䢇

Case Report

Rehabilitation for Balance and

Ambulation in a Patient With
Attention Impairment Due to
Intracranial Hemorrhage
Background and Purpose. The purpose of this case report is to describe
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physical therapy to improve the balance and ambulation of a 16-year-

old patient with attention impairment following intracranial hemor-
rhage. Case Description. The patient initially had frequent losses of
balance, especially in distracting environments, due in part to
decreased attention. He was managed with a balance and ambulation
training program that incorporated the principles of cognitive reha-
bilitation for attention impairments. Outcomes. Following 11 weeks of
outpatient therapy, the patient returned to independent ambulation at
school without losses of balance. Discussion. Research is needed to
determine the interaction between balance and attention in patients
with brain injury and effective treatment for patients with decreased
balance related to attention impairments. [Tappan RS. Rehabilitation
for balance and ambulation in a patient with attention impairment due
to intracranial hemorrhage. Phys Ther. 2002;82:473– 484.]

Key Words: Ambulation, Attention, Balance, Cognition.

Rachel S Tappan
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Physical
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P
atients with central nervous system disorders
frequently require physical therapy to improve
balance and ambulation. Current physical ther-
apist practice for the management of central
nervous system disorders largely emphasizes manage-
ment of the motor and sensory impairments affecting
balance and ambulation.1(pp372–381) However, patients
with central nervous system disorders frequently demon-
strate cognitive impairments that also affect mobility,
especially in the home or community settings and during
activities of daily living.2– 4 I believe that unless physical
and cognitive impairments are addressed, functional
limitations in mobility may persist.
Patients with central nervous system disorders often have
impairments in attention. Various definitions and theo-
ries of attention exist. In general, attention theories
propose that a pool or pools of attentional or informa-
tion processing resources (attentional capacity) exist
that can be allocated to activities at any given time.
Different activities draw from these pools in varying
amounts. When the information-processing require-
ments of an activity or activities interfere with each other
or exceed the attentional capacity, a decrease in perfor-
mance results.5,6
Using this framework for attention, researchers have
demonstrated that postural control and motor tasks
require attentional demands, which increase with the
complexity of the task.7–11 Lajoie et al10 found that when
subjects without known attention or balance impair-
ments were asked to respond to an auditory stimulus
during a simultaneous motor task (ie, sitting, walking),
their reaction times to the auditory stimulus increased
with the complexity of the motor task. Andersson et al7
examined the relationship between mental activity and
postural control. In this study, subjects performed a
mental task with and separate from 2 balance tasks
(standing on a moving platform with eyes open and with
eyes closed). Subjects without known attention or bal-
ance impairments demonstrated increases in anteropos-
terior postural sway when each of the balance tasks was
performed simultaneously with the mental task com-
pared with anteroposterior postural sway on the balance
tasks alone. The accuracy of the subjects’ mental task
performance decreased when the mental task and the
balance tasks were performed simultaneously compared
RS Tappan, PT, is a physical therapist at the Rehabilitation Institute of Chicago, Chicago, Ill. She was a physical therapist at CRS Rehabilitation
Specialists, Skokie, Ill, when this case report was written. Address all correspondence to Ms Tappan at 4704 N Rockwell St, Chicago, IL 60625 (USA)
(Tapler@earthlink.net).
The author acknowledges the support of Alisa RG Halfman, MHS, CCC-SLP; Dena Kolosieke, OTR/L, MS; Ethan Stoller; and Georgia Tappan for
their consultation (including review of manuscript before submission) on this project. The author also acknowledges the support of Beth Connelly,
PT, MPT, who was a student at Northwestern University and participated in the treatment of this patient as part of her internship at CRS
Rehabilitation Specialists.
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Patients with central nervous system
disorders frequently demonstrate
cognitive impairments that also affect
mobility.
with their accuracy on the mental task when they were
sitting. Together, the results of these studies7,10 suggest
that complex balance tasks require attentional resources
in people without known problems with attention.
Although research on the effect of impaired attention
on balance in patients after acquired brain injury is
limited, the results of several studies support a relation-
ship between attention and balance in these patients.
When the information processing system of the brain is
impaired following brain injury, attentional capacity is
decreased. This decreased attentional capacity was dem-
onstrated by Van Zomeren and Deelman,12 who found
that patients with head injury had an increased reaction
time during a reaction-time task and that the reaction
time was proportional to the duration of coma after
injury. Patients with attention impairments after brain
injury could be expected to demonstrate decreased
performance on a balance task if the attentional require-
ments at the time of the task exceed the reduced
attentional capacity. In one study of subjects at least 3
months after mild traumatic brain injury (ie, subjects
who had sustained direct head trauma with subsequent
impaired consciousness or amnesia and with the lowest
Glasgow Coma Scale scores ranging from 13 to 15 after
hospitalization), researchers found that poor perfor-
mance on the Symbol-Digit Substitution Test (which
tests attention and mental speed) was associated with
decreased postural stability as measured during quiet
standing and weight shifting on a force platform.13
The balance tasks performed in these studies tended to
be clinical tests of balance rather than “real-life” tasks;
therefore, it is difficult to draw definitive conclusions
regarding the relationship between attention impair-
ments and balance during functional tasks such as
walking across the street at a busy intersection. The
studies do suggest, however, that people with impair-
ments in attention tend to demonstrate decreased pos-
tural stability, especially during complex mobility tasks
that require them to attend to multiple stimuli (eg, walking
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Table.
Definitions of the Five Categories of Attention14
Type of
Attention Definition
Focused The ability to process and respond to specific
information or input.
Sustained The ability to perform an activity continuously
over a period of time.
Selective The ability to perform an activity in the
presence of distracting stimuli, including
ignoring irrelevant information.
Alternating The ability to shift the focus of attention
beween multiple stimuli.
Divided The ability to respond to multiple stimuli
simultaneously.
in the grocery store while carrying a bag of sugar and
looking for the next item).
Patients with impaired attention, especially impaired
divided attention (see Table for definitions of types of
attention),14 may also be likely to have balance problems
due to difficulty performing a task while simultaneously
processing and using feedforward information to avoid
obstacles. Patients with decreased divided attention, for
example, may not notice spills on the floor of the
grocery store because they are attending to the search
for food items. These patients may be likely to fall after
stepping on a wet floor. This possibility is supported by
one study that showed that avoiding obstacles places an
attentional demand on the information-processing sys-
tem. In that study, subjects stepped over obstacles with
and without performing a secondary task (responding
vocally when specific lights were turned on).15 Both
young and older adults without known problems with
attention contacted the obstacles more often when their
attention was divided between stepping over the obsta-
cles and performing the secondary task. In patients with
a limited attentional capacity, the attention required to
avoid obstacles while performing a secondary task would
be more likely to exceed their attentional capacity. Thus,
their ability to process all relevant information simulta-
neously and produce a rapid, accurate response to avoid
obstacles would be decreased. The implications of
impairments in attention are especially important when
we consider that many patients with central nervous
system disorders also have impairments in motor control
and balance.
