prior to blow, (6) ability to walk with the prosthesis independently without any technical aid, (vii) correct-handed and right-footed, (8) absence of any cognitive bug, and (9) absenteeism of any other weather condition that could limit walking power.
The mean age of the amputees group was 54.iii years with a standard deviation (SD) of 2.1 years, their mean weight was 81.3 kg with an SD of 3.5 kg, and their mean tiptop was 1.82 m with a SD of 0.04 m. The mean time from amputation surgery was 38.nine weeks with an SD of 3.i weeks, and the mean time from limb fitting was 16.3 weeks with an SD of 5.8 weeks. Xiii nondisabled male subjects as well participated in the study. The mean age of the control group was 52.3 years with an SD of 11.3 years, their mean weight was 79.1 kg with an SD of three.0 kg, and their mean height was 1.79 chiliad with an SD of 0.03 m.
Fabrication and Plumbing equipment of Prostheses
The casting, rectification, socket lamination, assembly, alignment, and fitting of the prostheses for all disabled participants were carried out by the same person (the author). The alignment procedures were carried out co-ordinate to the instructions given by the manufacturer of the prosthetic components, with different designs of the ii anxiety taken into account. After the bench alignment, the subject was asked to endeavor the prosthesis with his own customary footwear of appropriate heel peak. Afterward, the subject underwent a preliminary static and dynamic alignment process to assure standing balance and the comfort of the prosthesis. On successful completion of the preliminary alignment, the amputee was trained in the use of the prosthesis and dynamic alignment.
Increased attending was paid during the transfer from the SACH foot to the Greissinger Plus foot, since alignment changes were required to minimize the alterations of the control of stability due to the differences in these two prosthetic anxiety. When the anteroposterior alignment was considered for both types of prosthetic foot, the middle of the foot was taken equally the neutral position in the sagittal plane according to the instructions of the manufacturer (i.e., to increase the forefoot lever, the middle of the foot was positioned anteriorly to the weight-begetting line).
Measurement Procedure
Subjects were asked to wearable dark-colored swimsuits made of elastic, nonreflective material. Half-dozen hemispherical retroreflective markers xix mm in diameter were placed on both sides of each subject's body at specific anatomical points: fifth metatarsal bone, calcaneus, lower 3rd of tibia, human knee joint line, greater trochanter, and illiac crest (Effigy 2).
The markers were placed onto the predefined positions with hypoallergenic tape. The placement of the skin-mounted markers was consequent during all tests. The location of the anatomical landmarks was achieved equally follows. (1) Fifth metatarsal bone: the mark was placed laterally over the head of the 5th metatarsal bone. (2) Calcaneus: the mark was placed at the heel, laterally of calcaneus, at the same horizontal aeroplane with the 5th metatarsal bone marking. (3) Lower third of tibia: the mark was placed 30 mm proximally of the lateral malleolus along the fibula. (iv) Knee joint joint line: the knee joint line was constitute via the lateral tubercle of tibia; the width of the lateral aspect of the knee (with the patella excluded) was divided into two equal parts and the marking practical in the heart. (5) Greater trochanter: the hip of the patient was flexed and adducted for the trochanter to become more than prominent; the marking was then applied with the hip extended, i.e., without flexion. (6) Illiac crest: the marker was applied one-third of the distance between the anterior superior iliac spine and the posterior superior iliac spine. The above setup of the markers was chosen so that the relevant bony landmarks would be close to the skin with a minimum of mankind in betwixt, in order to minimize skin movement artifacts.
