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Çerezci-Duygu S, Erbahçeci F, Durutürk N, Ümit-Yemişçi O. The effects of spinal stabilization exercises on functional exercise capacity in individuals with transtibial amputation: A randomized trial. Prosthet Orthot Int 2024:00006479-990000000-00263. [PMID: 39259574 DOI: 10.1097/pxr.0000000000000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 07/29/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Optimization of mobility activities with spinal stabilization exercises and reducing spinal loads in individuals with transtibial amputation are recommended by researchers; however, the effect of spinal stabilization exercises on functional exercise capacity has not been investigated. OBJECTIVE This study aims to investigate the effect of spinal stabilisation exercises on functional exercise capacity in individuals with transtibial amputation. STUDY DESIGN Randomized controlled trial with concealed allocation, assessor blinding. METHODS Eighteen individuals with transtibial amputation were included. Conventional physiotherapy program was applied to individuals in control group, and spinal stabilization exercise training was applied to individuals in intervention group together with conventional physiotherapy program for 8 weeks. The primary outcome was maximal oxygen uptake during 6-Minute Stepper Test. The secondary outcomes were maximal energy expenditure, step count and fatigue during 6-Minute Stepper Test, perceived mobility level with prosthesis, and stabilization strength of deep spinal muscles. RESULTS In the within-group comparisons, the change in the functional exercise capacity, step count, and stabilization strength of deep spinal muscles were found to be statistically significant in both groups. In the between-group comparison, the changes in the functional exercise capacity, perceived mobility level, and stabilization strength of deep spinal muscles were found to be significant in favor of the group in which spinal stabilization exercises were applied. CONCLUSIONS Along with improvement in proximal control of movement, improvements were observed in some parameters that are indicative of physical capacity. Considering the described developments, exercise programs focused on spinal stabilization in individuals with amputation are becoming a serious alternative in clinical practice.
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Affiliation(s)
- Senay Çerezci-Duygu
- Department of Orthotics and Prosthetics, Gülhane Faculty of Health Sciences, University of Health Sciences, Ankara, Türkiye
| | - Fatih Erbahçeci
- Faculty of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Türkiye
| | - Neslihan Durutürk
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Başkent University, Ankara, Türkiye
| | - Oya Ümit-Yemişçi
- Department of Physical and Rehabilitation Medicine, Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Türkiye
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Wong CK, Youdan GA, Chihuri ST. Beyond exercise. Can application of manual therapy before exercise benefit a low functioning person with limb loss? A case study. J Man Manip Ther 2023; 31:383-389. [PMID: 36942674 PMCID: PMC10566409 DOI: 10.1080/10669817.2023.2192650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Most people with lower-limb loss (PLL) have musculoskeletal conditions and range-of-motion and muscle performance impairments. Such impairments limit potential for functional movement but can be reduced with manual therapy. Manual therapy, however, is rarely used for PLL. This case demonstrated how integrating manual therapy, exercise, and functional training led to lasting benefits for one low functioning PLL. CASE DESCRIPTION A 54-year-old woman more than 1 year after transtibial amputation due to peripheral artery disease presented with multiple comorbidities and yellow flags. Her function remained limited to the Medicare K-1 household walking level with slow gait speed <0.25 m/s. Treatment included four weekly sessions each beginning with manual therapy, followed by exercise and functional training. OUTCOMES After 1 month, performance-based strength, balance, walking speed, and physical activity increased. She advanced to the K-2 limited community walking level and maintained her functional level without further treatment after 3 months. DISCUSSION Improvements maintained without treatment expanded upon research that lacked follow-up and excluded K-1 level walkers. Marked improvement after only four sessions was noteworthy since exercise protocols require ≥4 sessions. CONCLUSION Manual therapy followed by exercise and functional training may optimize movement potential and contribute to improving strength, balance, gait, and physical activity among PLL.