The physical therapy literature offers limited guidance
for addressing attention impairments as they relate to
mobility. In order to compensate for attention impair-
ments in patients who are easily distracted, some sources
recommend decreasing distractions in the environment
during physical therapy.16,17 Others recommend initially
Physical
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decreasing distractions in the environment and then
increasing distractions as the patient improves.18
The neuropsychology and cognitive rehabilitation liter-
ature supports the effectiveness of both compensatory
techniques and attention training for the management
of attention impairments.19 –24 Compensatory techniques
for attention are techniques in which patients use strat-
egies to improve performance on a given task despite
continued impairment. Determining which strategy to
use for an individual patient depends on the environ-
ment in which the patient must function and on the
patient’s specific combination of cognitive and physical
impairments.19 Examples of compensatory techniques
for decreased attention include decreasing the number
of distractions in the environment, double-checking
work for accuracy, positive reinforcement of attentive
behavior,25 and using self-instructional techniques in
which patients repeat statements instructing them-
selves to focus their attention and then repeat infor-
mation presented to them subvocally to maintain
concentration.26
The second type of cognitive rehabilitation for attention
is attention training, which uses cognitive exercises to
challenge impairments in the 5 types of attention
(Table), increasing the demands of the exercises in a
controlled manner.19 –22,24 The effectiveness of attention
training continues to be a topic of study. Some stud-
ies20 –24 demonstrated improvement in attention in sub-
jects with brain injury who received cognitive retraining
for attention compared with subjects who did not receive
cognitive retraining for attention. These studies, how-
ever, differed in the outcome measures of attention that
showed improvement—measures of neuropsychological
testing for attention,20 –23 measures of attention behavior
(ie, attending to a therapy task),24 or measures of
independent living or employment.21 Overall, the stud-
ies support the effectiveness of attention training that:
(1) incorporates different levels of complexity and a
variety of stimuli and response demands (ie, using
different modalities such as visual and auditory stimu-
li),19 –24 (2) uses training tasks that closely relate to the
outcome measure,21,22 and (3) provides subjects with
feedback on performance or results.20,27
Although improvement in outcome measures has been
shown for subjects with moderate to severe attention
impairments,20,28 no single study has addressed which
patients will benefit most from attention training. How-
ever, the Cognitive Rehabilitation Committee of the
American Congress of Rehabilitation Medicine has
issued practice guidelines in a review article that com-
bined the results from several studies.28 In these practice
guidelines, attention training is “recommended during
postacute rehabilitation for persons with TBI [traumatic
Tappan . 475
 brain injury] or stroke.”28(p1610) This guideline was
supported by several single studies as well.18,19 For
patients in the acute/inpatient rehabilitation phase,
evidence was insufficient to support attention training
over more general cognitive rehabilitation and spon-
taneous recovery.28,29
In general, attention training techniques attempt to
improve attention by repeated practice. However, theo-
ries to provide the rationale for treatment and the
process by which treatments bring about improvement
are not well delineated. Several theories about the
process by which cognitive rehabilitation in general
leads to recovery of function have been proposed. One
theory suggests that the brain reorganizes, allowing
undamaged areas to take over the responsibilities of the
damaged areas.30 Another theory suggests that recovery
of function occurs when the brain uses its remaining
functional capacities to achieve behavioral goals by dif-
ferent routes.30
The purpose of this case report is to describe how
cognitive rehabilitation techniques were integrated into
an interdisciplinary treatment plan for a patient with a
brain injury whose decreased attention and balance
limited his ability to ambulate independently in a com-
munity environment.
Case Description
Examination
History. The patient was a 16-year-old male with a
diagnosis of intracranial hemorrhage secondary to
arteriovenous malformation (AVM). His subsequent
medical history included placement of a ventriculoperi-
toneal shunt (VPS) after the initial hemorrhage,
repeated intracranial hemorrhage with 2 episodes of
generalized seizures 1 month after the initial hemor-
rhage, embolization of the AVM 2 months after the
initial hemorrhage, hydrocephalus causing midline shift
and mass effect 4 months after the original hemorrhage
with replacement of the original VPS, and gall bladder
surgery 8 months after the initial hemorrhage. Because
of time constraints in the clinic, results of any diagnostic
testing done to determine the specific areas of the brain
involved in the hemorrhages were not sought by the
therapy team. Six months after the initial hemorrhage,
immediately following acute hospitalization and a
6-week stay in an inpatient rehabilitation unit, the
patient was admitted for outpatient rehabilitation. In
addition to physical therapy services, the patient also
received speech-language therapy, occupational ther-
apy, social work, and nursing services. The patient’s
outpatient rehabilitation program was overseen by a
physiatrist.
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Prior to the hemorrhage, the patient was a junior in high
school with average academic performance and no rel-
evant prior medical history. He spent his leisure time
“hanging out with friends” and was a member of his high
school football team. The patient and his grandmother
reported that following his discharge from the hospital,
he demonstrated unsteadiness while walking at home—
including one fall. Their goals were improving balance,
returning to school, and participating in after-school
sports as a line coach for his high school football team
(his physician had restricted him from playing football
because of the risk of further brain injury).
Physical therapy tests and measures. Observational gait
analysis was performed as the patient walked more than
30.5 m (100 ft) at a self-selected pace in a nondistracting
environment. He had right knee hyperextension in
approximately 30% of his steps during the right stance
phase and a positive Trendelenburg sign bilaterally. No
losses of balance were noted during this gait analysis.
(Unless otherwise noted, a loss of balance refers to pos-
tural instability requiring stepping or upper-extremity
balance strategies or physical assistance from another
person to prevent a fall.) When the patient walked for
61 m (200 ft) in a more distracting environment (an area
of the clinic with other people, equipment and furniture
placed around the room, and pictures on the walls), he
was distracted 4 times, as evidenced by head turning and
gazing toward the distraction, followed by losses of
balance requiring stepping responses to prevent a fall.