During each testing session, and prior to actual image capturing, an orientation catamenia was allowed for participants to do walking under testing conditions; each participant was asked to walk on the 6.50 k � 2.xc m walkway 4 times at a self-selected speed. Then the participant'south functioning during two consecutive gait cycles was recorded at the sagittal plane (Ten-Y) with a charge-coupled device (CCD) camera (T-123A, Cohu, Inc.) at a capture rate of 60 Hz. The captured images were simultaneously digitized and analyzed with an paradigm-processing system (VP110 video processor, Movement Analysis Corporation), and and then the coordinates of the centroid of all markers at each frame were obtained. The camera was placed five m from the middle of the pathway, mounted on a tripod, and leveled to the ground with its optical axis perpendicularly oriented to the longitudinal axis of the pathway. The orientation of the photographic camera lens was kept the aforementioned each fourth dimension it was used. In addition, the image capture was initiated and terminated when predefined positions were crossed by the subject. In some cases, markers were obscured ("winked out" and reappeared) because of arm position and/or body orientation. Hence, the corresponding paths exhibited gaps. These gaps in the trajectories were filled by interpolation with the utilise of a spline.
Information Reduction
The x- and y-coordinates for all markers at each frame were smoothed at 8 Hz past a low-pass Butterworth digital filter. Since the filtered coordinates of the markers were known, the angles of the pelvis, thigh, shank, and foot segments could be derived (Figure ii). And so, the angles of the hip, knee, and ankle joints were calculated with the following equations:
The range of motion (ROM) of the named joint was calculated (in degrees) by subtraction of the minimum value of a specific joint angle from the maximum one. In addition, the stride length (cm) and the pace time (s) for each limb were calculated every bit follows: the step length and the step time of one (uninvolved or involved) limb as the distance and time by which the named limb moved forward in front of the other one, or the altitude and fourth dimension between the heel strike of the backward human foot to the heel strike of the named foot. The pace time (s) was calculated by addition of the step times of the involved and uninvolved limb. The opinion phase time (southward) for each limb was calculated equally the time between the showtime heel strike to toe-off. The walking speed (cm/s) for each limb was obtained by the altitude covered in a given unit of time or by sectionalization of step length of the named limb over the footstep time of the same limb. The cadence (steps/min) was calculated by division of the walking velocity over the step length and multiplication by 60. The stance phase period (% step time) was obtained by division of the stance stage time by the pace time and multiplication past 100.
Reliability of Data
For an evaluation of the accuracy of the measurement setup and method of analysis, a process similar to the one suggested by Richards [18] was followed.
The power to measure the altitude between two constantly visible markers moving on the sagittal plane was evaluated by a recording of the motion of two nineteen mm markers affixed to a rigid rod such that their centers were 400 mm autonomously; the rod was located on a calibrated aeroplane and rotated about its center. During all reliability tests, the SD was less than 0.six pct and the range deviation less than 1.two percent.
Symmetry
Several methods have been used to quantify symmetry [19-21]. Each gives different results, which might lead to varied conclusions; thus, it might exist useful to nowadays symmetry index values obtained with unlike methods. The symmetry indexes of the measured spatial and temporal parameters betwixt the involved and the uninvolved limb were calculated with the use of the following methods.
Method I
The gait parameter measured for i limb (exhibiting the smaller value) was divided by the same parameter for the contralateral limb. The obtained result was so multiplied by 100:
where S.I. stands for the symmetry index and P R, P L stand for the values of the gait parameter measured for the involved and uninvolved limb, respectively.
Method II
The absolute difference between the gait parameters measured for the correct and left limbs was divided past 0.v and multiplied by the sum of the values of the same parameter for the right and the left limb. The obtained result was and so multiplied by 100 and subtracted from 100:
Method III
The absolute difference between the gait parameters measured for the right and left limbs was multiplied past l and divided by the difference between the maximum and minimum values of the same parameter measured in the control group. The obtained result was and then subtracted from 100 (a method used past Motion the Analysis Corporation):
where Due north max( R,Fifty ) and North min( R,L ), stand for the maximum and minimum values of the correspondent gait parameter measured in the nondisabled subjects.