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Affiliation(s)
- Christopher K. Wong
- Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Gregory A. Youdan
- Biobehavioral Sciences, Teachers College Columbia University, Bronx, NY, USA
| | - Stanford T. Chihuri
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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Davis-Wilson HC, Christiansen CL, Gaffney BMM, Lev G, Enabulele E, Hoyt C, Stoneback JW. Changes in lower extremity joint moments one-year following osseointegration in individuals with Transfemoral lower-limb amputation: A case series. Clin Biomech (Bristol, Avon) 2023; 104:105948. [PMID: 37043833 PMCID: PMC10988390 DOI: 10.1016/j.clinbiomech.2023.105948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Dissatisfaction with socket prostheses has led to the development of bone-anchored prostheses through osseointegration for people with transfemoral amputation, eliminating the need for a prosthetic socket. Gait deviations of transfemoral prosthesis users may be linked to increased risk of osteoarthritis, and it remains unknown if gait biomechanics change following osseointegration. The purpose of this case series was to evaluate the longitudinal changes in joint kinetics one year post-osseointegration in patients with transfemoral amputation during walking. METHODS Knee, hip, and trunk internal moments were evaluated in the prosthetic and intact limbs during walking at a self-selected speed in four participants pre- and one-year post-osseointegration. Longitudinal changes were quantified using the percent change (%∆) in peak joint moments between the two time points and Cohen's d (d) effect size was used to determine the magnitude of effect on joint moments during walking one year following osseointegration. FINDINGS Participants demonstrated increased peak knee extension moment (224 ± 308%∆, d = -1.31) in the prosthetic limb, while demonstrating reduced peak knee extension moment (-43 ± 34%∆, d = 1.82) in the intact limb post-osseointegration. Participants demonstrated bilateral reduction of peak hip extension moment (prosthetic: -22 ± 37%∆, d = 0.86; intact: -29 ± 10%∆, d = 1.27) and bilateral increase of peak hip abduction moment (prosthetic: 45 ± 40%∆, d = 1.20; intact: 23 ± 44%∆, d = 0.74) post-osseointegration. Participants demonstrated reduced peak trunk moments on both the prosthetic (extension: -31 ± 16%∆, d = 1.51; lateral flexion: -21 ± 20%∆, d = 0.63) and intact side (extension: -7 ± 22%∆, d = 0.38; lateral flexion: -22 ± 18%∆, d = 1.12) post-osseointegration. INTERPRETATION This case series suggests improved gait symmetry in individuals with transfemoral amputation one year following osseointegration, justifying future investigation.
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Affiliation(s)
- Hope C Davis-Wilson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurura, CO, USA.
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurura, CO, USA
| | - Brecca M M Gaffney
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, USA; Center for Bioengineering, Univeristy of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Guy Lev
- University of Colorado, Hospital, Aurora, CO, USA
| | - Eseosa Enabulele
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher Hoyt
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jason W Stoneback
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Wong CK, Vandervort EE, Moran KM, Adler CM, Chihuri ST, Youdan GA. Walking asymmetry and its relation to patient-reported and performance-based outcome measures in individuals with unilateral lower limb loss. Int Biomech 2022; 9:33-41. [PMID: 36414237 PMCID: PMC9704090 DOI: 10.1080/23335432.2022.2142160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gait asymmetry persists for most people after lower limb amputation and is associated with slower walking speeds. However, the relationship between gait asymmetry and patient-reported function remains unclear because they are not commonly assessed together. The purpose of this study was to determine relationships between gait asymmetries in people with lower limb loss and (1) patient-reported outcomes and (2) performance-based prosthetic functional measures. This cross-sectional analysis included nine people with unilateral limb loss aged 48.2 ± 13.1 years of mixed amputation etiology. Patient-reported outcomes included the Prosthetic Evaluation Questionnaire mobility subscale and Activities-specific Balance Confidence scale. Performance outcomes included the Berg Balance Scale and the 30-second sit-to-stand test. Walking performance measures included the 2-Minute Walk Test, during which APDM Opal sensors recorded spatiotemporal gait parameters, and daily step-counts from StepWatch4 activity monitors. The study found that the most asymmetric gait symmetry ratios (prosthetic-limb divided by intact-limb) could be attributed to prosthetic foot dorsiflexion-plantarflexion and rotation motion limitations: prosthetic-limb trailing double support (0.789 ± 0.052), toe-off (0.760 ± 0.068) and toe-out angle (0.653 ± 0.256). Single limb stance, and stance and swing phase durations were most strongly associated with balance and walking performance measures. Notably, no symmetry ratio was significantly associated with patient-reported prosthetic function (unadjusted Pearson correlation coefficients r < 0.50, P > 0.05). More gait symmetry was associated with better balance and walking performance but had no significant relationship with patient-reported function. Although achieving gait symmetry after lower limb loss is a common walking goal, symmetry was unrelated to the perception of functional mobility for people with lower limb loss.