The losses of balance decreased to 1 to 2 incidents over
a 61-m (200-ft) distance when verbal and tactile cues
were provided to help focus the patient’s attention on
upcoming obstacles (eg, a change in surface from tile to
carpeting). The patient also frequently stopped walking
when conversation was initiated. The tendency to “stop
walking when talking” in elderly people has been shown
to correlate with a higher incidence of falls.31 In
instances when he did not stop walking while carrying on
a conversation, the patient often lost his balance. The
patient required standby assistance when walking in
familiar, indoor settings and contact guard assistance
when walking in more distracting environments, such as
outside and at church, because of frequent loss of
balance.
On balance assessment in standing, the patient had
decreased balance compared with the level of balance
that would be expected in a typical person of his age.
The patient was unable to perform tandem gait, losing
his balance laterally with each step (19 steps over 6.1 m
[20 ft] total) and requiring physical assistance with each
step to recover balance and prevent falls. Several studies
have investigated the relationship between tandem gait
speed and impaired postural control and gait32,33; how-
ever, the patient was not even able to perform the
Physical Therapy . Volume 82 . Number 5 . May 2002

activity. The patient was unable to maintain one-legged
stance or tandem stance bilaterally for longer than 2
seconds. In a study of 184 subjects without balance
deficits between 20 and 79 years of age, all subjects
under 40 years of age (n⫽62) were able to maintain
one-legged stance for 30 seconds.34 Together, the results
of these tests indicated a balance impairment.
Manual muscle testing also was performed to help
determine whether weakness was playing a role in the
patient’s losses of balance during gait. The manual
muscle tests were performed as described by Kendall et
al35 and ranged from 3-/5 to 4⫹/5 bilaterally in the hip,
knee, and ankle musculature, with increased time
required (4 –5 seconds) for full muscle activation with all
manual muscle testing. Wadsworth et al36 found that the
intrarater reliability of data obtained with manual mus-
cle testing for various upper- and lower-extremity mus-
cles was good, with test-retest reliability coefficients
ranging from .63 to .98 (P ⬍.05) and with the paired t
test revealing no significant test-retest mean differences
between manual muscle tests (P ⬎.05). Manual muscle
testing has some content validity in that it measures the
ability of the muscles to generate torque.37 Its predictive
validity, however, has been debated in the literature.38
The appropriateness of manual muscle testing in
patients with brain lesions also has been debated in the
literature.38,39 Some of the arguments against the use of
manual muscle testing in these patients include: (1) spastic
antagonists may be opposing the muscles being tested,
(2) muscles may be stronger when acting in a mass
pattern than in the muscle test, and (3) apparent
weakness in muscles may actually be due to sensory
impairments.39 However, in this case, the patient had
minimal hypertonicity in his lower extremities, no ten-
dency to move in mass patterns on observation, and
intact sensation. As measured by the Modified Ashworth
Scale, his lower-extremity muscle tone was normal,
except for a score of 1⫹ in both ankle plantar flexors
and knee flexors.
Bohannon and Smith40 reported good interrater reliabil-
ity for the Modified Ashworth Scale when they found
that 2 raters agreed on 86.7% of their ratings of elbow
flexor spasticity and that these ratings were significantly
correlated (P ⬍.001). Blackburn et al41 found that the
intrarater reliability for the Modified Ashworth Scale was
acceptable, with 73.3% agreement, when used on the
lower extremities of subjects with stroke. The Modified
Ashworth Scale may have face validity, because it appears
to measure spasticity by assigning a grade to resistance
felt on passive stretching.40 Further studies examining
both reliability and validity are needed before a deter-
mination of the Modified Ashworth Scale’s validity can
be made. The patient’s bilateral lower-extremity range of
Physical
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motion was normal on goniometric measurement dur-
ing active and passive movement, and he performed the
isolated movements required in active range of motion
testing without difficulty (ie, no mass patterns were
observed). Active and passive range of motion were
measured with a universal goniometer as described by
Norkin and White.42 Intratester reliability of goniomet-
ric measurements of lower-extremity passive range of
motion has been found to be good, with intraclass
correlation coefficients (ICCs) of .91 and .99 for knee
extension and flexion, respectively,43 and ICCs of .86
and .90 for ankle plantar flexion and dorsiflexion,
respectively.44 Limited studies of the validity of gonio-
metric measurements are available, although Gogia et
al45 found good validity (ICC⫽.98 –.99) when goniomet-
ric measurements of the knee were compared with
measurements of the joint angle of a roentgenogram.
Sensation was tested as described by Schmitz46 and
found to be intact to light touch, position sense, and
kinesthesia in both lower extremities. Therefore, the
main arguments against using manual muscle testing in
patients with brain lesions are not applicable to this
patient’s case.
Occupational therapy and speech-language pathology
tests and measures. The assessments of the occupa-
tional therapist and the speech-language pathologist
indicated that the patient’s primary cognitive impair-
ment was decreased attention, including decreased sus-
tained attention, divided attention, alternating atten-
tion, and selective attention. The occupational therapist
and the speech-language pathologist based their assess-
ments of the patient’s attention on testing and on
observation of his behavior. To test for attention impair-
ment, the speech-language pathologist administered
portions of the Word Sequences Subtest of the Detroit
Tests of Learning Aptitude.47 The Word Sequences
Subtest consists of 30 series of unrelated words from 3 to
8 words long, which are read to the subject. The subject
then repeats each series of words back to the tester. In
this case, the speech-language pathologist read only 17
of the 30 series of words to the patient, with the series
ranging from 3 to 7 words long. Although the patient
demonstrated an attention impairment based on the
judgment of the speech-language pathologist, specific
data from this ad hoc version of the Word Sequences
Subtest cannot be shown to be reliable or valid. The
occupational therapist administered a revised version of
the Trail Making Test, Part B. The Trail Making Test,
Part B, is a test that measures attention as well as other
abilities such as visual tracking.48,49 In this test, 25 circles
are spread over a page and labeled with numbers (1–13)
and letters (A-L). The subject draws a line to connect the
circles in order, alternating between numbers and letters
(ie, 1, A, 2, B, 3, C, and so on).48 The test that the
occupational therapist administered in this case con-
Tappan . 477
 sisted of 22 circles placed along the perimeter of a larger
circle and labeled with numbers (1–11) and letters (A-K)
in random order. The patient then drew a line connect-
ing the circles in order, alternating between letters and
numbers. There are no reliability or validity studies
available for this test. When observed, the patient dem-
onstrated behavior consistent with an attention impair-
ment. He attended to a given task for no more than 1 to
2 minutes at a time, required frequent redirection to the
task, was easily distracted by his environment, and had
difficulty shifting from one task to another. He also
demonstrated impairments in auditory comprehension
(understanding spoken information) when answering
questions about a story that was read to him and
impaired organization skills when organizing a shopping
list; however, these impairments were judged to be
secondary to his attention deficits. For example, the
patient had difficulty answering questions about a story
because he was unable to attend to the story while it was
being read to him.
