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European Journal of Physiotherapy

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Task-oriented training and lower limb strengthening

to improve balance and function after stroke: A pilot
study
a b b b
Beatriz Fernandes , Maria José Ferreira , Filomena Batista , Isabel Evangelista , Leonor
b c
Prates & Joaquim Silveira-Sérgio
a
Escola Superior de Tecnologia da Saúde de Lisboa, Lisbon, Portugal
b
Hospital Fernando Fonseca, Lisbon, Portugal
c
Escola Superior de Saúde da Cruz Vermelha Portuguesa, Lisbon, Portugal
Published online: 03 Apr 2015.

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To cite this article: Beatriz Fernandes, Maria José Ferreira, Filomena Batista, Isabel Evangelista, Leonor Prates & Joaquim
Silveira-Sérgio (2015) Task-oriented training and lower limb strengthening to improve balance and function after stroke: A
pilot study, European Journal of Physiotherapy, 17:2, 74-80, DOI: 10.3109/21679169.2015.1028102

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 European Journal of Physiotherapy, 2015; 17: 74–80

ORIGINAL ARTICLE

Task-oriented training and lower limb strengthening to improve

balance and function after stroke: A pilot study
Downloaded by [b-on: Biblioteca do conhecimento online IPL], [Beatriz Fernandes] at 09:24 02 September 2015

BEATRIZ FERNANDES1, MARIA JOSÉ FERREIRA2, FILOMENA BATISTA2,

ISABEL EVANGELISTA2, LEONOR PRATES2 & JOAQUIM SILVEIRA-SÉRGIO3
1Escola Superior de Tecnologia da Saúde de Lisboa, Lisbon, Portugal, 2Hospital Fernando Fonseca, Lisbon, Portugal, and
3Escola Superior de Saúde da Cruz Vermelha Portuguesa, Lisbon, Portugal

Abstract
This study investigated the effects of task-oriented training and strengthening of the affected lower limb on balance and
function in people who have suffered a stroke. Sixteen male adults, with a mean age of 58 (SD 6.3) years, undergoing
outpatient physiotherapy less than 1 month after a single stroke in the territory of the middle cerebral artery were recruited.
Participants were allocated to one of two groups: the strengthening group (SG) or control group (CG). The main measures
used were the Berg Balance Scale (BBS), Barthel Index (BI) and Modified Ashworth Scale (MAS). After 12 weeks of
intervention, both groups showed improvements in outcome measures. For BBS, there was a significant difference between
groups, with an increase of 26 points in the SG and 11 points in the CG. For BI, the SG improved by 39 points and the
CG improved by 22 points. After intervention, the difference between groups was not significant. For MAS, differences
were not significant, showing that for both groups intervention programmes did not increase spasticity. In conclusion,
physiotherapy intervention for postural control dysfunctions after stroke seems to benefit from strength training of the
affected lower limb and the practising functional tasks. A large randomized controlled trial is recommended to further
investigate the effects of this intervention.

Key words: Functionality, independence, physiotherapy, postural control

Introduction
Cerebrovascular diseases are among the primary
causes of morbidity and disability in developed coun-
tries. Stroke can affect different areas of the cerebral
hemispheres according to the blood vessels involved
and the territories they supply (1). Postural instabil-
ity is one of the most common consequences of
stroke. People with difficulty in maintaining stability
become more inactive and unfit and are predisposed
to a sedentary lifestyle with reduced physical activity
(2,3). This behaviour also contributes towards limit-
ing the performance of activities of daily living
(ADL), and increases the risks of falling, stroke rep-
etition and cardiovascular disease (2).
After a stroke, individuals show increased diffi-
culty in activating trunk and limb muscles from the
affected side and experience a reduced ability to
move and walk (4–6). Muscle weakness and the
decrease in endurance, in addition to the loss of
motor dexterity, are common changes that are con-
sidered primary causes of motor dysfunctions (7).
These problems result directly from the brain lesion
and can persist beyond physiotherapy intervention
(7–10). Muscle weakness after stroke was assumed
to be the result of co-contraction of antagonist mus-
cle groups (11). These theories stated that muscle
weakness was due to an excessive co-contraction pre-
venting the effective contraction of agonists (12).
Recent research has not found evidence for this
assumption and has pointed out that the prime cause
for muscle weakness is the impaired activation of
agonist muscle groups (7,13).
Lower limb muscle strength is a major concern
for physiotherapists during the rehabilitation of indi-
viduals who have suffered a stroke, because it is
critical to sustain body weight and maintain stance.
Balance problems are related to falls and patients
with severe incapacity after stroke are more likely to

