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doi:10.1111/ncn3.

12092

ORIGINAL ARTICLE

Pelvic alignment in standing, and its relationship with trunk


control and motor recovery of lower limb after stroke
Suruliraj Karthikbabu,1 Mahabala Chakrapani,2 Sailakshmi Ganesan3 and Ratnavalli Ellajosyla4
Departments of 1Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal Hospital, Bangalore, 2Medicine, 3Physiotherapy,
Kasturba Medical College, Manipal University, Mangalore, and 4Neurology, Manipal Hospital, Bangalore, India

Key words Abstract


motor recovery, pelvic tilt, postural control, Background: The pelvis is not stable after stroke, and poor trunk recovery might
stroke, trunk control.
be the foremost contributor to altered pelvic alignment in sitting, standing and
during walking.
Accepted for publication 31 July 2016.
Aim: To analyze the relationship between pelvic alignment in standing and trunk
control after stroke, and also test how these correlations are related to Brunn-
Correspondence
S Karthikbabu
stroms lower limb motor recovery.
Department of Physiotherapy, School of Allied
Methods: In the present cross-sectional study, 116 ambulant patients after stroke
Health Sciences (SOAHS), A Constituent were assessed for their pelvic tilt angles in standing and trunk control using a pal-
College of Manipal University, Manipal pation meter (PALM device) and the Trunk Impairment Scale (TIS), respectively.
Hospital, Old Airport Road, Bangalore 560017, The pelvic tilt values were correlated to TIS scores by the Pearsons correlation
India. Emails: karthik.babu@manipal.edu; coefficient.
karthikbabu78@gmail.com Results: The mean age, post-stroke duration, and Brunnstroms lower limb motor
recovery of study participants were 55 (13) years, 14.2 (11.3) months and 3.75
(0.79), respectively. The present study reported more lateral pelvic tilt of 2.47
(1.78) towards the most affected side and an anterior pelvic tilt of 4.4 (1.8)
bilaterally. The mean score of TIS was 10.4 (3). Pelvic tilt angles had a moderately
inverse correlation with the total TIS score and coordination subscale of TIS (r-
value from 0.44 to 0.54), but a low inverse relationship to the dynamic sitting
balance subscale of TIS (0.36 to 0.45). Also, the pelvic tilt had a high negative
correlation with trunk control (r-value from 0.68 to 0.84) in lower limb motor
recovery stage 5.
Conclusion: Pelvic alignment when standing is not normal after stroke, and this is
influenced by poor trunk control and impairment of the lower extremities. Assess-
ment of the pelvis provides further insight into planning the appropriate rehabilita-
tion strategies in stroke.

the pelvic movement, and this transverse thoraxpelvis coor-


Introduction
dination is related to poor gait and balance capacities in
Lower trunk and hip muscular coactivity provides stability people post-stroke.6
to the pelvis, and serves the function of postural stability After stroke, there is a reduced anterior displacement of
and transferring the load to the lower extremities in stand- the body mass with an unequal weight bearing on both feet
ing.1,2 The altered recruitment of hip abductors and exten- during forward reaches in the sitting position. Most of the
sors on the most affected leg influences the pelvic stability, flexion movement is accomplished by the upper trunk, with
thus resulting in more lateral and anterior pelvic tilt in the minimum anterior tilt of the pelvis indicating poor postural
frontal and sagittal plane, respectively.3 There is a gross stability of lower trunk.7 In a cross-sectional study, an
impairment of gluteus medius muscle activity during pertur- increased lateral pelvic towards of the most affected side
bations in standing, and this is compensated by increased was observed using a PALM device, and was related to
activity of the contralateral hip muscles after stroke.4 People poor trunk control and lower limb recovery after stroke.8
post-stroke have a more forward-leaning posture with an Brunnstroms motor recovery grading is widely used by
anteriorly tilted pelvis in standing, and their altered postural physical therapists to assess the prognosis of lower limb
alignment is related to worse trunk control and balance abil- motor recovery in people with stroke.9 The involvement of
ity.5 On observing the intersegmental trunk coordination trunk control after stroke is related to balance, gait and
during gait, the thoracic range of movement is more than function, but how impaired trunk control influences the

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2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
Pelvic alignment and trunk control after stroke S Karthikbabu et al.