The patient also demonstrated mild impairment in
visual perception, which is the ability to attend to
appropriate visual stimuli and to integrate and interpret
them.50 Testing for visual perception was done by the
occupational therapist with the Motor-Free Visual Per-
ception Test (MVPT).51 The MVPT had good test-retest
reliability (r ⫽.81),51 and it was found to demonstrate
construct validity when subjects’ scores on the MVPT
had higher correlations with their visual-motor test
scores than with their achievement and intelligence
scores.51 Because vision plays a role in maintaining
postural stability,52 this mild visual impairment may have
contributed to the patient’s balance impairment. How-
ever, because it was a mild impairment, it was probably
not a major factor in the patient’s frequent losses of
balance during gait.
Evaluation
Based on examination results, the interdisciplinary treat-
ment team hypothesized that the factors contributing to
the patient’s losses of balance were his impairments in
balance, attention, strength, and vision. We believed that
the combined attentional requirements of walking,
maintaining balance, and interacting visually and ver-
bally with the environment exceeded his capacity and
resulted in decreased performance. This hypothesis was
supported by the observations that the patient had more
frequent losses of balance while walking in distracting
environments, that he frequently diverted his attention
to a distraction (eg, turning his head to look at the
distraction) immediately before losing his balance, and
that his losses of balance that required a stepping
response were less frequent when verbal cues were
provided to focus his attention on upcoming obstacles.
Although the patient’s lower-extremity weakness and
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visual-perceptual impairment may have been factors in
his decreased stability, we did not believe that they
contributed to his frequent losses of balance as much as
his balance and attention impairments. By discharge, the
patient would need to maintain his balance during
complex ambulation tasks (eg, carrying a book bag and
talking) in the presence of multiple distractions in order
to return to school and the community. Ambulating
safely with distractions in a community environment
became the primary goal of physical therapy.
The patient was seen in an interdisciplinary, day reha-
bilitation setting 3 hours per visit, 3 times per week, for
11 weeks of treatment. The patient engaged in one
50-minute physical therapy session per visit for all but 4
visits, when he was seen for a 2-hour session. The 4
longer treatment sessions were scheduled when more
time was required for interventions such as family train-
ing and community outings. The remainder of the time
(1–2 hours per visit) was divided between sessions with
the occupational therapist and the speech-language
pathologist. The patient was seen by the social worker for
1-hour sessions once every 1 to 3 weeks. The treatment
course was interrupted after 10 weeks of treatment for
approximately 2 weeks when the patient was hospitalized
and recovering from gall bladder surgery. The frequency
of 3 times per week was chosen in order to provide
services intensive enough to facilitate improvement
while still allowing the patient enough time outside of
therapy to practice the skills learned in therapy. The
duration was chosen to allow time for improvement
adequate for resumption of previous activities and to
coordinate with re-entry to school at the beginning of a
semester.
Intervention
To address the patient’s losses of balance resulting from
distraction, the patient’s physical therapy plan of care
was designed to include attention training and compen-
satory techniques for attention within the context of gait
and balance training. Initially, the use of several com-
pensatory techniques enabled the patient to ambulate
with fewer losses of balance. For instance, a quiet,
nondistracting environment was provided for the patient
to practice ambulation and balance tasks such as walking
or reaching overhead for objects. In addition, if I
detected signs of distraction—such as the patient turn-
ing his head to a stimulus or initiating discussion about
an irrelevant topic—I provided verbal or tactile cues to
refocus his attention on the task. During the first 2
physical therapy sessions, while using these compensa-
tory techniques, the frequency of loss of balance
decreased from 4 events to 1 or 2 over 61 m (200 ft) of
ambulation in a nondistracting environment. Initially,
the patient’s family was also instructed to cue the patient
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to refocus his attention on his balance and ambulation
as needed outside of therapy.
After the patient walked in this nondistracting environ-
ment without loss of balance during the first 2 physical
therapy sessions, physical therapy tasks progressed to
include attention training. According to the theory that
balance tasks of increasing complexity require increas-
ing amounts of attention,10 attention training was imple-
mented by gradually increasing the complexity of ambu-
lation tasks and balance exercises while manipulating
the environment to increase attention demand. The 3
aspects of effective attention training noted earlier were
integrated into this modified approach: (1) training
tasks that closely relate to the desired outcome (ambu-
lation in all environments without falls) were chosen,21,22
(2) different levels of complexity and multimodal stimuli
and response demands were incorporated into treat-
ment activities,19 –24 and (3) feedback was provided.20,27
The first aspect of an effective attention training pro-
gram was incorporated by choosing training tasks that
were closely related to the desired outcome. Ambulation
and balance exercises as well as environmental modifi-
cations were tailored to patient-specific criteria. This
patient’s goal was to return to school; therefore, envi-
ronmental factors such as conversational distractions
and crowds were introduced to simulate tasks such as
walking in the school corridors. Ambulation exercises
such as walking around obstacles and carrying books
while walking also were emphasized because this would
be the most physically challenging aspect of returning to
school (eg, compared with sitting at a desk). In another
patient, other modifications may have been made based
on that patient’s goals (such as walking while reading if
the patient were a mail carrier).
The second aspect of an effective attention training
program was incorporated by creating a structured
framework of treatment activities that required different
levels of complexity and multimodal stimuli and
response demands. The level of complexity was adjusted
by making balance and ambulation tasks more challeng-
ing to increase the attention required to perform the
tasks. Environmental modifications also were made to
augment both the amount of attention and the level of
attention (Table) required to perform the treatment
tasks. Further, the progressions in ambulation tasks and
the environmental modifications incorporated varied
stimulus and response demands. For example, during
the course of treatment, the patient received auditory,
visual, and tactile stimuli. He also produced varied
responses, including verbal and motor responses. These
progressions increased the demands of the attention
system and, thus, were hypothesized to bring about an
improvement in balance, ambulation, and attention.
Physical
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The following environmental modifications were intro-
duced and progressed as indicated:
• Increasing auditory input during ambulation: Ini-
tially, irrelevant auditory stimuli were introduced,
such as people conversing or the radio playing near
the patient, to increase the selective and sustained
attention required by the patient to focus on ambu-
lation and prevent a loss of balance. Once the
patient walked in the presence of a variety of
irrelevant auditory distractions without loss of bal-
ance, he received auditory input relevant to him,
such as conversation directed to the patient as he
walked. The complexity of this conversation was
increased as he progressed. That is, once the
patient responded to a simple greeting in a quiet
environment without loss of balance (after approx-
imately 2 weeks of outpatient physical therapy),
conversation was expanded to include complex
questions about school. These relevant auditory
stimuli required the patient to use alternating atten-
tion to switch his focus as needed between walking
and talking and to use divided attention to attend
simultaneously to auditory input and ambulation in
order to prevent a loss of balance.
