504942

2013
CRE28510.1177/0269215513504942Clinical RehabilitationTripp and Krakow

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effects of an aquatic therapy 2014, Vol. 28(5) 432­–439

© The Author(s) 2013
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DOI: 10.1177/0269215513504942

on functional mobility in cre.sagepub.com

subacute stroke patients:

a randomized controlled trial

Florian Tripp1 and Karsten Krakow2

Abstract
Objective: To evaluate the effects of an aquatic physiotherapy method (Halliwick-Therapy) upon mobility
in the post-acute phase of stroke rehabilitation.
Design: Randomized controlled trial.
Setting: Hospital for neurological rehabilitation.
Participants: Adult patients after first-ever stroke in post-acute inpatient rehabilitation at least two
weeks after the onset of stroke (n = 30).
Interventions: In the Halliwick-Therapy group (n = 14) the treatment over a period of two weeks
included 45 minutes of aquatic therapy three times per week and a conventional physiotherapeutic
treatment twice a week. Subjects in the control group (n = 16) received conventional physiotherapeutic
treatment over a period of two weeks five times per week.
Outcome measures: The primary outcome variable was postural stability (Berg Balance Scale).
Secondary outcome variables were functional reach, functional gait ability and basic functional mobility.
Results: Compared to the control group, significantly more subjects in the Halliwick-Therapy group
(83.3% versus 46.7%) attained significant improvement of the Berg Balance Scale (P < 0.05). Improvement
of the functional gait ability was significantly higher in the Halliwick-Therapy group (mean (SD) 1.25(0.86))
than in the control group (mean (SD) 0.73 (0.70)) (P < 0.1). The mean differences of improvements in
functional reach and basic functional mobility were not statistically significant between groups.
Conclusions: This study indicates that Halliwick-Therapy is safe and well tolerated in stroke patients in
post-acute rehabilitation and has positive effects upon some aspects of mobility.

Keywords
Stroke, aquatic therapy, mobility, balance, Halliwick
Received: 12 October 2012; accepted: 18 August 2013

1Department of Physiotherapy, Asklepios Neurological Corresponding author:

Hospital Falkenstein, Königstein/Taunus, Germany
2Department of Neurology and Neurological Rehabilitation,
Asklepios Neurological Hospital Falkenstein, Königstein/
Taunus, Germany
Florian Tripp, Department of Physiotherapy, Asklepios
Neurologische Klinik Falkenstein, Asklepiosweg 15, 61462
Königstein, Germany.
Email: f.tripp@asklepios.com
Tripp and Krakow 433
Introduction
Many stroke survivors remain dependent on assis-
tance after the acute phase of treatment due to restric-
tions of mobility.1 The present knowledge about
motor recovery after stroke and successful therapeu-
tic interventions in motor rehabilitation emphasizes
the need for treatment strategies with early active and
repetitive training which focuses on realizing the
remaining motoric function in a meaningful and
motivating context. Nevertheless, the required active
input for motor relearning is difficult to realize for
patients and therapists when facing severe motor
impairments. Therefore patients in the early rehabili-
tation phase are often forced into inactivity or inef-
fective compensations. In order to enable patients to
be more active at an early stage of rehabilitation,
‘modifying the task or environment’2 is required. The
specific environmental conditions of water influenc-
ing physiological processes and motor activity are
described as density, buoyancy, hydrostatic pressure,
viscosity and thermodynamics.3 In this context the
training environment in water may facilitate motor
activity, as training of paretic muscles is promoted,
while their use might be restricted under conditions
of gravity outside the water.
Halliwick-Therapy, which this paper focuses on,
was developed and first described by James
McMillan and is characterized as a problem-solving
approach with systematic intervention.4–9 Halliwick-
Therapy focuses on postural stability and controlled
mobility as a basis for safe and coordinated move-
ment in and out of water. In a 10-point programme
skills for being safe and independent in the water are
gradually acquired. Phase 1 of the programme
includes adjustment to the environment, while the
second phase focuses on learning three-dimensional
active balance control utilizing dynamic and static
tasks. The goal of the third phase of movement is an
independent swimming technique adjusted to indi-
vidual physical disability. In the course of neurologi-
cal rehabilitation phase 3 is being conducted less
frequently, as the goal of the therapeutic use of the
Halliwick concept is not primarily independent
swimming, but to enhance general motor indepen-
dence both in and out of water. The 10-point pro-
gramme is therefore complemented by water-specific
therapy, a system for creating individual exercises
which can be adapted and increased in difficulty by
carefully selecting a combination of hydromechani-
cal effects, the starting position and the task.
Although previous studies found improvements
in postural stability,10 cardiovascular fitness,11 gait
speed11 and strength of the hemiparetic leg10,11 in
chronic stroke patients, a recent Cochrane review12
could neither endorse nor reject aquatic physiother-
apy for stroke patients, as the authors described a
‘lack of hard evidence for water-based exercises
after stroke’.
In particular, to our knowledge, so far no data
about the effectiveness of aquatic therapy in the
subacute phase of stroke rehabilitation in an inpa-
tient setting are available. Therefore the aim of this
study was to examine in this patient group the
effects of aquatic therapy in reference to postural
stability, ambulation and basic functional mobility
in comparison to standard physiotherapy within a
randomized controlled trial.
Methods
In this study we included adult patients after first-
ever stroke in post-acute inpatient rehabilitation at
least two weeks after the onset of stroke. It was
determined that as a minimum motor requirement
for inclusion, transferring from one chair to another
had to be possible independently or with assistance
of not more than one person. Excluded from partici-
pation were patients with independent gait ability
indoors. Further exclusion criteria were an instable
general condition, infectious diseases, severe heart
failure, tracheostomy, sores, incontinence, lack of
ability to cooperate, rejection of aquatic therapy,
perforation of the tympanic membrane and the pres-
ence of additional other neurological disorders.
All patients classified as suitable after a screen-
ing utilizing inclusion and exclusion criteria
received a detailed written and verbal explanation
of the structure and content of the study. After
informed consent was given, patients were ran-
domly allocated to one of the treatment groups by a
person not involved with the process of treatment,
testing and evaluation. The randomization was
434 Clinical Rehabilitation 28(5)
conducted using numbered pre-filled envelopes
which contained an equal number of lots for both
treatment groups. As the number of study partici-
pants was not exactly predictable before the onset
of the study, we conducted a blocked randomization
with the aim of achieving a similar number in both
study groups.13 Initially 20 lots were randomized
and further 14 at a later date.
For the Halliwick-Therapy group it was deter-
mined that the physiotherapeutic treatment con-
sisted of a combination of three Halliwick-Therapy
sessions and two conventional physiotherapy ses-
sions per week over a period of two weeks, with all
sessions having a treatment time of 45 minutes. The
Halliwick-Therapy sessions were conducted by
physiotherapists who had participated in a certified
Halliwick-Therapy course.
Included in the aquatic therapy sessions was the
time for entering and exiting the pool, time for prep-
arations and post-processing, such as towelling one-
self off and getting dressed in a bathrobe. The pure
treatment time in the pool was approximately 35
minutes, of which about 5 minutes were for exer-
cises in water familiarization and mental adaption
(learning phase 1 of the Halliwick concept)8 and
about 15 minutes for exercising rotational control
(learning phase 2 of the Halliwick concept).8 In the
remaining 15 minutes locomotion under various
disturbances and in changing water depths was pri-
marily exercised.
The control group received five sessions of stan-
dard physiotherapy per week over a period of two
weeks and treatment time was 45 minutes as in the
Halliwick-Therapy group. The contents of the stan-
dard physiotherapy sessions were not defined and
therefore the treatment consisted of an individual
mix of different treatment concepts, task-specific
exercising of various tasks in the area of mobility
and possibly treadmill training.
As the aim of this study was to investigate effects
on functional mobility, we decided to assess differ-
ent aspects of mobility that are meaningful for
safety and independence in the everyday mobility
of stroke patients.
As primary outcome measure postural stability
was determined and assessed by the Berg Balance
Scale.14 With this tool, performance as well as
dependency on assistance is scored with 0–4 points
in 14 different items in the area of mobility, so a
maximum of 56 points can be achieved on an inter-
val scale. Improvement of postural stability is
described as the most important prognostic factor in
stroke patients for achieving independent gait abil-
ity, while improving the strength of the hemiparetic
leg is less associated with the improvement of walk-
ing ability.15 Patients with a Berg Balance Scale
score of less than 45 are known to have an increased
risk of falling16 and changes of more than six points
indicate clinically relevant changes.17
For the secondary outcome measure, the mea-
surements of functional reach,18 functional gait
ability and basic functional mobility were deter-
mined. Whereas functional reach measures the safe
and stable weight shifting ability while standing,
Functional Ambulation Categories (FAC)19 describe
the dependency on assistance for gait on a 5-point
scale. The Rivermead Mobility Index20 assesses
independent performance of 15 tasks in the area of
everyday mobility.
In addition to the outcome measurements, descrip-
tive data were used to define the study groups. This
data consisted of age, gender, time since stroke, side
of lesion and type of stroke (ischaemic or haemor-
rhagic). Furthermore, the Barthel Index21 was col-
lected to determine and compare the patients’
functional status at the start of intervention.
All tests were conducted observer-blind and the
assignment of subjects to Halliwick-Therapy group
or control group was not made available to the eval-
uating person until after the study period.
We conducted a descriptive analysis of the base-
line data and performed a chi-square test of the
nominally scaled data for different distributions
between study groups at baseline. Furthermore we
tested the mean values of the quantitative baseline
data for differences with a t-test.
For both study groups we calculated median and
mean values of the differences between baseline
and follow-up measurements of all outcome vari-
ables. Group means were compared with t-tests for
unconnected samples to determine significant dif-
ferences. Additionally we determined for each
group the number of participants with clinically rel-
evant changes of the Berg Balance Scale, Functional
Tripp and Krakow 435