pelvic position in standing posture is less known.10 The aim The data were analyzed using SPSS software (version 16.0;
of the present study was to test the relationship between pel- SPSS, Chicago, IL, USA), and the demographic characteris-
vic alignment in standing and trunk control after stroke, tics were reported with descriptive statistics. Pearsons corre-
and also to find how these correlations are related to differ- lation coefficient (r) was used to test the relationship
ent stages of lower limb motor recovery. between pelvic alignment (lateral pelvic tilt on most affected
side, anterior pelvic tilt bilaterally) and trunk control (total
TIS score, dynamic sitting balance and coordination sub-
Methods
scales of TIS). Furthermore, we grouped the population into
The present cross-sectional study received the approval from three strata based on their lower limb recovery stage ranging
the institutional research committee of Manipal University, from 3 to 5, and then analyzed the correlation between the
India. People after stroke were contacted, and an explana- pelvic alignment and trunk control for each strata. The
tion was given about the purpose, benefits and brief interpretation of either positive or negative values of corre-
methodology of the study. All the volunteers signed an lation coefficient (r-value) is classified as follows: r < 0.20,
informed consent form before their participation in the very low; 0.200.39, low; 0.400.59, moderate; 0.600.79,
study. After screening for study eligibility, people after high; and 0.801.00, very high. A P-value <0.05 was consid-
stroke with an ambulatory capacity were recruited from ter- ered as statistically significant, and a P-value of <0.001 as
tiary care rehabilitation centres, community settings, and highly statistically significant. The scores of clinical measures
outpatient physiotherapy departments of speciality hospitals were plotted in a scattergram to allow a visual interpretation
between June 2011 and May 2015. People with first ever of how strong the relationship was between the variables.15
ischemic or hemorrhagic stroke, both sexes aged between 30
and 70 years, walk ability with/without walking aids, medi-
Results
cal stability, no brainstem and/or cerebellar stroke, absence
of visual field defects, and Brunnstroms recovery stage of Among 116 patients included in the study, 72 were men and
3 were included in the study. People with the following 44 were women, with a mean (SD) age of 55 years
impairments were excluded from the study: any peripheral (13 years) and post-stroke duration of 14 months
vestibular dysfunction, severe sensory loss on the soles of (11 months). A total of 70 patients (60%) had ischemic
the feet affecting standing balance, any perceptual dysfunc- stroke lesion, and 46 (40%) had hemorrhagic stroke lesion.
tion that might limit their understanding to verbal instruc- Right-sided stroke was present in 75 patients (65%),
tions, any diagnosed fracture and/or surgeries of lower whereas 41 patients (35%) had left-sided stroke. The mean
extremities in the recent 4-month period, severe chronic (SD) Brunnstroms lower limb motor recovery stage was 3.8
back and/or knee pain that affected their standing posture, (0.8), and the number of people from third, fourth, and fifth
and contracture of hip flexors and ankle plantar flexors lim- stage motor recovery was 43, 54 and 19 individuals, respec-
iting the passive range of movement to neutral hip extension tively. A total of 74 patients were independently ambulant,
and dorsiflexion, respectively. whereas 42 were using walking aids, such as a cane, tripod
After obtaining the demographic profile from patients with and so on (Table 1). When standing, the pelvic alignment
stroke, they were evaluated for their pelvic alignment in was not normal in both the frontal and sagittal planes show-
standing and trunk control in sitting by a palpation meter ing more lateral pelvic tilt of 2.47 (1.78) towards the most
(PALM device, Performance Attainment Associates, St. affected side, and an anterior pelvic tilt of 4.4 (1.8) bilater-
Paul, MN, USA)8,11,12 and Trunk Impairment Scale,13,14 ally. The mean (SD) score of total TIS (out of 16 maximum
respectively. The order of each test administration was deter- points), dynamic sitting balance (10), and coordination (6)
mined using the coin-toss method for each patient. Rest time subscales of TIS in people after stroke was found to be 10.4
of 5 min was given between the tests to overcome practice (3), 6.9 (2) and 3.6 (1.5). We measured the pelvic obliquity
effects. The palpation meter (PALM device) is a pelvic level- in the sagittal and coronal planes in 48 age-matched healthy
ing device that combines the features of a caliper and an individuals who had a weight-bearing asymmetry of 1.83%
inclinometer, and this device was tested for its intrarater and (2.82%). We observed that their pelvis was tilted 0.87
interrater reliability in measuring pelvic obliquity.11,12 Earlier (1.28) laterally towards the dominant side (95 % CI 2 to
in our settings, we carried out a testretest reliability of the 30). Also, the pelvis was tilted 2.33 (1.13) and 2.67
palpation device in 64 individuals post-stroke. We (1.27) anteriorly on the dominant and on the non-dominant
observed an excellent intrarater reliability for measuring sides, respectively (95% CI 15) in healthy people.
pelvic tilt that ranged from 0.76 to 0.91, and good interrater There was a moderate inverse correlation between total
reliability of 0.500.92. The Trunk Impairment Scale (TIS), a TIS scores and lateral pelvic tilt (r-value 0.54), and also
valid and reliable tool, has been widely used to assess the for two subscales of TIS and lateral pelvic tilt (r-value
trunk control after stroke. The dynamic sitting balance and 0.45 to 0.53). As for anterior pelvic tilt, the correlation
coordination subscales of the TIS scale with a maximum was moderate with total TIS score and coordination sub-
score of 16 points evaluate the dynamic stability of the scale of TIS (r-value 0.46 to 0.48; Table 2). On correlat-
lower trunk upon moving the upper trunk in the sagittal and - ing the pelvic tilt to trunk control in different Brunnstroms
coronal plane, and vice versa.14 These clinical measures were lower limb motor recovery, the lateral pelvic tilt was moder-
collected by four qualified physical therapists, and they ately inversely correlated with total TIS and the coordina-
were well trained to administer the TIS and PALM device. tion subscale of TIS in motor recovery stage 3 and 4