• Increasing the number of obstacles in the environ-
ment during ambulation: The patient ambulated in
increasingly cluttered environments. In less-
cluttered environments, the emphasis was on selec-
tive attention—the patient had to decide what stim-
uli to focus on intermittently. In more-cluttered
environments, the emphasis was on divided atten-
tion—the patient had to attend constantly to avoid-
ing obstacles and to planning his route as he
walked. For example, after 2 physical therapy ses-
sions, the patient could walk in an open gym
without loss of balance (using selective attention to
avoid obstacles); he then progressed to walking in a
kitchen or dining room with several tables, chairs,
countertops, appliances, objects on the floor, and
narrow walkways (using divided attention to plan his
route and avoid obstacles).
• Changing the characteristics of the walking sur-
faces: As the patient transitioned from walking on
tile to walking on less-even surfaces such as carpet,
he had to attend to the differences in walking
surface (selective attention) and adjust his walking to
accommodate the change. When the patient ini-
tially began treatment, he frequently had a loss of
balance. This required both a stepping strategy and
an upper-extremity strategy when crossing a thresh-
old between tile and carpet if he was not visually
attending to the change in surface. Once the
patient consistently negotiated a threshold between
Tappan . 479
 tile and carpet in a nondistracting environment
without loss of balance (after approximately 3
weeks of outpatient physical therapy), he practiced
negotiating larger changes in surface with more
environmental distractions (eg, negotiating thresh-
old between sidewalk and grass surface outside).
• Adding motion to the environment: Adding motion
to the environment made the patient attend both to
the state of his immediate environment and to
changes in the environment as they occurred or
before they occurred (selective attention, alternating
attention, and divided attention). Examples of tasks
that were used to integrate motion into the
patient’s environment included introducing exter-
nal perturbations (eg, another person bumping
into the patient), walking in a crowd of people, and
using escalators. As the complexity of the situation
increased (eg, from bumping into the patient in an
open gym without other people in the room to
bumping into the patient in a crowded mall), the
emphasis shifted from selective attention and alternat-
ing attention to divided attention where the patient
had to focus on walking and distractions at the
same time. Small external perturbations were intro-
duced after 1 week of physical therapy, when the
patient was able to maintain balance while walking
in open, nondistracting areas without a loss of
balance. Motion in the environment was progres-
sively increased as the patient improved. For exam-
ple, the patient used escalators in a distracting
environment (a bookstore) during a physical ther-
apy session after 10 weeks of physical therapy.
These techniques for increasing attention demands by
modifying the environment were introduced and pro-
gressed concurrently. Progression occurred when the
patient performed a given task without loss of balance.
In addition, practice of each activity occurred in variable
patterns; that is, the treatment activities were alternated
within each therapy session. As a result, the time frame
for each progression is approximate because the
patient’s ability to respond to each environmental mod-
ification depended on other variables in the environ-
ment. For example, although the patient was able to
respond to a simple greeting during ambulation in an
open, nondistracting environment without loss of bal-
ance after 2 weeks of physical therapy, his performance
tended to decrease if he was in a more-cluttered envi-
ronment. Therefore, specific time frames are difficult to
determine. Throughout the patient’s 11 weeks of physi-
cal therapy, these environmental modifications were
progressed and combined (eg, walking in a cluttered
environment over uneven surfaces while having a discus-
sion about physics) to continue to increase the atten-
tional demands of the activity.
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Within the context of attention training, balance exer-
cises were progressed. As the environmental modifica-
tions increased the attention demands, the balance
exercises increased in difficulty to augment their atten-
tion demand. Balance exercises the patient performed
included Romberg stance with eyes open and closed,
tandem walking, single-limb stance, tandem stance, side-
stepping, braiding, kicking a ball in sitting and standing
positions, standing exercises with one foot on a foam
roller, and hopping on one foot. The balance exercises
were made more difficult by decreasing sensory input
(ie, performing the exercises with eyes closed)9 and by
decreasing the base of support such as during perfor-
mance of tandem stance or single leg stance.10 For
example, once the patient kicked a ball in a sitting
position without loss of balance requiring upper-
extremity balance response, he progressed to kicking a
ball in a standing position.
Ambulation tasks were also progressed. As the environ-
mental modifications increased the attention demands,
the complexity of the ambulation tasks also were
increased by adding components that required simulta-
neous manipulation of an object or a change in the
variables of ambulation. The first component added to
the patient’s ambulation was carrying a book bag,
because he would have to carry it to each of his classes
when he returned to school. Once the patient ambu-
lated 30.5 m (100 ft) while carrying his book bag without
loss of balance, other components were added to the
task—the weight of the book bag was increased, speed
was increased (as if he was late for class), and directions
were changed suddenly. Increasing the complexity of
the ambulation task demanded additional attention in
order to maintain balance and to perform the task.
When the patient responded to the challenges in the
clinic without a loss of balance, community ambulation
was introduced. In this environment, all of these
demands were present in various combinations. As in the
clinic, the community environments were introduced
progressively, depending on their attention and balance
demands. For instance, a quiet library had fewer atten-
tion demands than a crowded, noisy grocery store.
The third aspect of an effective attention training pro-
gram was incorporated by providing the patient with
feedback to maximize his learning and retention. I
provided extrinsic feedback, which outlined specific
knowledge of results (eg, “You lost your balance 3 times
during that last walk.”) and knowledge of performance
(eg, “Just before you lost your balance, you turned your
head toward that distraction.”). As the patient pro-
gressed, he verbalized aspects of his intrinsic feedback as
well. For example, after a walking and talking task, he
stated, “When I started talking, I had to take a step to
Physical Therapy . Volume 82 . Number 5 . May 2002

Figure.