Correspondence: Beatriz Fernandes, Av. D. João II, Lote 4.69.01, 1990-096 Lisboa, Portugal. E-mail: beatriz.fernandes@estesl.ipl.pt

(Received 14 November 2014 ; accepted 8 March 2015)

ISSN 2167-9169 print/ISSN 2167-9177 online © 2015 Informa Healthcare
DOI: 10.3109/21679169.2015.1028102

fall, even during rehabilitation. This instability limits
function and increases the need for assistance during
ADL (14–16). Balance is specific for each activity
and people need to use precise strategies according
to the task and the environment in which it is being
performed (7,11). During treatment, balance must
be trained in several settings, considering the activi-
ties that the individual needs to learn. In physiother-
apy sessions each task performed also allows postural
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control training because it requires postural adjust-
ments before, during and after each movement.
Recent evidence has indicated that strengthening
exercises increase strength, improve activity and do
not increase spasticity (17–20). However, there is a
lack of studies with patients in the subacute stage
after stroke that are designed to verify whether the
combination of a task-oriented programme with
lower limb strengthening is effective in increasing
balance and functionality.
Methods
Subjects
Data were collected at a general hospital: Hospital
Fernando Fonseca. Inclusion criteria were: one single
stroke in the territory of the middle cerebral artery in
the previous month, age between 50 and 65 years, no
cognitive deficit according to the Mini-Mental State
Examination, and a Berg Balance Scale (BBS) score
lower than 45. Participants were excluded if they had
comorbid conditions interfering with the rehabilita-
tion process (e.g. cardiac failure, musculoskeletal dys-
functions on lower limbs or neurological conditions
interfering with postural stability).
Sixteen participants were recruited and alter-
nately assigned into one of two groups as they were
enrolled in the study: strengthening group (SG)
(N ⫽ 9) and control group (CG) (N ⫽ 7). All par-
ticipants were male, 12 with cerebral vascular acci-
dent on the right hemisphere and four on the left.
The mean age of all participants was 58 (SD 6.3)
years (range 50–65 years).
All participants provided written informed con-
sent to participate in the study and agreed to carry
out physiotherapy treatments at Fernando Fonseca
Hospital. Ethical approval was obtained from the
Fernando Fonseca Ethics Committee.
Outcome measures
The main outcome measures were balance, func-
tional independence and spasticity. We assessed all
variables at baseline and at the end of 12 weeks of
physiotherapy intervention. To assess balance we
used the BBS (21), for functional independence the
Strength and balance after stroke 75
Barthel Index (BI) (22) and for spasticity the Modi-
fied Ashworth Scale (MAS) (23).
BBS is an instrument developed by Katherine
Berg in 1992 to assess balance in elderly people
(24). This scale has been used to assess balance in
people with stroke and has proven to be valid and
reliable (16,21,25). It has been shown that it is sen-
sitive to changes in balance and therefore is suitable
to measure outcomes in rehabilitation programmes
(21,25–27). BBS is easy to use. It comprises
14 items that assess balance while performing well-
described activities. Each item is classified from 0
(inability to perform the task) to 4 (independent
and safe performance). The maximum score is
56 points. Despite its ceiling and floor effects, it is
valuable in assessing clinical change in balance
after stroke; however, it should be used with cau-
tion to assess patients who have severe or mild
impairments (21).
The BI, developed by Mahoney and Barthel (28),
is a valid and reliable scale (22,29) that assesses the
level of autonomy in performing ADL. In 1989, Shah
(22) developed a modified version which is more
sensitive for individuals with stroke. The BI is an
ordinal scale that comprises 10 activities related to
self-care and mobility. Each activity is classified
according to the level of assistance that the person
needs to accomplish the task, ranging from level 1
(inability to perform the activity) to level 5 (total
independence). The maximum score of 100 points
corresponds to total independence.
The evidence indicates that there is an excellent
correlation between BBS and BI (21). This correla-
tion is also related to the ability of BBS to predict
disability. It has been demonstrated that BBS admin-
istered 14 days after stroke is correlated with BI at
90 days post-stroke, which means that BBS could
predict disability level (30).
The MAS is a six-point ordinal scale developed
to graduate spasticity evaluated by passive stretching
of specific muscle groups (23), varying from 0 (no
increase in muscle tone) to 4 (affected parts rigid in
flexion or extension), with a level “1⫹” between lev-
els 1 and 2. Although its reliability has been shown
in patients with stroke, caution is recommended
when using it (31,32).
Procedure
The SG received therapy based on task-oriented
training focused on balance and strength training of
the affected lower limb. The task-oriented interven-
tion programme was based on the guidelines pro-
posed by Shumway-Cook and Woollacott (33) and
Carr and Shepherd (34) and is focused on the spec-
ificity of postural adjustments that occur before and
 76 B. Fernandes et al.
during voluntary motor actions as well as in response populations from independent samples and the Wil-
to perturbations. The participants were invited to coxon signed rank test to compare populations from
practise activities that require specific postural paired samples. A Spearman’s correlation was run to
responses and to perform exercises to strengthen investigate whether there were associations between
muscles from the affected lower limb that are essen- balance and function.
tial to maintain stability. The activities include reach-
ing and dexterity tasks with different objects
performed in different settings, seated and standing, Results
in order to be varied and motivating while creating
A total of 16 men participated in this study. The time
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challenging situations that can stimulate the ability