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Affiliation(s)
- Christopher K. Wong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA,CONTACT Christopher K. Wong Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, 617 West 168th St, Georgian-311, New York, NY10032, USA
| | | | - Kayla M. Moran
- Program in Physical Therapy, Columbia University, New York, NY, USA
| | - Carly M. Adler
- Program in Physical Therapy, Columbia University, New York, NY, USA
| | - Stanford T. Chihuri
- School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
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Kablan N, Alaca N, Atalay ES, Tatar Y. Immediate effect of stair exercise on stiffness, tone, and pressure pain threshold of thoracolumbar fascia in individuals with lower limb amputation: a preliminary report. Prosthet Orthot Int 2022; 46:314-319. [PMID: 35333830 DOI: 10.1097/pxr.0000000000000120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 01/07/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adaptations to the use of prosthesis in individuals with a lower limb amputation may cause changes in lumbopelvic region structures during daily life activities. OBJECTIVE To investigate the effect of stair exercise on the stiffness, tone, and pressure pain threshold (PPT) of the thoracolumbar fascia (TLF) in individuals with unilateral lower limb amputation. DESIGN This is a prospective preliminary study. METHODS The study was conducted in Prosthetic Orthotic Centers in Istanbul. Syrian individuals with unilateral transtibial (n = 17) and transfemoral (n = 15) amputation who received prosthesis and rehabilitation services at the centers between February 2020 and December 2020 were included in the study. The subjects were instructed to ascend and descend a nine-step stair one at a time at their maximum possible speed. Measurements were made before and immediately after the stair exercise. Tone and stiffness of TLF was measured using myometer. PPT was measured using algometer. Low back pain was evaluated using numerical pain rating scale. RESULTS In the transfemoral amputation group, PPT measurements taken immediately after stair exercise were significantly decreased in both the amputated ( P = 0.001) and intact ( P = 0.021) sides, whereas significant reduction in stiffness when compared with the prestair levels was observed only at the intact side ( P = 0.019). The change in PPT values on the amputated side was significantly higher in individuals with transfemoral amputation than those in individuals with transtibial amputation ( P = 0.011). CONCLUSION The decrease in PPT values of TLF in the transfemoral amputation group was considered as a precursor sign for low back pain development. Thus, exercises and preventive rehabilitation programs targeting TLF may be needed, especially in this group.
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Affiliation(s)
- Nilüfer Kablan
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Medeniyet University, Istanbul, Turkey
| | - Nuray Alaca
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Emre Serdar Atalay
- Department of Physiotherapy and Rehabilitation, Faculty of Hamidiye Health Sciences, Health Sciences University, Istanbul, Turkey
| | - Yaşar Tatar
- Faculty of Sports Sciences, Marmara University, Istanbul, Turkey
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Gaffney BMM, Vandenberg NW, Davis-Wilson HC, Christiansen CL, Roda GF, Schneider G, Johnson T, Stoneback JW. Biomechanical compensations during a stand-to-sit maneuver using transfemoral osseointegrated prostheses: A case series. Clin Biomech (Bristol, Avon) 2022; 98:105715. [PMID: 35839740 DOI: 10.1016/j.clinbiomech.2022.105715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/24/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with transfemoral amputation and socket prostheses are at a heightened risk of developing musculoskeletal overuse injuries, commonly due to altered joint biomechanics. Osseointegrated prostheses, which involve direct anchorage of the prosthesis to the residual limb through a bone anchored prosthesis, are a novel alternative to sockets yet their biomechanical effect is largely unknown. METHODS Four patients scheduled to undergo unilateral transfemoral prosthesis osseointegration completed two data collections (baseline with socket prosthesis and 12-months after prosthesis osseointegration) in which whole-body kinematics and ground reaction forces were collected during stand-to-sit tasks. Trunk, pelvis, and hip kinematics, and the surrounding muscle forces, were calculated using subject-specific musculoskeletal models developed in OpenSim. Peak joint angles and muscle forces were compared between timepoints using Cohen's d effect sizes. FINDINGS Compared to baseline with socket prostheses, patients with osseointegrated prostheses demonstrated reduced lateral trunk bending (d = 1.46), pelvic obliquity (d = 1.09), and rotation (d = 1.77) toward the amputated limb during the stand to sit task. This was accompanied by increased amputated limb hip flexor, abductor, and rotator muscle forces (d> > 0.8). INTERPRETATION Improved lumbopelvic movement patterns and stabilizing muscle forces when using an osseointegrated prosthesis indicate that this novel prosthesis type likely reduces the risk of the development and/or progression of overuse injuries, such as low back pain and osteoarthritis. We attribute the increased muscle hip muscle forces to the increased load transmission between the osseointegrated prosthesis and residual limb, which allows a greater eccentric ability of the amputated limb to control lowering during the stand-to-sit task.