2 Neurology and Clinical Neuroscience (2016) 17


2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
S Karthikbabu et al. Pelvic alignment and trunk control after stroke

Table 1 Demographic characteristics of people with stroke we further stratified them into three groups (aged 30
Demographic variables (n = 116) 45 years in the first strata; 4659 years in the second strata
Mean age, years (SD) 54.83 (12.97) and 60 years in the third strata). The pelvic tilt angles were
Sex (male/female) 72 (62%)/44 (38%) highly negatively correlated to the trunk impairment scale
Type of lesion (ischemic/ 70 (60%)/46 (40%) for people who were categorized into the first and second
hemorrhagic) strata, and the corresponding P-value was statistically signif-
Side of hemiplegia (right/left) 41 (35%)/75 (65%) icant (P < 0.05). The correlation coefficient (r) of lateral pel-
Mean post-stroke duration, 14.16 (11.31) vic tilt, most affected and least affected side anterior pelvic
months (SD) tilt to trunk performance in the first strata was 0.42,
Mean Brunnstrom recovery 3.75 (0.79) 0.46 and 0.64, respectively. The correlation coefficient (r)
stage 16 (SD) in second strata was 0.61, 0.40 and 0.47, respectively.
Recovery stage 3, 4 and 5 43 (37%)/54 (47%)/19 (16%) Conversely, the correlation of trunk performance to most
Walk ability (independent/ 74 (64%)/42 (36%) affected side anterior pelvic tilt was highly positive (r-value
walking Aid) 0.32), and there was a moderate positive correlation with
Mean height, cm (SD) 167.4 (9.04) lateral pelvic tilt (0.32) and least affected side anterior pelvic
Mean weight, kg (SD) 69.66 (9.89)
tilt (0.38).
Mean BMI, kg/m2 (SD) 24.96 (3.05)

BMI, body mass index.


Discussion
(r-value 0.48 to 0.55). In recovery stage 3 and 4, the The aim of the present study was to test the relationship
dynamic sitting balance subscale of TIS showed a similar between pelvic tilt in standing and trunk control after
low negative relationship with lateral pelvic tilt (r-value 0.39 stroke, and also to find how these correlations are related to
to 0.44). Whereas the correlation of bilateral anterior pel- different stages of lower limb motor recovery. The study
vic tilt with total TIS score and its subscales was low (r- findings showed that there was an excessive anterior pelvic
value 0.25 to 0.39) in motor recovery stage 3 and 4 tilt bilaterally and a lateral pelvic tilt towards the most
(Tables 3 and 4). Interestingly, the correlation of lateral and affected side, and these pelvic deviations were moderately
anterior pelvic tilt degrees with trunk control ranged correlated to trunk control as measured by the TIS and the
between high and very high (r-value from 0.68 to 0.84) coordination subscale of TIS, but the correlation of anterior
in people with lower limb motor recovery stage 5 (Table 5; pelvic tilt was low with the dynamic sitting balance subscale
Figs. 13). According to the age of participants with stroke, of the TIS.

Table 2 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke

TIS-16 DSB-TIS Coord-TIS


10.41 (3.15) 6.88 (2.02) 3.55 (1.45)
n = 116 Mean (SD)
Pelvic tilt Degree r P r P r P

LPT 2.47 (1.78) 0.541 <0.001 0.448 <0.001 0.529 <0.001


APTMAS 4.43 (1.8) 0.431 <0.001 0.364 <0.001 0.457 <0.001
APTLAS 4.32 (1.8) 0.444 <0.001 0.364 <0.001 0.475 <0.001

P < 0.05 is significant. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS, coordination
subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r, correlation
coefficient; TIS-16, Trunk Impairment Scale-16.