from stroke onset was 16.2 ⫹ 4.4 days. Eleven subjects
to solve problems posed by the task. Tasks were
had had an ischaemic stroke (six in SG and five in
adapted to each participant according to his needs
CG) and five a haemorrhagic stroke (three in SG and
and capacities and were performed repeatedly during
two in CG). Twelve had had a stroke in the right hemi-
the sessions. The activities were also adjusted to each
sphere (eight in SG and four in CG) and four in the
participant’s progress. In addition, this group received
left hemisphere (one in SG and three in CG).
strength training of the affected lower limb based on
At baseline, there were no significant differences
the orientations by Carr and Shepherd for individu-
between groups for all variables including age and
als who have suffered a stroke (34). The intervention
time after stroke (Table I). Regarding BBS, the
protocol included isometric, isotonic, eccentric and
median score was 25 (range 5–44) points for the SG
concentric exercises in open and closed kinetic
and 36 (28–40) points for the CG. For BI, the median
chains. For each muscle group, the participants were
score was 46 (33–80) in the SG and 74 (51–84) in
asked to perform the movement against gravity. If
the CG. In both groups, spasticity levels in different
this was not possible an alternative position was cho-
muscle groups of the affected lower limb varied from
sen. In each session, participants performed three
1 to 2 on MAS. Although there were no significant
series of 10 repetitions for each muscle group. In the
differences between groups, it should be noted that
first session and for resistance exercises, one repeti-
the median values for BI and BBS at baseline were
tion maximum (1RM) was calculated. Progression
quite different.
was carried out in two ways: to a position allowing
After 12 weeks of intervention, both groups showed
isolated movement or by increasing the resistance in
an improvement in outcome measures (Table II).
the same position.
For BBS, there was an increase in the median scores
The CG intervention consisted only of therapy
of 26 points in the SG and 11 points in the CG. The
based on task-oriented training without specific
median score change for BI in the SG was 39 points
strengthening exercises. The activities proposed for
this group were the same as for the CG. Both groups
received 70 min of therapy, four times per week, for
12 weeks, ensuring that all participants spent the Table I. Baseline characteristics.
same time in practice and eliminating the effects due Strengthening Control
to extra time spent in therapy. Each person in both group group p
groups received a total of 48 treatment sessions. (N ⫽ 9) (N ⫽ 7)
Given the nature of the treatment, it was not pos- Age (years) 58 ⫾ 6 (50–65) 58 ⫾ 7 (50–65) NS
sible to ensure that the therapist and the outcome Time after stroke (days) 15 ⫾ 5 (8–26) 17 ⫾ 4 (14–23) NS
assessor were blinded. However, participants were Spasticity
blinded to group allocation. Intervention programmes Knee extensors 1 (0–2) 1 (0–2) NS
were administered by two different physiotherapists, (MAS)
Knee flexors (MAS) 0 (0–0) 0 (0–0) NS
both experts in stroke rehabilitation. Participants
Ankle dorsiflexors 0 (0–0) 0 (0–0) NS
also received occupational therapy and speech ther- (MAS)
apy if required. Ankle plantarflexors 1 (0–2) 1 (0–2) NS
(MAS)
Functional 46 (33–80) 74 (51–84) NS
Data analysis independence (BI)
Balance (BBS) 25 (5–44) 36 (28–40) NS
Data were analysed using the Statistical Package for
the Social Sciences (SPSS 20.0; SPSS, Chicago, IL, MAS, Modified Ashworth Scale; BI, Barthel Index; BBS, Berg
Balance Scale.
USA). Descriptive statistics was used to characterize
Differences between groups (Mann–Whitney U test); NS, non-
the sample. Considering that data were not normally significant (p ⱖ 0.05).
distributed, we used non-parametric tests for statisti- Data are shown as mean ⫾ SD or median (minimum–
cal inference: the Mann–Whitney U test to compare maximum).