Enrolment

Randomized (n=30)

Allocation

Allocated to Halliwick-Therapy group (n=14) Allocated to Control group (n=16)

♦ Received allocated intervention (n=13) ♦ Received allocated intervention (n=16)
♦ Did not receive allocated intervention (n=1) ♦ Did not receive allocated intervention (n=0)
(reason: incontinence)

Follow-up

Lost to follow-up (n=2) Lost to follow-up (n=1)

Discontinued intervention (n=1) Discontinued intervention (n=1) (reason:

(reason: diarrhoea) transferred to other hospital after falling)

Analysis

Analysed (n=12) Analysed (n=15)

♦ Excluded from analysis (n=0) ♦ Excluded from analysis (n=0)

Figure 1.  Flow diagram.

Ambulation Categories and Rivermead Mobility
Index. Analysis of the collected data was performed
using BiAS. for Windows 10.0 and G * Power 3.22
Results
During the study period 30 stroke patients met the
inclusion criteria and were randomized to one of the
study groups (Figure 1). Fourteen patients were
assigned to the Halliwick-Therapy group and 16 to
the control group and baseline measurements were
conducted with all 30 patients. Two participants in
the Halliwick-Therapy group and one participant
in the control group dropped out during the course
of the study. Aside from these drop-outs, which
occurred independently of the interventions in this
study, no other complications or negative side-
effects of the Halliwick-Therapy were observed.
The follow-up measurements after the study period
were conducted with 27 patients, so that complete
data of 12 participants of the Halliwick-Therapy
group and 15 participants of the control group could
be evaluated.
Table 1 shows the participants´ characteristics.
The characteristics of the participants were similar
in both study groups and there were no statistically
significant differences before the treatment period
with regard to the investigated outcome measures.
Table 2 shows significant improvements (P <
0.01) of the primary outcome measure (Berg Balance
Scale) as well as the secondary outcome measures
(functional reach, Functional Ambulation
Categories, Rivermead Mobility Index) in both the
436 Clinical Rehabilitation 28(5)
Table 1.  Characteristics of the participants.
Gender (male/female)ª
Age (years)ª
Side of lesion (left/right)ª
Type of stroke (ischaemic/haemorrhagic)ª
Days since strokeª
Barthel Index at baselineª
ªDifference between the study groups not significant (P > 0.05).
Halliwick-Therapy group and the control group. We
tested the mean improvements of the outcome mea-
sures for group differences with a t-test for indepen-
dent samples. The t-test shows the mean improvement
of the Functional Ambulation Categories was sig-
nificantly higher in the Halliwick-Therapy group
than in the control group (P < 0.1). The differences
in mean values of the improvements in the Berg
Balance Scale, functional reach and the Rivermead
Mobility Index were not statistically significant.
With regard to the Berg Balance Scale, improve-
ments greater than 6 points are described as clini-
cally relevant.17 Likewise this applies to changes of
at least 1 point in the Functional Ambulation
Categories23 or at least 2 points in the Rivermead
Mobility Index.20 Table 3 shows a higher number
and proportion of participants with clinically
relevant improvements after the treatment period in
the Halliwick-Therapy group. The different distri-
butions were statistically significant (P < 0.05) in a
chi-square test concerning the Berg Balance Scale
(83.3% (n = 10) versus 46.7% (n = 7)) in favour of
interventional treatment. The different distributions
in the evaluation of the results of the Functional
Ambulation Categories and the Rivermead Mobility
Index were not statistically significant.
Discussion
The results of this study support the hypothesis that
aquatic therapy may have positive effects on func-
tional mobility in subacute stroke patients. This
study has shown that significantly more participants
Halliwick-Therapy group n = 14 Control group n = 16
9/5 10/6
64.8 ± 15.0 65.0 ± 15.1
4/10 6/10
12/2 15/1
51.9 ± 37.7 39.0 ± 27.9
48.57 ± 15.74 54.38 ± 17.21
of the Halliwick-Therapy group achieved clinically
relevant improvements of the Berg Balance Scale
compared to standard treatment. Furthermore the
improvement in functional gait ability was signifi-
cantly greater in the Halliwick-Therapy group than
in the control group. We did not observe any nega-
tive side-effects of the application of aquatic ther-
apy after a minimum of two weeks post stroke.
Considering the limited number of participants
and the short intervention period of two weeks in
this study, the power to detect significant differ-
ences between standard treatment and aquatic ther-
apy was limited. A power analysis conducted post
hoc showed that with respect to 30 included patients,
the relatively short study period of two weeks
achieved only a 30% probability of detecting a false
null hypothesis in relation to the primary outcome
measure. Therefore the results need to be inter-
preted with caution. This also applies to generaliz-
ability of the results of this study to the stroke
population, as we do not know what proportion of
subacute stroke patients in principle meets the
inclusion criteria to take part in aquatic therapy.
This study did not investigate any long-term
effects of an aquatic treatment. Therefore it is
unknown if the observed improvements in favour of
interventional treatment were a functional advan-
tage for the patients at a later point in time.
With regard to the effect on functional mobility,
the Rivermead Mobility Index, which we chose due
to its reliability and fast performance, did not have
the sensitivity to detect minor changes over the
short treatment period in a group of severely
impaired patients.
Tripp and Krakow 437