Statistical Assay
The unpaired t-exam was used to characterize the difference of the temporal and the spatial parameters and their symmetry indexes observed between the amputees wearing a prosthesis with a SACH foot and those wearing a prosthesis with a Greissinger Plus foot. A 2-tailed p-value of 0.05 or less was chosen to reflect statistical significance. When the p-value was betwixt 0.01 and 0.05, the departure amongst the tested parameters was characterized as "significant." For p-values between 0.001 and 0.01, it was characterized as "very significant," and for p-values less than 0.001, "extremely significant." An improvement meant that the values came closer to the ones observed in the nondisabled grouping.
RESULTS
Typical graphs of the variation of the hip, human knee, and ankle joint angles during a gait cycle for i of the examined amputees are shown in Figures iii, iv, and five. The two curves in each graph correspond to the data obtained with the field of study wearing a Greissinger Plus pes (thick line) and a SACH foot (thin line). In both cases, the human knee was flexed at heel strike (Figure 4). Therefore the hip was forced into increased flexion (Figure 3). This behavior was more than prominent in the case of the SACH foot, where the hip was flexed almost 20� at heel strike. As expected, the ankle joint behavior improved when the Greissinger Plus foot was used (Figure 5). With the SACH foot, the ankle joint was continuously at a depression-angle dorsiflexion, reaching a maximum of three.0�. With the Greissinger Plus foot, the maximum dorsiflexion was 6.5�, and the maximum plantar flexion 11�, resulting in an ROM within the lower limits of the range of values observed during measurements with the nondisabled subjects.
The values of the calculated spatial and temporal parameters are presented in Tables 1 and 2. For the spatial parameters, the hateful values of the hip, genu, and ankle joint ROMs of the involved limb were increased by xviii.half-dozen, nine.7, and 128.one percentage when the Greissinger Plus foot was used. The observed differences were pregnant for the human knee joint and extremely significant for the hip and ankle joints, equally shown by the statistical assay in Table 1.
Table one.
Spatial parameters (hateful value � standard difference).
Parameter
SACH
Greissinger Plus
p-value
Hip ROM (�)-R
28.0 � 2.half dozen
33.2 � 2.v
0.0005 (ES)
Hip ROM S.I. (%)-I
86.7 � 3.iii
89.vi � two.3
0.0460 (S)
Hip ROM S.I. (%)-II
85.7 � 3.9
89.0 � 2.seven
0.0532 (NS)
Hip ROM S.I. (%)-Iii
85.5 � four.4
87.2 � 3.0
0.3525 (NS)
Knee ROM (�)-R
54.vii � 5.3
60.0 � 5.three
0.0499 (South)
Knee ROM S.I. (%)-I
86.2 � seven.five
91.9 � 4.9
0.0744 (NS)
Genu ROM S.I. (%)-II
84.9 � 8.7
91.4 � five.two
0.0723 (NS)
Knee ROM South.I. (%)-III
lxxx.half dozen � 12.two
88.v � 7.0
0.1114 (NS)
Ankle ROM (�)-R
v.7 � 1.iii
13.0 � 3.half dozen
<0.0001 (ES)
Ankle ROM Due south.I. (%)-I
37.6 � x.7
52.ii � 15.3
0.0322 (South)
Ankle ROM South.I. (%)-II
23.7 � 3.1
63.five � 22.6
<0.0001 (ES)
Talocrural joint ROM S.I. (%)-Three
53.0 � 12.two
64.iv � 17.8
0.1326 (NS)
R = right (involved) limb
S.I. = symmetry indexI, Ii, or 3 = method used to summate S.I.
NS = not significantS = significant
VS = very pregnantES = extremely significant
Table 2.
Temporal parameters (mean value � standard deviation).