Table II. Outcome measures scores at each time-point.
Strengthening group (N ⫽ 9)
Baseline Post-intervention
BI 46 98
BBS 25 52
Spasticity
Knee extensors (MAS) 1 1
Knee flexors (MAS) 0 0
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Ankle dorsiflexors (MAS) 0 0
Ankle plantarflexors (MAS) 1 1
BI, Barthel Index; BBS, Berg Balance Scale; MAS, Modified Ashworth Scale.
Differences between groups (Mann–Whitney U test); NS, non-significant (p ⱖ 0.05).
Data are shown as median values.
and in the CG 22 points. Wilcoxon signed rank tests
were run to compare the values before and after the
intervention. The results showed that the differences
were significant in both groups, for BBS (SG p ⫽ 0.002;
CG p ⫽ 0,008) and BI (SG p ⫽ 0.002; CG
p ⫽ 0.008).
With regard to BBS, the comparison between
groups after the intervention showed that there was
a significant difference, with the SG achieving a
larger improvement (Table II). For MAS, the median
values at baseline were low and at the end of the
intervention the differences were not significant,
showing that for both groups the intervention pro-
grammes did not affect spasticity.
Regarding the associations between BBS and BI,
we found a strong positive correlation between bal-
ance and functionality (rs ⫽ 0.743, n ⫽ 16, p ⬍ 0.01).
Discussion
Given the small size of the sample and the fact that
the SG started at lower scores than the CG in BBS
and BI, the conclusions of our study must be taken
with caution. Improvements in balance and function
were observed in all participants submitted to phys-
iotherapy programmes; however, improvements in
balance were higher when the intervention both
included task-oriented training and affected lower
limb muscle strengthening.
Balance
At baseline, BBS scores indicated that the partici-
pants in our study had balance impairments, which
are associated with an increased risk of falling
(15,16,35,36). BBS items that showed lower marks
are those requiring the displacement of the centre of
mass and/or the performance of the activity in a short
period. The literature points out that individuals who
have suffered a stroke have increased response timing
Strength and balance after stroke 77
Control group (N ⫽ 7)
Difference Baseline Post-intervention Difference p
39 74 96 22 NS
26 36 47 11 0.008
0 1 1 0 NS
0 0 0 0 NS
0 0 0 0 NS
0 1 1 0 NS
to balance perturbations and a lower response range
on the affected side compared with the non-affected
side (35,37). The delay in motor response, namely in
the affected lower limb muscles, increases the risk of
falling, which is higher for the affected side (4–6).
The statistically significant improvements in BBS
indicate that both programmes had positive effects on
balance. There is evidence suggesting that interven-
tions based on task-oriented training can improve pos-
tural control (11,33,38–42). Our intervention
programme was designed to promote stability during
the performance of specific tasks, requiring different
postural responses in different environments. This
intervention promotes the recovery of postural con-
trol, developing effective sensitive and motor strategies
in controlling the centre of mass in relation to the base
of support (7). The goal is not to decrease sway but
to be able to move the centre of mass in different
directions while maintaining stability (7,40,43).
The SG performed a programme with task-
oriented training and strengthening exercises of the
affected lower limb designed to increase coordina-
tion and muscle strength, in order to allow body
weight support and decrease the fall risk (7,8,11,44).
The strengthening exercises should start in the acute
phase since there is a positive correlation between
muscle strength, functionality and fall prevention
(8). Our results showed that the SG had higher scores
than the CG on the BBS, which is in accordance with
the studies mentioned above. However, in our study
the SG started with lower scores than the CG, which
could influence the results since it is easier to improve
when starting scores are lower.
Function
BI scores at baseline showed somewhat low to moder-
ate dependency levels (22). This means that some of
the individuals were to some extent independent in
self-care and others needed moderate assistance to
 78 B. Fernandes et al.
perform some activities (45). After-stroke functional-
ity depends on mobility. Patients have a tendency for
inactivity, which leads to physical deconditioning (2).