The results of the Berg Balance Scale of our

8.87 (9.08)b
6 (6.19)b
0.73 (0.70)b
2.07 (1.33)b
Mean (SD)
difference
study can be compared with those of the study of
Noh et al.,10 which is, as far as is known to us, the
only published study investigating the effects of
Halliwick-Therapy on stroke patients. At baseline
Noh et al. found a mean Berg Balance Scale score of
difference
(90% CI)
5 (2–14)
4 (2–12)
1 (0–1)
2 (1–3)
Median

43.3 in the aquatic therapy group, which is consid-

erably higher than the mean Berg Balance Scale
score of the Halliwick-Therapy group at baseline in
our study (mean (SD) 27.08 (13.46)). However, the

BBS, Berg Balance Scale; FR, functional reach; FAC, Functional Ambulation Categories; RMI, Rivermead Mobility Index; CI, confidence interval.
37.60 (11.01)

mean improvement of postural stability after two

16.86 (8.52)
2.93 (1.22)
7.93 (2.49)
Follow-up

weeks of intervention was higher, with a mean (SD)

of 11.0 (6.25) points on the Berg Balance Scale than
the mean (SD) improvement of 7.6 (6.2) points in
the study of Noh et al. after an eight-week interven-
tion. This greater effect after a shorter intervention
Control group

28.73 (14.93)ª
10.86 (9.75)ª
2.20 (1.47)ª
5.86 (2.61)ª

period can be explained by the considerably differ-

ent functional status at baseline and a different
Baseline

potential for motor recovery due to the difference in

time between stroke and the start of the study (2.8
years vs. 51.93 days).
11 (6.25)b
7.42 (7.36)b
1.25 (0.86)b
2.42 (2.35)b

A Cochrane review12 states ‘no significant

Mean (SD)
difference

improvement of postural control for people after

Table 2.  Outcome measures at baseline and after two weeks of intervention.

stroke’ following aquatic therapy in comparison to

standard treatment when analysing the pooled mean
difference of the Berg Balance Scale. However,
unlike our investigation, the two studies10,11 included
Median difference

cSignificant difference between improvements of the study groups (P < 0.1).