Table 3 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 3

TIS-16 DSB-TIS Coord-TIS


9.35 (2.77) 6.19 (1.92) 3.17 (1.28)
n = 43 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 2.7 (1.99) 0.501 0.001 0.386 0.007 0.545 0.001


APTMAS 4.33 (1.81) 0.293 0.050 0.248 0.100 0.297 0.048
APTLAS 4.31 (1.83) 0.358 0.016 0.293 0.051 0.373 0.012

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

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2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
Pelvic alignment and trunk control after stroke S Karthikbabu et al.

Table 4 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 4

TIS-16 DSB-TIS Coord-TIS


10.36 (3.06) 6.86 (1.94) 3.50 (1.43)
n = 54 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 2.45 (1.66) 0.499 0.001 0.442 0.001 0.481 0.001


APTMAS 4.58 (1.84) 0.388 0.004 0.349 0.010 0.357 0.009
APTLAS 4.45 (1.95) 0.369 0.007 0.302 0.028 0.373 0.006

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

Table 5 Correlation between Trunk Impairment Scale and Pelvic Tilt in people post stroke with Brunnstroms recovery stage 5

TIS-16 DSB-TIS Coord-TIS


12.68 (3.09) 8.29 (1.77) 4.47 (1.47)
n = 19 Mean (SD)
Pelvic tilt Mean (SD) r P r P r P

LPT 1.64 (1.12) 0.841 0.001 0.722 0.012 0.733 0.010


APTMAS 4.09 (1.70) 0.748 0.008 0.802 0.003 0.758 0.007
APTLAS 3.73 (1.27) 0.677 0.022 0.736 0.010 0.675 0.023

P < 0.05 is significant.

Tilt values are expressed in degrees. APTLAS, anterior pelvic tilt least affected side; APTMAS, anterior pelvic tilt most affected side; Coord-TIS,
coordination subscale of trunk impairment scale; DSB-TIS, Dynamic Sitting Balance subscale of Trunk Impairment Scale; LPT, lateral pelvic tilt; r,
correlation coefficient; TIS-16, Trunk Impairment Scale-16.

12 12 Brunnstrom's recovery stage -3


Brunnstrom's recovery stage (35)
10 10
Lateral pelvic tilt
Lateral pelvic tilt

8 8

6 6

4 4

2 2

0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16

9 Brunnstrom's recovery stage -4 3.5 Brunnstrom's recovery stage -5


8 3 3
3
7
Lateral pelvic tilt

Lateral pelvic tilt

6 2.5
5 2
2
4
1.5
3
2 2
2 1
1 0.5
0 2 3
0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 1 Scattergram showing the relationship between lateral pelvic tilt and trunk control in different Brunnstroms motor recovery of the lower
extremities.

An increased bilateral forward tilted pelvis and lateral pel- abdominal wall are attached to the linea alba by more than
vic tilt towards the most affected side in standing post- half through central aponeurosis fascial expansions bilater-
stroke patients, and also their moderate correlation to trunk ally. After stroke, poor abdominal muscle activity of the
control might be explained by the following facts. The trunk most and least affected sides, and excessive trunk extensor
is activated bilaterally in postural control by extrapyramidal activity together contribute to forward tilting of the anterior
supra-spinal inputs.16 The bilateral involvement of the trunk superior iliac spines towards the femur, allowing more hip
after stroke has been widely studied.17 Also, apart from the flexion in standing. Our findings are in agreement with Ver-
rectus abdominal muscle, the rest of the muscles of the heyden et al.,5 who showed an excessive forward tilted pelvis

4 Neurology and Clinical Neuroscience (2016) 17


2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
S Karthikbabu et al. Pelvic alignment and trunk control after stroke

Anterior pelvic tilt -most affected side


Brunnstrom's recovery stage (3-5)

Anterior pelvic tilt -most affected side


Brunnstrom's recovery stage -3
12 10
9
10 8
7
8
6
6 5
4
4 3
2
2
1
0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16
Anterior pelvic tilt -most affected side

Anterior pelvic tilt -most affected side


Brunnstrom's recovery stage -4 9 Brunnstrom's recovery stage -5
12
8
10 7
3
8 6
2 2
5
6
4
2 3 4
4 3
2
2
1
0 0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 2 Scattergram showing the relationship between anterior pelvic tilt on the most affected side and trunk control in different Brunnstroms
motor recovery of the lower extremities.
Anterior pelvic tilt-least affected side