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Affiliation(s)
- Brecca M M Gaffney
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America; Center for Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America.
| | - Nicholas W Vandenberg
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America
| | - Hope C Davis-Wilson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America; VA Eastern Colorado Healthcare System, Aurora, CO, United States of America
| | - Cory L Christiansen
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America; VA Eastern Colorado Healthcare System, Aurora, CO, United States of America
| | - Galen F Roda
- Department of Mechanical Engineering, University of Colorado Denver, Denver, CO, United States of America
| | - Gary Schneider
- University of Colorado Hospital, Aurora, CO, United States of America
| | - Tony Johnson
- University of Colorado Hospital, Aurora, CO, United States of America
| | - Jason W Stoneback
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
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Trunk Muscle Characteristics: Differences Between Sedentary Adults With and Without Unilateral Lower Limb Amputation. Arch Phys Med Rehabil 2021; 102:1331-1339. [PMID: 33684366 DOI: 10.1016/j.apmr.2021.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/06/2021] [Accepted: 02/03/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The primary purpose of this study was to compare trunk muscle characteristics between adults with and without unilateral lower limb amputation (LLA) to determine the presence of modifiable trunk muscle deficits (ie, impaired activity, reduced volume, increased intramuscular fat) evaluated by ultrasonography (US) and magnetic resonance imaging (MRI). We hypothesized that compared with adults without LLA (controls), individuals with transfemoral or transtibial LLA would demonstrate reduced multifidi activity, worse multifidi and erector spinae morphology, and greater side-to-side trunk muscle asymmetries. DESIGN Cross-sectional imaging study. SETTING Research laboratory and imaging center. PARTICIPANTS Sedentary adults (n=38 total) with LLA (n=9 transfemoral level; n=14 transtibial level) and controls without LLA (n=15). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We examined bilateral multifidi activity using US at levels L3/L4-L5/S1. MRI was performed using 3-dimensional quantitative fat-water imaging; bilateral L1-L5 multifidi and erector spinae were manually traced, and muscle volume (normalized to body weight) and percentage intramuscular fat were determined. Between-group and side-to-side differences were evaluated. RESULTS Compared with adults without LLA, participants with LLA demonstrated reduced sound-side multifidi activity; those with transfemoral LLA had larger amputated-side multifidi volume, whereas those with transtibial LLA had greater sound- and amputated-side erector spinae intramuscular fat (P<.050). With transfemoral LLA, side-to-side differences in erector spinae volume, as well as multifidi and erector spinae intramuscular fat, were found (P<.050). CONCLUSIONS Impaired trunk muscle activity and increased intramuscular fat may be modifiable targets for intervention after LLA.
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Harper NG, Wilken JM, Neptune RR. Muscle Contributions to Balance Control During Amputee and Nonamputee Stair Ascent. J Biomech Eng 2020; 142:121007. [PMID: 32469051 DOI: 10.1115/1.4047387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Indexed: 11/08/2022]
Abstract
Dynamic balance is controlled by lower-limb muscles and is more difficult to maintain during stair ascent compared to level walking. As a result, individuals with lower-limb amputations often have difficulty ascending stairs and are more susceptible to falls. The purpose of this study was to identify the biomechanical mechanisms used by individuals with and without amputation to control dynamic balance during stair ascent. Three-dimensional muscle-actuated forward dynamics simulations of amputee and nonamputee stair ascent were developed and contributions of individual muscles, the passive prosthesis, and gravity to the time rate of change of angular momentum were determined. The prosthesis replicated the role of nonamputee plantarflexors in the sagittal plane by contributing to forward angular momentum. The prosthesis largely replicated the role of nonamputee plantarflexors in the transverse plane but resulted in a greater change of angular momentum. In the frontal plane, the prosthesis and nonamputee plantarflexors contributed oppositely during the first half of stance while during the second half of stance, the prosthesis contributed to a much smaller extent. This resulted in altered contributions from the intact leg plantarflexors, vastii and hamstrings, and the intact and residual leg hip abductors. Therefore, prosthetic devices with altered contributions to frontal-plane angular momentum could improve balance control during amputee stair ascent and minimize necessary muscle compensations. In addition, targeted training could improve the force production magnitude and timing of muscles that regulate angular momentum to improve balance control.
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Affiliation(s)
- Nicole G Harper
- Walker Department of Mechanical Engineering, The University of Texas at Austin, 204 E. Dean Keeton Street, Stop C2200, Austin, TX 78712
| | - Jason M Wilken
- Extremity Trauma and Amputation Center of Excellence, Center for the Intrepid, Brooke Army Medical Center, Ft. Sam Houston, TX 78234; Department of Physical Therapy and Rehabilitation Science, The University of Iowa, 1-252 Medical Education Building, Iowa City, IA 52240
| | - Richard R Neptune
- Walker Department of Mechanical Engineering, The University of Texas at Austin, 204 E. Dean Keeton Street, Stop C2200, Austin, TX 78712
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Simoneau-Buessinger É, Jakobi JM, Toumi A, Mathys A, Bassement J, Barbier F, Leteneur S. Does Unilateral Lower Limb Amputation Influence Ankle Joint Torque in the Intact Leg? Arch Phys Med Rehabil 2019; 100:1259-1266. [DOI: 10.1016/j.apmr.2018.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/05/2018] [Accepted: 12/12/2018] [Indexed: 01/11/2023]
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