The combination of these factors contributes towards
restricting the performance of ADL, such as feeding,
bathing, dressing and walking.
After 12 weeks of intervention, both groups had
statistically significant improvements in BI scores,
which suggests that the interventions based on task-
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oriented training are beneficial to the recovery of
functional independence (40,44).
Comparing both groups, we can see that there are
no significant differences in BI, probably owing to the
small group sizes. The participants in the SG had
larger improvements in BI than those in the CG; how-
ever, the SG started with lower scores. Lower limb
strengthening of the affected leg has shown positive
effects on functionality of individuals with stroke.
Activities such as personal hygiene, feeding and walk-
ing are easier to perform after physiotherapy pro-
grammes that include lower limb strengthening
(8,17,20,46,47). Task-oriented training is critical to
recover function since the practice of specific activities
during treatment allows the individual to reacquire the
ability to perform them in an independent way (7,11).
Our intervention programme included several task-
oriented activities designed to improve postural con-
trol; however, these tasks were not specific ADL.
Our strengthening exercises were directed towards
muscles of the affected lower limb. We think that it
would be important to study the variable muscle
strength in both lower limbs. The inclusion of
strengthening exercises for the non-affected lower
limb may be an interesting research line to explore
in future studies, in order to investigate whether it
contributes to a better improvement in function
along with task-oriented training.
Spasticity
The results of our study indicate that lower limb
strengthening exercises seem to be appropriate for
people with stroke who have muscle weakness, as
recent evidence suggests (48). Strengthening exer-
cises for lower limb muscle groups seem to contrib-
ute towards increasing strength and improving
activity without increasing spasticity, and should be
included in intervention plans (18–20).
Limitations
The sample size is one of the major limitations of this
study. A large sample is needed to obtain results that
allow the effects of the intervention programme to
be analysed more accurately.
Another limitation is related to the median scores
in BBS and BI at baseline. As mentioned before, for
both BBS and BI the SG started with lower median
scores than the CG, which means that it may have
been easier for the SG than the CG to achieve larger
improvement.
Finally, the lack of data about levels of lower limb
muscle strength prevents analysis of the effects of
strengthening exercises on muscle strength. Future
studies could investigate whether lower limb muscle
strength is decreased after stroke and whether the
strengthening programme contributes towards
increasing lower limb strength and improving bal-
ance and function.
Conclusion
Physiotherapy intervention for postural control
dysfunctions after stroke seems to benefit from
strength training of the affected lower limb com-
bined with the practice of task-oriented training.
The two strategies are complementary since
strength training must be conducted in accordance
with the task and, at the same time, the repetition
of the task also involves a certain degree of strength
training.
Acknowledgements
This study was made possible thanks to the work of
the interdisciplinary staff of the Department of
Physical Medicine and Rehabilitation of Hospital
Fernando da Fonseca, Amadora, Portugal.
Funding
This study was partially supported by a grant
from the Portuguese Foundation for Science and
Technology [SFRH/PROTEC/49675/2009].
Declaration of interest: None to declare.
References
1. Baer G, Durward B. Stroke. In: Stokes M, editor. Physical
management in neurological rehabilitation. 2nd ed. London:
Elsevier Mosby; 2004, pp. 75–98.
2. Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA,
Roth EJ, et al. Physical activity and exercise recommenda-
tions for stroke survivors: an American Heart Association
Scientific Statement from the Council on Clinical Cardio-
logy, Subcommittee on Exercise, Cardiac Rehabilitation and
Prevention; the Council on Cardiovascular Nursing; the
Council on Nutrition; Physical Activity and Metabolism; and
the Stroke Council. Stroke. 2004;35:1230–40.