ªDifference between the study groups at baseline not significant (P > 0.05).

in this comparison described chronic stroke patients

10.5 (6–15)
4.5 (1–15)
1 (1–2)
2 (0–5)

who were able to walk independently. Furthermore,

(90% CI)

in this Cochrane review Mehrholz et al.12 found the

bSignificant difference between baseline and follow-up (P < 0.01).

ability to walk was not significantly improved by

water-based exercises, but again this conclusion
was based on a study population of independently
ambulatory patients at least one year post stroke.11
38.08 (15.95)
21.08 (11.75)
2.75 (1.65)
7.50 (3.55)

The different findings on the effect of aquatic

Follow-up

therapy upon postural stability and gait ability in

Halliwick-Therapy group

our study compared with previous studies about

chronic, independently ambulatory patients may
imply a higher effectiveness of water-based exer-
27.08 (13.46)ª
13.66 (10.70)ª

cises earlier post stroke and with patients who are

1.50 (1.24)ª
5.08 (2.42)ª

not independently ambulatory.

Baseline

In addition to significant improvements of all

measured outcome variables no negative side-
effects of the aquatic therapy occurred in this study.
Therefore this study indicates a relatively safe
FR (cm)

application of the Halliwick-Therapy in post-acute

FACc
RMI
BBS

stroke rehabilitation when utilizing the defined

438 Clinical Rehabilitation 28(5)

Table 3.  Participants with clinically relevant outcome improvement.

Halliwick-Therapy Control group (n = 15)

group (n = 12)
BBS Mean (SD) difference 11 (6.25) 8.87 (9.08)
Improvement >6 n = 10 (83.3%)ª n = 7 (46.7%)ª
Improvement ≤6 n = 2 (16.7%)ª n = 8 (53.3%)ª
FAC Mean (SD) difference 1.25 (0.86)b 0.73 (0.70)b
Improvement ≥1 n = 10 (83.3%) n = 9 (60%)
Improvement <1 n = 2 (16.7%) n = 6 (40%)
RMI Mean (SD) difference 2.42 (2.35) 2.07 (1.33)
Improvement ≥2 n = 5 (41.7%) n = 5 (33.3%)
Improvement <2 n = 7 (58.3%) n = 10 (66.7%)

ªSignificant difference between study groups (P < 0.05).

bSignificant difference between mean improvements of the study groups (P < 0.1).

BBS, Berg Balance Scale; FAC, Functional Ambulation Categories; RMI, Rivermead Mobility Index.