Cognitive rehabilitation techniques used in occupational therapy and speech-language pathol-
ogy to address the patient’s attention impairments.
catch my balance.” This intrinsic feedback was aug-
mented by additional extrinsic feedback as needed
(eg, “You also had to use your arms on the wall to keep
from falling.”). I provided the extrinsic feedback as both
summary feedback and bandwidth feedback. Summary
feedback is defined as a summary of knowledge of results
or performance over multiple trials after the trials are
completed.53 The number of trials in the summary
increased as the patient’s skill in the given activity
improved. Bandwidth feedback is defined as feedback that
is given if performance falls outside of a predetermined
acceptable range.53,54 Bandwidth feedback was provided
by giving the patient immediate feedback if he appeared
in danger of falling according to the judgment of the
therapist. By using both summary and bandwidth feed-
back, the feedback was decreased as the patient
improved to minimize dependency on extrinsic feed-
back and maximize retention.53–56
The program addressing the patient’s ambulation, atten-
tion, and balance in physical therapy sessions was part of
a larger interdisciplinary plan of care. In addition to the
interventions described above, the patient’s physical
therapy plan of care included the following elements:
(1) cardiovascular endurance training on a stationary
bicycle and a treadmill, (2) patient and family instruc-
tion about the patient’s impairments, his functional
limitations, and techniques for providing him with safe
care, and (3) instruction in a home exercise program for
trunk and lower-extremity strengthening.
The home program exercises were performed for 15
repetitions each and consisted of single-plane antigravity
active range of motion exercises for the trunk flexors
and each major muscle group of the lower extremities.
They were performed in supine, side-lying, sitting, and
* The Hygenic Corporation, 1245 Home Ave, Akron, OH 44310.
Physical
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standing positions. After 9 weeks of
treatment, these exercises were pro-
gressed to include resistance from a
Thera-Band.* Compensatory tech-
niques for balance and attention were
introduced in which the patient and
his family were initially instructed in
decreasing distractions during ambula-
tion and in providing verbal and tactile
cues to help him focus attention on
ambulation. As the patient progressed,
he and his family were instructed in
how to increase environmental distrac-
tions during ambulation at home to
maximize carryover of progress in
physical therapy sessions. For example,
once the patient began to work on
community ambulation in physical
therapy, he was encouraged to accom-
pany his family members on trips into
the community, such as to the grocery store or a
shopping mall. The patient’s grandmother attended
therapy sessions frequently and was kept informed of the
patient’s progress and abilities. She and the patient
reported that he carried out his home program. The
patient’s occupational therapist and speech-language
pathologist also managed the patient’s attention impair-
ments (as well as other impairments listed in “Occupa-
tional Therapy and Speech-Language Pathology Tests
and Measures”). Cognitive rehabilitation techniques
used in occupational therapy and speech-language
pathology to address the patient’s attention impairments
are outlined in the Figure.
Outcome
At the time of the physical therapy discharge examina-
tion, the patient had improved in all areas of impair-
ment. I observed no significant gait deviations in clinic
or community environments. The patient ambulated in
community environments, negotiating uneven surfaces
and escalators without loss of balance. The patient also
ambulated in a crowded environment carrying a book
bag and engaging in conversation without slowing down
or stopping and without loss of balance. This ability to
walk and talk simultaneously marked a change from the
initial examination and indicated a lower chance of
falls.31 The patient demonstrated improved balance on
both tandem gait and one-legged stance when compared
with the initial testing. He performed tandem gait for
6.1 m (20 ft) independently in approximately 20 seconds
without loss of balance and with appropriate balance
responses. The patient performed this test faster than
people who had not fallen and who participated in a
study by Gunter et al.33 In this study, a group of people
Tappan . 481
 who had not fallen performed tandem gait faster than a
group of people who had fallen.33 The patient per-
formed right and left one-legged stance for 30 seconds
each without loss of balance, which is within normal
limits for adults younger than 40 years of age.34 The
patient also performed age-appropriate activities such as
running, jumping, and skipping without loss of balance.
The patient’s lower-extremity manual muscle tests
ranged from 4/5 to 5/5 bilaterally. Muscle tone as
measured by the Modified Ashworth Scale was normal
throughout the lower extremities.
The occupational therapist and the speech-language
pathologist were unable to perform formal retesting of
cognition at the time of discharge because the patient
was discharged suddenly for financial and personal
reasons. However, the patient demonstrated functional
improvement in areas affected by attention. At the time
of discharge, the patient engaged in written tasks and
schoolwork for up to an hour in the presence of distrac-
tions. He also used strategies to increase attention inde-
pendently, such as double-checking work and reading
instructions aloud.
One month after discharge from physical therapy, the
patient and his grandmother reported that he had
successfully returned to school, navigating crowded hall-
ways between classes without loss of balance or unsteadi-
ness. They also reported that he attended full days of
classes and was a line coach for his high school football
team.
Discussion
This treatment approach was consistent with the frame-
work of transfer-appropriate processing. According to
the concept of transfer-appropriate processing, maxi-
mum learning occurs when the processing requirements
of the practice conditions are similar to the processing
requirements of the transfer test.57 Therefore, in this
case, learning would occur if the processing require-
ments of the therapy activities were similar to the pro-
cessing requirements of walking in school. The treat-
ment approach described in this case report applied the
concept of transfer-appropriate processing in 3 ways.
First, the described treatment approach required the
patient to perform progressively more challenging bal-
ance and ambulation exercises in the presence of dis-
tractions. The processing requirements of this approach
were hypothesized to be more similar to those of walking
in school than to those when performing the ambulation
and balance exercises alone. That is, both the treatment
activities and walking in school required the patient to
use attentional capacity for maintaining balance and for
interacting with the environment simultaneously.
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Second, both the practice conditions and the transfer
test conditions (walking in school) were variable. Just as
the conditions in school varied during each school day
(eg, walking in an empty hallway before school versus
walking up and down stairs between classes), the ambu-
lation and balance exercises and of the attention train-
ing varied within each therapy session. Furthermore, in
several studies variable and random practice conditions
promoted improved performance on transfer tests and
increased retention.58,59 According to the transfer-
appropriate processing framework, the variable and ran-
dom practice conditions required the patient to regen-
erate the appropriate movement pattern for each trial
rather than simply repeating or revising the previous
movement pattern as with blocked practice.