3. Mead G. What is stroke? In: Mead G, Wijck Fv, editors.
Exercise and fitness training after stroke. Edinburgh:
Churchill Livingstone; 2013, pp. 3–20.
4. Messier S, Bourbonnais D, Desrosiers J, Roy I. Dynamic
analysis of trunk flexion after stroke. Arch Phys Med Rehabil.
2004;85:1619–24.
5. Dickstein R, Shefi S, Marcovitz E, Villa Y. Anticipatory
postural adjustment in selected trunk muscles in poststroke
hemiparetic patients. Arch Phys Med Rehabil. 2004;
85:261–7.
6. Dean C, Shepherd R. Task-related training improves
Downloaded by [b-on: Biblioteca do conhecimento online IPL], [Beatriz Fernandes] at 09:24 02 September 2015
performance of seated reaching tasks after stroke: a randomized
controlled trial. Stroke. 1997;28:722–8.
7. Carr J, Shepherd R. Neurological rehabilitation: optimizing
motor performance. 2nd ed. Edinburgh: Churchill Living-
stone; 2011.
8. Duncan P, Zorowitz R, Bates B, Choi J, Glasberg J, Graham G,
et al. Management of adult stroke rehabilitation care: a clinical
practice guideline. Stroke. 2005;36:e100–43.
9. Dehkordi S, Talebian S, Olyaei G, Montazeri A. Reliability
of isokinetic normalized peak torque assessments for knee
muscles in post-stroke hemiparesis. Gait Posture. 2008;
27:715–8.
10. Kesar T, Ding J, Wexler A, Perumal R, Maladen R,
Binder-Macleod S. Predicting muscle forces of individuals
with hemiparesis following stroke. J Neuroeng Rehabil.
2008;5:7.
11. Shumway-Cook A, Woollacott M. Motor control: translating
research into clinical practice. 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2011.
12. Bobath B. Adult hemiplegia: evaluation and treatment.
2nd ed. Oxford: Butterworth-Heinemann; 1978.
13. Gracies J. Pathophysiology of spastic paresis. I: Paresis and
soft tissue changes. Muscle Nerve. 2005;31:535–51.
14. Czernuszenko A, Czionkowska A. Risk factors for falls in
stroke patients during inpatient rehabilitation. Clin Rehabil.
2009;23:176–88.
15. Teasell R, McRae M, Foley N, Bhardwaj A. The incidence
and consequences of falls in stroke patients during inpatient
rehabilitation: factors associated with high risk. Arch Phys
Med Rehabil. 2002;83:329–33.
16. Andersson AG, Kamwendo K, Seiger A, Appelros P. How to
identify potential fallers in a stroke unit: validity indexes of
four test methods. J Rehabil Med. 2006;38:186–91.
17. Parvataneni K, Olney S, Brouwer B. Changes in muscle
group work associated with changes in gait speed of persons
with stroke. Clin Biomech. 2007;22:813–20.
18. Ada L, Dorsch S, Canning CG. Strengthening interventions
increase strength and improve activity after stroke: a systematic
review. Aust J Physiother. 2006;52:241–8.
19. Kim CM, Eng JJ. The relationship of lower extremity muscle
torque to locomotor performance in people with stroke.
Phys Ther. 2003;83:49–57.
20. Teixeira-Salmela LF, Olney SJ, Nadeau S, Brouwer B.
Muscle strengthening and physical conditioning to reduce
impairment and disability in chronic stroke survivors. Arch
Phys Med Rehabil. 1999;80:1211–8.
21. Blum L, Korner-Bitensky N. Usefulness of the Berg Balance
Scale in stroke rehabilitation: systematic review. Phys Ther.
2008;88:559–66.
22. Shah S. Modified Barthel Index or Barthel Index (Expanded).
In: Salek S, editor. Compendium of quality of life instru-
ments. Part II. Chichester: Wiley and Sons; 1998, pp. 1–9.
23. Bohannon RW, Smith MB. Interrater reliability of a Modified
Ashworth Scale of muscle spasticity. Phys Ther. 1987;
67:206–7.
Strength and balance after stroke 79
24. Berg KO, Wood-Dauphinee SL, Williams J, Maki B. Measuring
balance in the elderly: validation of an instrument. Can J
Public Health. 1992;83(Suppl 2):S7–11.
25. Mao HF, Hsuch IP, Tang PF, Sheu CF, Hsich CL. Analysis
and comparison of the psychometric properties of three bal-
ance measures for stroke patients. Stroke. 2002;33:1022–7.
26. Stevenson TJ. Detecting change in patients with stroke using