Parameter
SACH
Greissinger Plus
p-value
Walking speed (cm/s)-R
47.6 � 6.viii
56.ix � 5.1
0.0047 (VS)
Walking speed S.I. (%)-I
89.half dozen � iv.4
ninety.4 � 5.7
0.7432 (NS)
Walking speed S.I. (%)-II
88.9 � v.0
89.seven � 6.3
0.7692 (NS)
Walking speed S.I. (%)-III
95.4 � 1.7
96.four � one.9
0.2565 (NS)
Cadence (steps/min)-R
88.six � 8.9
98.3 � 10.ii
0.0472 (S)
Cadence S.I. (%)-I
95.9 � iii.9
97.2 � 1.3
0.3569 (NS)
Cadence Due south.I. (%)-Two
95.7 � four.one
97.1 � 1.4
0.3468 (NS)
Cadence S.I. (%)-III
87.vii � 12.ane
93.ii � 2.9
0.2034 (NS)
Stance phase flow (%)-R
74.9 � three.2
61.3 � one.8
<0.0001 (ES)
Stance phase catamenia S.I. (%)-I
81.1 � six.2
96.9 � one.8
<0.0001 (ES)
Stance phase period South.I. (%)-II
78.9 � 7.half-dozen
97.0 � 1.nine
<0.0001 (ES)
Opinion phase flow S.I. (%)-Iii
59.3 � 9.1
92.8 � 5.0
<0.0001 (ES)
R = right (involved) limb
S.I. = symmetry indexI, 2, or Iii = method used to calculate S.I.
NS = non meaningS = significant
VS = very significantES = extremely significant
In addition, the minimum (among the three methods used) increase observed for the symmetry alphabetize of the ROM of the hip, knee, and ankle joints was 1.nine, 6.six, and 21.5 percent, respectively. However, a significant deviation was found for the symmetry indexes of the hip and the ankle ROMs and non for the symmetry index of the knee joint ROM.
Furthermore, the symmetry index values varied considerably amongst the three different methods used to calculate them. When the symmetry of the hip ROM was considered, the resulting p-values for methods I, Ii, and III were 0.0460 (meaning), 0.0532 (not meaning), and 0.3525 (non significant). This variation was more than prominent in the symmetry indexes calculated for the ROM of the talocrural joint joint, where the obtained p-values were 0.0322 (significant), beneath 0.0001 (extremely significant), and 0.1326 (not significant).
For the temporal parameters, the hateful values of the walking speed and cadence of the involved limb were increased by 19.five percent and 10.9 percent when the Greissinger Plus pes was used, whereas the opinion phase period was decreased by 22.2 percent. The observed differences were pregnant for the cadency, very meaning for the walking speed, and extremely significant for the opinion stage period, as shown by the statistical analysis in Table two.
In addition, the minimum increment observed for the symmetry indexes of the walking speed, cadence, and stance phase menstruation was 0.89 percent, 1.3 percent, and 19.five percent, respectively. However, pregnant difference was found for the symmetry index of the opinion stage period but and non for the symmetry indexes of the walking speed and the cadency.
Discussion
In most cases, the amputees' walking deviated from the then-called "normal" pattern. However, normal patterns vary from individual to individual and change with walking speed, age, weight, superlative, and other factors. Therefore, it is of import to go along in heed one of the most outstanding characteristic of normal locomotion-that is, symmetry [22].
For most rehabilitation professionals, the accomplishment of symmetry of the lower limbs during walking has been an unquestioned goal of gait reeducation.
The selection of the advisable type of technical aid and, more specifically, of lower-limb prostheses, especially while amputees are even so in the early stage of rehabilitation, is of disquisitional importance in the accomplishment of this goal. Gait analysis provides useful data for both rehabilitation professionals and patient feedback, contributing to the choice of the most effective and efficient prosthetic treatment. In improver, quantitative measurement of role is sometimes desirable to let documentation of changes in the patient's condition.