Third, the practice conditions in this treatment
approach incorporated knowledge of results in a pattern
that maximized transfer-appropriate processing. In the
transfer test (walking in school), the patient would not
know the results from external sources. The patient
would only receive knowledge of results by self-
monitoring his balance. Therefore, practice conditions
were structured to develop the patient’s use of internal
knowledge of results and minimize the amount of sum-
mary and bandwidth feedback given to the patient. In
addition, this pattern of minimizing extrinsic feedback
likely maximized the patient’s retention. In a study in
which subjects received bandwidth feedback on a ballis-
tic timing task (goal⫽200 milliseconds), subjects in the
0% bandwidth group received feedback on each trial,
whereas subjects in the 5% and 10% bandwidth groups
received feedback only if their performance fell outside
of their respective goal bandwidth (between 190 and 210
milliseconds for the 5% bandwidth group and between
180 and 220 milliseconds for the 10% bandwidth
group). The subjects who received feedback in a 10%
bandwidth (and, therefore, at the lowest frequency)
performed just as accurately and more consistently on
retention tests than the subjects who received more
frequent feedback.54
This case report cannot identify how the patient’s
improvement came about. The patient’s improved per-
formance may have resulted from more automatic per-
formance of walking and thus lowering the attention
demand of the task. Alternately, improved attentional
capacity may have resulted in improved ability to attend
to both walking and interaction with the environment.
This case report also cannot show that this method of
addressing attention in the context of balance and gait
training is effective in improving attention, balance, or
ambulation. Other factors were involved in this patient’s
recovery. Other interventions, such as strength training,
occupational therapy, and speech therapy, were applied
simultaneously. The patient likely experienced some
Physical Therapy . Volume 82 . Number 5 . May 2002

degree of spontaneous recovery as well. By structuring
the patient’s treatment plan to conform to the frame-
work of transfer-appropriate processing, however, I
hypothesize that the carryover of motor and attention
skills learned in therapy into the patient’s activities in
school and the community was maximized.
Attention-related balance impairments in people with
brain injuries may limit independence and safety during
community ambulation. Physical therapists need to
determine effective techniques to address attention as it
relates to balance and ambulation in order to maximize
patient recovery. In this case, the patient demonstrated
impairments in attention along with physical impair-
ments. Although no research on the relationship among
balance, ambulation, and attention in subjects with this
patient’s diagnosis is available, other studies on subjects
without impairments,7,8,10 subjects with lower-extremity
amputations,9 and elderly people8,11 suggest that balance
does require attention and that a decrease in attention
in patients with traumatic brain injury may be associated
with decreased postural stability.13 This case report out-
lines one method of addressing the patient’s attention
impairments in the context of balance and gait training.
Continued research is needed to determine the interac-
tion between balance and attention in patients with
brain injury and to determine optimal evaluation and
treatment variables for patients with decreased balance
related to attention impairments.
References
1 Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:
9 –744.
2 Diamond PT, Felsenthal G, Macciocchi SN, et al. Effect of cognitive
impairment on rehabilitation outcome. Am J Phys Med Rehabil. 1996;
75:40 – 43.
3 Galski T, Bruno RL, Zorowitz R, Walker J. Predicting length of stay,
functional outcome, and aftercare in the rehabilitation of stroke
patients: the dominant role of higher-order cognition. Stroke. 1993;24:
1794 –1800.
4 Mysiw WJ, Beegan JG, Gatens PF. Prospective cognitive assessment of
stroke patients before inpatient rehabilitation: the relationship of the
Neurobehavioral Cognitive Status Examination to functional improve-
ment. Am J Phys Med Rehabil. 1989;68:168 –171.
5 Deutsch JA, Deutsch D. Attention: some theoretical considerations.
Psychol Rev. 1963;70:80 –90.
6 Navon D, Gopher D. On the economy of the human-processing
system. Psychol Rev. 1979;86:214 –255.
7 Andersson G, Yardley L, Luxon L. A dual-task study of interference
between mental activity and control of balance. Am J Otol. 1998;19:
632– 637.
8 Brown LA, Shumway-Cook A, Woollacott MH. Attentional demands
and postural recovery: the effects of aging. J Gerontol A Biol Sci Med Sci.
1999;54:M165–M171.
9 Geurts ACH, Mulder TW. Attention demands in balance recovery
following lower limb amputation. J Mot Behav. 1994;26:162–170.
Physical
Downloaded from Therapy . Volume 82 . Number 5 . May 2002
https://academic.oup.com/ptj/article-abstract/82/5/473/2837005/Rehabilitation-for-Balance-and-Ambulation-in-a
by Universitas Indonesia user
on 04 September 2017
ўўўўўўўўўўўўўўўўўўўўўўўў
10 Lajoie Y, Teasdale N, Bard C, Fleury M. Attentional demands for
static and dynamic equilibrium. Exp Brain Res. 1993;97:139 –144.
11 Shumway-Cook A, Woollacott M, Kerns KA, Baldwin M. The effects
of two types of cognitive tasks on postural stability in older adults with
and without a history of falls. J Gerontol A Biol Sci Med Sci. 1997;52:
M232–M240.
12 Van Zomeren AH, Deelman BG. Long-term recovery of visual
reaction time after closed head injury. J Neurol Neurosurg Psychiatry.
1978;41:452– 457.
13 Geurts ACH, Knoop JA, van Limbeek J. Is postural control associ-
ated with mental functioning in the persistent postconcussion syn-
drome? Arch Phys Med Rehabil. 1999;80:144 –149.
14 Mateer CA, Kerns KA, Eso KL. Management of attention and
memory disorders following traumatic brain injury. J Learn Disabil.
1996;29:618 – 632.
15 Chen HC, Schultz AB, Ashton-Miller JA, et al. Stepping over obsta-
cles: dividing attention impairs performance of old more than young
adults. J Gerontol A Biol Sci Med Sci. 1996;51:M116 –M122.
16 Charness A. Stroke/Head Injury: A Guide to Functional Outcomes in
Physical Therapy Management. Gaithersburg, Md: Aspen Publishers Inc;
1986:96, 140 –141.
17 Shumway-Cook A, Woollacott M. Motor Control: Theory and Practical
Applications. Baltimore, Md: Williams & Wilkins; 1995:222.
18 Malkmus D. Integrating cognitive strategies into the physical ther-
apy setting. Phys Ther. 1983;63:1952–1959.
19 Namerow NS. Cognitive and behavioral aspects of brain-injury
rehabilitation. Neurol Rehabil. 1987;5:569 –583.
20 Niemann H, Ruff RM, Baser CA. Computer-assisted attention
retraining in head injured individuals: a controlled efficacy study of an
outpatient program. J Consult Clin Psychol. 1990;58:811– 817.
21 Sohlberg MM, Mateer CA. Effectiveness of an attention-training
program. J Clin Exp Neuropsychol. 1987;9:117–130.
22 Sohlberg MM, McLaughlin KA, Pavese A, et al. Evaluation of
attention process training and brain injury education in persons with
acquired brain injury. J Clin Exp Neuropsychol. 2000;22:656 – 676.
23 Strache W. Effectiveness of two modes of training to overcome
deficits of concentration. Int J Rehabil Res. 1987;10(4 suppl
5):141S–145S.