the Berg Balance Scale. Aust J Physiother. 2001;47:29–38.
27. English CK, Hillier SL, Stiller K, Warden-Flood A. The sen-
sitivity of three commonly used outcome measures to detect
change amongst patients receiving inpatient rehabilitation
following stroke. Clin Rehabil. 2006;20:52–5.
28. Mahoney FI, Barthel DW. Functional evaluation: the Barthel
Index. Md Med J. 1965;14:61–5.
29. Novak S, Johnson J, Greenwood R. Barthel revisited: making
guidelines work. Clin Rehabil. 1996;10:128–34.
30. Chou C, Chien C, Hsueh I, Sheu C, Wang C, Hsieh C.
Developing a short form of the Berg Balance Scale for peo-
ple with stroke. Phys Ther. 2006;86:195–204.
31. Blackburn M, Van Vliet P, Mockett S. Reliability of measure-
ments obtained with the Modified Ashworth Scale in the lower
extremities of people with stroke. Phys Ther. 2002;82:25–34.
32. Johnson GR. Outcome measures of spasticity. Eur J Neurol.
2002;9(S1):10–6.
33. Shumway-Cook A, Woollacott M. Motor control: translating
research into clinical practice. 3rd ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2007.
34. Carr J, Shepherd R. Stroke rehabilitation: guidelines for exercise
and training to optimize motor skill. London: Butterworth-
Heinemann; 2003.
35. Ikai T, Kamikubo T, Takehara I, Nishi M, Miyano M.
Dynamic postural control in patients with hemiparesis.
Am J Phys Med Rehabil. 2003;82:463–9.
36. Ustinova KI, Ioffe ME, Chernikova LA. Characteristic
features of disorders of the upright posture in patients with
poststroke hemipareses. Hum Physiol. 2003;29:140–7.
37. Garland S, Willems D, Ivanova T, Miller K. Recovery of
standing balance and functional mobility after stroke.
Arch Phys Med Rehabil. 2003;84:1753–9.
38. International Bobath Instructors Training Association.
Theoretical assumptions and clinical practice. IBITA; 2008
Available from http://www.ibita.org/ [updated September
2008; cited July 27, 2010].
39. Intercollegiate Stroke Working Party. Physiotherapy concise
guide for stroke. London: Royal College of Physicians of
London; 2006.
40. Leroux A, Pinet, H, Nadeau S. Task-oriented intervention in
chronic stroke: changes in clinical and laboratory measures
of balance and mobility. Am J Phys Med Rehabil.
2006;85:820–30.
41. Pollock A, Baer G, Pomeroy V, Langhorne P. Physiotherapy
treatment for the recovery of postural control and lower limb
function following stroke [database on the Internet].
Cochrane Database Syst Rev. John Wiley & Sons; 2007.
42. Langhammer B, Stanghelle J. Bobath or motor relearning
programme? A comparison of two different approaches of
physiotherapy in stroke rehabilitation: a randomized control-
led study. Clin Rehabil. 2000;14:361–9.
43. Roerdink M, De Haart M, Daffertshofer A, Donker SF,
Geurts ACH, Beek PJ. Dynamical structure of center-
of-pressure trajectories in patients recovering from stroke.
Exp Brain Res. 2006;174:256–69.
44. Van Peppen RPS, Kwakkel G,Wood-Dauphinee S, Hendriks HJM,
Van der Wees PJ, Dekker J. The impact of physical therapy
on functional outcomes after stroke: what’s the evidence?
Clin Rehabil. 2004;18:833–62.
 80 B. Fernandes et al.
45. Sulter G, Steen C, De Keyser J. Use of the Barthel Index
and Modified Rankin Scale in acute stroke trials. Stroke.
1999;30:1538–41.
46. Sullivan K, Brown D, Klassen T, Mulroy S, Ge T, Azen S, et al.
Effects of task-specific locomotor and strength training in
adults who were ambulatory after stroke: results of the STEPS
randomized clinical trial. Phys Ther. 2007;87:1580–602.
Downloaded by [b-on: Biblioteca do conhecimento online IPL], [Beatriz Fernandes] at 09:24 02 September 2015
47. Yang Y, Wang R, Lin K, Chu M, Chan R. Task oriented pro-
gressive resistance strength training improves muscle strength
and functional performance in individuals with stroke. Clin
Rehabil. 2006;20:860–70.
48. Logan LR. Rehabilitation techniques to maximize
spasticity management. Top Stroke Rehabil. 2011;18:
203–11.