All methods used to calculate the symmetry index of the measured spatial and temporal parameters exhibited advantages and disadvantages. An advantage of methods I and Ii is that "normal" information are not required, and thus measurement time is saved and calculations are simplified. The main disadvantage of method I is the relatively small asymmetry observed in almost of the tested parameters. The main disadvantage of method II is that differences are reported confronting their average values; i.e., if a large asymmetry is present, the average value does non correctly reflect the performance of either limb [22]. Method Three requires data from "normal" subjects, leading to a longer measurement procedure. However, asymmetrical behavior of the lower limbs during able-bodied ambulation has been addressed by many investigations [22-24]; therefore, information technology could be useful to incorporate it in the calculation of the symmetry indexes. A disadvantage of method Iii is that there is a possibility (although quite small-scale) that calculations will result in a denominator with a zero value (i.e., no difference between the minimum and maximum parameters in the command subjects), leading to a meaningless consequence.
All the measured spatial and temporal parameters were significantly improved when the SACH pes was replaced by the Greissinger Plus foot, every bit expected. All the same, when the symmetry indexes were considered, the observed differences were not significant for all the measured parameters. And this seems to be more than important when the symmetry of the walking speed and cadence is considered, since these 2 parameters are commonly used to evaluate the functional event of the prosthetic treatment.
Although the increment of the symmetry indexes of some parameters such as the knee joint range of motility, walking speed, and cadency was relatively small-scale, information technology may be clinically important, given the high free energy cost of transtibial amputee walking. In add-on-particularly in the case of the knee range of motion-although the divergence observed could not be characterized as meaning, the p-values, when calculated with methods I and II, were very shut to the fix limit of 0.05 (0.0744 and 0.0723). In any case, one must keep in mind that each of the three methods used to calculate the symmetry indexes gave different results, and in some cases, these led to varied conclusions. This was particularly true in the case of the spatial parameters, as reported earlier.
Another point that caught my attending during this study was that 16.3 weeks later prosthesis fitting, most patients withal wanted to employ the conventional SACH human foot, fifty-fifty though a meliorate outcome in terms of their gait profile could exist accomplished if they were to use the Greissinger pes. Only 4 of them agreed to change their prosthesis. However, the final conclusion to use one or the other type of prosthetic foot is not subjected only to the judgment of the rehabilitation professionals merely also to factors that the patients consider important, such every bit feeling of stability, feeling of safety, and cost. One factor related to toll is that since all the tested amputees were prescribed a SACH foot, their insurance companies would not cover any expenses connected to a different type of prosthetic foot. The subject'southward decisions could also reflect the finding that the symmetry indexes of the walking velocity and cadence were non significantly improved. Patient decisions may be based, in the early rehabilitation phase, on many issues and not gait profile lonely. However, this study did not include structured interviews with questions that cover major aspects of life that might be afflicted while living with a prosthesis (e.g., physical, physiological, and social) and why patients chose the foot they did. Therefore, a more justified caption cannot exist given.
This written report volition continue with more than subjects wearing various types of prostheses (including more modern ones) and following different treatment strategies, since the fitting of a prosthesis is an integral part of the treatment program. In addition, patient outcomes, such as stability and safety, combined with data obtained via structured interviews, will exist included, since selecting a prosthesis solely on the basis of gait analysis data is unwise.
CONCLUSION
For the examined group of traumatic correct-limb transtibial amputees fitted with a PTB prosthesis and tested in the early rehabilitation stage, the spatial and temporal parameters were significantly improved when the SACH pes was replaced past the Greissinger Plus foot. Meaning improvement was also observed for the symmetry indexes of the hip and ankle ROMs and the stance phase period. Nevertheless, no pregnant deviation was plant for the symmetry indexes of the human knee ROMs, cadency, and walking speed. In addition, for well-nigh of spatial parameters, the statistical significance varied considerably amid the 3 methods used for the analysis of symmetry.
ACKNOWLEDGmENTS
I wish to give thanks the bearding reviewers for their constructive advice and Mr. Jasdip Mangat for his assistance with the statistics.
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Submitted for publication April nine, 2003. Accepted in revised form April 22, 2003.
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Source: https://www.rehab.research.va.gov/jour/04/41/4/marinakis.html