24 Wood RLI, Fussey I. Computer-based cognitive retraining: a con-
trolled study. Int Disabil Studies. 1987;9:149 –153.
25 Wood RLI. Rehabilitation of patients with disorders of attention.
J Head Trauma Rehabil. 1986;1:43–53.
26 Webster JS, Scott RR. The effects of self-instructional training on
attentional deficits following head injury. Clin Neuropsychol. 1983;5:
69 –74.
27 Ponsford JL, Kinsella G. Evaluation of a remedial programme for
attentional deficits following closed-head injury. J Clin Exp Neuropsychol.
1988;10:693–708.
28 Cicerone KD, Dahlberg C, Kalmar K, et al. Evidence-based cognitive
rehabilitation: recommendations for clinical practice. Arch Phys Med
Rehabil. 2000;81:1596 –1615.
29 Novack TA, Caldwell SG, Duke LW, Berquist T. Focused versus
unstructured intervention for attention deficits after traumatic brain
injury. J Head Trauma Rehabil. 1996;11:52– 60.
30 Caplan B. Neuropsychology in rehabilitation: its role in evaluation
and intervention. Arch Phys Med Rehabil. 1982;63:362–366.
Tappan . 483
 31 Lundin-Olsson L, Nyberg L, Gustafson Y. “Stops walking when 47 Hammill DD. DTLA– 4: Detroit Tests of Learning Aptitude. Austin, Tex:
talking” as a predictor of falls in elderly people. Lancet. Pro-Ed; 1998.
1997;349(9052):617.
48 Crowe SF. The differential contribution of mental tracking, cogni-
32 Cho C, Kamen G. Detecting balance deficits in frequent fallers tive flexibility, visual search, and motor speed to performance on Parts
using clinical and quantitative evaluation tools. J Am Geriatr Soc. A and B of the Trail Making Test. J Clin Psychol. 1998;54:585–591.
1998;46:426 – 430.
49 O’Donnell JP, MacGregor LA, Dabrowski JJ, et al. Construct validity
33 Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility of neuropsychological tests of conceptual and attentional abilities.
discriminates nonfallers from one-time and frequent fallers. J Gerontol J Clin Psychol. 1994;50:596 – 600.
A Biol Sci Med Sci. 2000;55:M672–M676.
50 Warburg CL. Assessment and treatment planning strategies for
34 Bohannon RW, Larkin PA, Cook AC, et al. Decrease in timed perceptual deficits. In: O’Sullivan SB, Schmitz TJ, eds. Physical Rehabil-
balance test scores with aging. Phys Ther. 1984;64:1067–1070. itation: Assessment and Treatment. 3rd ed. Philadelphia, Pa: FA Davis Coy;
1994:603– 632.
35 Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Func-
tion. 4th ed. Baltimore, Md: Williams & Wilkins; 1993. 51 Colarusso RP, Hammill DD. Motor-Free Visual Perception Test–Revised.
Novato, Calif: Academic Therapy Publications; 1996.
36 Wadsworth CT, Krishnan R, Sear M, et al. Intrarater reliability of
manual muscle testing and hand-held dynametric muscle testing. Phys 52 El-Kahky AM, Kingma H, Dolmans M, De Jong I. Balance control
Ther. 1987;67:1342–1347. near the limit of stability in various sensory conditions in healthy
subjects and patients suffering from vertigo or balance disorders:
37 Lamb RL. Manual muscle testing. In: Rothstein JM, ed. Measurement
impact of sensory input on balance control. Acta Otolaryngol. 2000;120:
in Physical Therapy. New York, NY: Churchill Livingstone Inc; 1985:
508 –516.
47–55.
53 Schmidt RA. Motor Learning and Performance: From Principles to
38 Bohannon RW. Is the measurement of muscle strength appropriate
Practice. Champaign, Ill: Human Kinetics Books; 1991.
in patients with brain lesions? A special communication. Phys Ther.
1989;69:225–236. 54 Sherwood DE. Effect of bandwidth knowledge of results on move-
ment consistency. Percept Mot Skills. 1988;66:535–542.
39 Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd ed.
Oxford, England: Butterworth-Heinemann; 1990. 55 Lavery JJ. Retention of simple motor skills as a function of type of
knowledge of results. Can J Psychol. 1962;16:300 –311.
40 Bohannon RW, Smith MB. Interrater reliability of a Modified
Ashworth Scale of muscle spasticity. Phys Ther. 1987;67:206 –207. 56 Lavery JJ, Suddon FH. Retention of simple motor skills as a function
of the number of trials by which KR is delayed. Percept Mot Skills.
41 Blackburn M, van Vliet P, Mockett SP. Reliability of measurements
1962;15:231–237.
obtained with the Modified Ashworth Scale in the lower extremities of
people with stroke. Phys Ther. 2002;82:25–34. 57 Lee TD. Transfer-appropriate processing: a framework for concep-
tualizing practice effects in motor learning. In: Meijer OG, Roth K, eds.
42 Norkin CC, White DJ. Measurement of Joint Motion: A Guide to
Complex Movement Behaviour: “The” Motor-Action Controversy. Amsterdam,
Goniometry. 2nd ed. Philadelphia, Pa: FA Davis Co; 1995.
the Netherlands: Elsevier Science Publishers BV; 1988:201–215.
43 Rothstein JM, Miller PJ, Roettger RF. Goniometric reliability in a
58 Lee TD, Magill RA, Weeks DJ. Influence of practice schedule on
clinical setting: elbow and knee measurements. Phys Ther. 1983;63:
testing schema theory prediction in adults. J Mot Behav. 1985;17:
1611–1615.
283–299.
44 Elveru RA, Rothstein JM, Lamb RL. Goniometric reliability in a
59 Shea JB, Morgan RL. Contextual interference effects on the acqui-
clinical setting: subtalar and ankle joint measurements. Phys Ther.
sition, retention and transfer of a motor skill. J Exp Psychol [Hum Learn].
1988;68:672– 677.
1979;5:179 –187.
45 Gogia PP, Braatz JH, Rose SJ, Norton BJ. Reliability and validity of
goniometric measurements at the knee. Phys Ther. 1987;67:192–195.
46 Schmitz TJ. Sensory assessment. In: O’Sullivan SB, Schmitz TJ, eds.
Physical Rehabilitation: Assessment and Treatment. 3rd ed. Philadelphia,
Pa: FA Davis Co; 1994:91.

484 https://academic.oup.com/ptj/article-abstract/82/5/473/2837005/Rehabilitation-for-Balance-and-Ambulation-in-a
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