inclusion and exclusion criteria and a minimum of
two weeks between stroke and beginning of aquatic
treatment. With regard to the safety of stroke
patients with impaired mobility who are likely to
have an increased risk of falling, Halliwick-Therapy
differs from other aquatic therapy approaches in
that it offers a systematic structure beginning with
water familiarization and breath control. In the
course of the therapy sessions, the goal is to learn to
organize motor control in order to keep or regain
balance while performing different tasks. The thera-
pist uses fluid mechanics to facilitate and challenge
motor activity, while the buoyancy and viscosity of
the water give the patient more time to develop
coordinated motor strategies to accomplish the task.
It is important to note that the findings in this study
suggest that motor relearning in the water utilizing
the Hallwick concept has positive effects on mobil-
ity outside the water, however it remains unclear if
the overall effect on mobility is greater than with
standard land-based physiotherapy.
This study did not investigate whether a longer
intervention period increases the observed effects of
Halliwick-Therapy on postural stability and func-
tional gait ability, or whether a follow-up study would
show any differences between the study groups at a
later date. As the highest potential for motor recovery
can be observed in the first months after a stroke,
early improvements in the area of functional mobility
by aquatic therapy could positively influence the
further outcome of independent mobility. Thus, the
improvement of postural stability is the most impor-
tant factor for achieving independent gait ability.15
Further studies with larger sample sizes, a longer
intervention period and follow-up measurements are
therefore necessary.
Clinical messages
•• Aquatic physiotherapy with application of
the Halliwick-Therapy in combination
with conventional physiotherapy may
effectively improve postural stability and
gait ability in stroke patients in a subacute
rehabilitation phase.
•• This study indicates a safe application of
the Halliwick-Therapy after a minimum
of two weeks post stroke.
Acknowledgements
The authors would like to acknowledge the contributions
of Stephanie Humbert, Ann-Kathrin Bruhn and Gisela
Göser for organizing the participants´ appointments and
the support of Joy Coulton, Barbara Pudlo and Kristina
Pudlo for translation of this manuscript. We would also
like to thank the team of physiotherapists at the Asklepios
Neurological Hospital Falkenstein for supporting the
study.
Tripp and Krakow 439
Conflict of interest
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit
sectors.
References
1. Roth EJ. Trends in Stroke Rehabilitation. Eur J Phys Reha-
bil Med 2009; 45: 247–254.
2. Carr J and Shepherd R. Stroke rehabilitation: guidelines
for exercise and training to optimize motor skill. London:
Butterworth-Heinemann, 2003, p. 22.
3. Becker BE. Aquatic therapy: scientific foundations and
clinical rehabilitation applications. Phys Med Rehabil 2009;
9: 859–872.
4. McMillan J. The role of water in rehabilitation. Fysiotera-
peuten 1978; 45: 43–46, 87–90, 236–240.
5. Martin J. The Halliwick Method. Physiotherapy 1981; 67:
288–291.
6. Paeth B. Schwimmtherapie “Halliwick-Methode” nach
McMillan bei erwachsenen Patienten mit neurologischen
Erkrankungen. Z Krankengymn 1984; 36: 100–112.
7. Gamper UN. Wasserspezifische Bewegungstherapie und
Training. Stuttgart: Gustav-Fischer-Verlag, 1991.
8. Lambeck J. Das Halliwick-Konzept, 2001. http://www.hal-
liwick.de/downloads (accessed 17 November 2009).
9. Schick T, Lambeck J and Hulselmans M. Evidente Was-
sertherapie in der Rehabilitation. Halliwick-Konzept nach
McMillan. Pt Z Physiother 2011; 5: 30–35.
10. Noh DK, Lim JY, Shin HI and Paik NJ. The effect of
aquatic therapy on postural balance and muscle strength in
stroke survivors – a randomized controlled pilot trial. Clin
Rehabil 2008; 22: 966–976.
11. Chu KS, Eng JJ, Dawson AS, Harris JE, Ozkaplan A and
Gylfadóttir S. Water-based exercise for cardiovascular
fitness in people with chronic stroke: a randomized con-
trolled trial. Arch Phys Med Rehabil 2004; 85: 870–874.
12. Mehrholz J, Kugler J and Pohl M. Water-based exercises for
improving activities of daily living after stroke. Cochrane
Database Syst Rev 2011; (1): CD008186.
13. Schulz KF, Altman DG and Moher D for the CONSORT
Group. CONSORT 2010 Statement: updated guidelines for
reporting parallel group randomized trials. BMJ 2010; 340:
698–702.
14. Berg K, Wood-Dauphinee S and Williams GD. Clinical and
laboratory measures of postural balance in an elderly popu-
lation. Physiother Can 1989; 41: 304–311.
1 5. Kollen B, Van de Port I, Lindeman E, Twisk J and
Kwakkel G. Predicting improvement in gait after
stroke: a longitudinal prospective study. Stroke 2005;
36: 2676–2680.
16. Andersson AG, Kamwendo K, Seiger A and Appelros P.
How to identify potential fallers in a stroke unit: Valid-
ity indexes of four test methods. J Rehabil Med 2006; 38:
186–191.
17. Stevenson TJ. Detecting change in Patients with stroke
using the Berg Balance Scale. Austr J Physiother 2001; 47:
29–38.
18. Duncan PW, Weiner DK, Chandler J and Studenski S.
Functional reach: a new clinical measure of balance. J
Gerontol 1990; 45: M192–M197.
19. Holden MK, Gill KM, Magliozzi MR, Nathan J and Piehl-Baker
L. Clinical gait assessment in the neurologically impaired. reli-
ability and meaningfulness. Phys Ther 1984; 1: 35–40.
20. Collen FM, Wade DT, Robb GF and Bradshaw CM. The
Rivermead Mobility Index. A further development of the
Rivermead Motor Assessment. Int Disabil Stud 1991; 2:
50–54.
21. Schädler S, Kool J, Lüthi H, et al. Assessments in der Reha-
bilitation, Vol 1: Neurologie, second edition. Bern: Verlag
Hans Huber, 2009, pp. 76–78.
22. Faul F, Erdfelder E, Lang AG and Buchner A. G*Power 3:
A flexible statistical power analysis program for the social,
behavioral, and biomedical sciences. Behav Res Meth 2007;
2: 175–191.
23. Mehrholz J, Wagner K, Rutte K, Meissner D and Pohl M.
Predictive validity and responsiveness of the Functional
Ambulation Category in hemiparetic patients after stroke.
Arch Phys Med Rehabil 2007; 88: 1314–1319.