12 Brunnstrom's recovery stage (35) Anterior pelvic tilt-least affected side 10 Brunnstrom's recovery stage-3
9
10 8
8 7
6
6 5
4
4 3
2 2
1
0 0
0 5 10 15 20 0 2 4 6 8 10 12 14 16
Trunk impairment scale -16 Trunk impairment scale -16
Anterior pelvic tilt-most affected side
Anterior pelvic tilt-least affected side

12 Brunnstrom's recovery stage-4 8 Brunnstrom's recovery stage-5


10 7
6
8 3
5
6 2 2
4
2 3 4
4 3
2
2
1
0 0
0 5 10 15 20 0 5 10 15 20
Trunk impairment scale -16 Trunk impairment scale -16

Figure 3 Scattergram showing the relationship between anterior pelvic tilt on the least affected side and trunk control in different Brunnstroms
motor recovery of the lower extremities.

in standing, and was correlated to poor trunk control and It is well-known from the published literature that the
balance ability in people with chronic stroke. It is believed contribution of hip muscles to the pelvic stability during
that muscular balance between flexors and extensors of the standing and walking is different from sitting. Movement
trunk is required for active elongation of the trunk lateral analysis of trunkpelvis dissociation during forward reach-
flexors; that is, quadratus lumborum of the most affected outs in sitting post-stroke showed that the trunk movement
side in standing after stroke. With impaired muscular con- was largely executed from the upper trunk with pelvis tilt
trol of the lower trunk, the pelvis is tilted excessively for- posteriorly.7 Impaired co-activity between the gluteus max-
ward bilaterally and laterally on the most affected side, so imus and lower trunk abdominal muscles in sitting early
as to orient the pelvis towards the least affected leg with after stroke might be responsible for restricted posterior pel-
asymmetrical weight distribution between the feet. After vis tilt. As motor recovery proceeds, the gluteus maximus of
stroke, any trunk-initiated weight transfer in standing allows the paretic leg could assist the trunk muscles during forward
excessive lateral pelvic shift towards the least affected side movement of trunk in sitting, but the gluteus medius muscle
with a forward tilted pelvis.18 The gluteus medius muscle does not contribute to the lateral movement of the trunk,
inactivity during perturbations in standing is much more which is otherwise controlled only by trunk muscles. Van
evident during stroke recovery, and is compensated by more Nes et al.20 in their study confirmed the above statement.
activity of the contralateral muscles.19 As the dynamic sitting balance subscale of the TIS evaluates

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2016 Japanese Society of Neurology and John Wiley & Sons Australia, Ltd
Pelvic alignment and trunk control after stroke S Karthikbabu et al.

the lateral stability of upper and lower trunk movements in ability after stroke.27,28 Posterior rotation of the pelvis on the
the coronal plane for people with stroke, its low correlation most affected side is the commonest observational finding
to anterior pelvic tilt bilaterally, particularly in recovery seen in stroke, and it was not reported in the present study
stage 3, was justifiable. because of the methodological limitations.
The movement sequence of the head, trunk and pelvis We concluded that lateral pelvic tilt in standing after
during lateral reach post-stroke was analyzed using the stroke is moderately correlated with trunk control in lower
CODA motion system in a recent study.21 Although reach- extremity motor recovery stages 3 and 4. The correlation of
ing to the least affected side, people with stroke moved their bilateral anterior pelvic tilt degrees to trunk control was low
pelvis first, followed by the trunk and the head. This is in in similar recovery stages. In recovery stage 5, the relation-
contrast to the movement of healthy controls who initiated ship of pelvic tilt with trunk control ranged from high to
from the head, and then moved their trunk and pelvis. Poor very high. The findings of the present study stress the
dynamic stability of the lower trunk after stroke might allow importance of measuring pelvic tilt in standing, and would
the pelvis to move first while reaching for a target initiated also help physical therapists to plan suitable pelvic control
from the upper body. Postural deviation of the pelvis in sit- treatment strategies for people post-stroke.
ting, as measured through photogrammetry, showed a direct
correlation to poor seated postural control in people with
acute and subacute stroke.22 A recent study by Pathak Acknowledgments
et al.8 supports our views. An increased lateral pelvic tilt We are grateful to all the study participants. This study
measured using the PALM device in sitting was found to be received no funding support from any governmental or non-
related to poor trunk control after stroke.9 governmental organization. We all authors state that there
We found a stronger relationship between pelvic tilt is no conflict of interest.
degrees in standing and trunk control in lower limb motor
recovery stage 5 than recovery stage 3 and 4. The present
study findings also show that people with Brunnstroms
lower limb motor recovery displayed an improved pelvic References
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