PARTICULARITIES OF GAIT REHABILITATION IN ADULT HEMIPLEGIC PATIENTS
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1 PARTICULARITIES OF GAIT REHABILITATION IN ADULT HEMIPLEGIC PATIENTS Lucaci P. 1, Neculăeş M. 1 ¹ Alexandru Ioan Cuza University, Iaşi, Romania, Faculty of Physical Education and Sport lucacipaul91@yahoo.com ABSTRACT This study aims at underscoring the importance of gait rehabilitation process in adult hemiplegic patients and the necessity of individualizing the treatment by the type of stroke, by its location and gravity. The study was conducted on a sample of thirty-one patients diagnosed with hemiplegia, who benefitted from significant outcomes concerning gait rehabilitation, after a particularized application of rehabilitation programs. Long-term rehabilitation programs and the patient s interest for regaining independence represent the motivational engine and the main pillar for attaining the proposed and expected outcomes. Thanks to these programs, the patients managed to walk on their own; as for locomotion under difficult circumstances, subjects have benefitted from increased degree of movement autonomy. KEYWORDS: locomotion re-education, kinesiotherapy, movement autonomy, parameters. INTRODUCTION Rehabilitation assistance has always focused on the sequelae of neurological diseases; among them, hemiplegia came first, in terms of both frequency and the great results achievable through functional reeducation. [4] Clinical studies, anatomopathological data, and the development of modern neuroimagistic technique allow the pinpointing of hemiplegia physiopathology, thus providing the premises for understanding the normal and pathological biological process, in order to offer more efficient therapies. Gait implies a coordination action that requires a corresponding integration of the sensory and motor functions. [1] In order to walk, the hemiplegic uses to the maximum the remaining muscular functions, which entails an alteration of step structure. The alteration of the stance and the swing phase is due to the following phenomena: positive support response, negative support response, and crossed extensor reflex. [3] During gait, the plegic lower limb remains rigid and it describes a circular motion, because it is projected forward through the pelvic swing. The kinesiotherapist must teach the patient how to walk, first using parallel bars, then a cane, and eventually without any support. Kinesiotherapy also plays the crucial role of providing stability to gait, by equalizing as much as possible the frontal symmetrical motor skills and by establishing their accurate sequence in sagittal plane, all of them in optimal relation with the floor. [5] The coordination of a movement, wrote Bernstein, represents the process of controlling the multiple possibilities of movement, characteristic to all organisms in motion; more precisely, the conversion of these movements into a determinate structure. The multiple movement possibilities can be reduced by connecting muscles to joints, so that they can act together as a whole or as a synergy; the goal is to simplify movement coordination. Such a connexion is greatly illustrated in the co-operation between the muscle force of the hip, the knee, and the ankle, to produce a support force that provides complete safety to the leg. [2] Gait involves a basic locomotion model adapted to the demands of the environment and to the obstacles that it may entail: border stones, stairs, etc. Among the ways that a hemiplegic may use for coping with the variable conditions of the environment and for improving his gait performance, I mention the following: walking in a crowded hallway, crossing the street fast enough to ensure safety, going up and down the stairs, walking through automatic doors, walking on top of or under obstacles, climbing platforms, walking in various light conditions. The patient must practice this type of exercises to identify the potential dangers and to build his own strategies for solving more difficult situations. The ability to walk fast or to overcome obstacles represents a very important factor for the security of the hemiplegic. Gait is an important factor for reinserting the hemiplegic in the society; such reinsertion is far from easy and it cannot be accomplished directly; it requires a family stage, in its turn conditioned by the patient s state. It may be attained if he is autonomous enough, if his mental state does not make him prone to a catastrophe when left alone, if the family has a free caregiver to take him over, to help him, and to improve the rehabilitation level achieved up to that moment. METHODS The study was conducted on a sample of thirty-one adult hemiplegic patients, who were advised to benefit from kinesiotherapy, accompanied by continuous training of locomotion. 116
2 Through the Tinetti mobility test, we analyzed several components of gait: gait initiation, step length, step continuity, walking itinerary deviation, torso movement, and distance between heels while walking. For gait assessment, we tested the step pace, the step length, and the distance covered within two minutes. Step pace and distance were tested with the help of the Omron Walking Style Pro pedometer, which calculates mean velocity, distance, and number of steps per time unit. In order to calculate step length, the subjects stepped on talc powder in order to have their plantar print on the floor. After asking them to do ten steps, we measured the distance covered and then we divided it by ten, thus determining a mean step length for each patient. We began the gait re-education exercises between parallel bars. Therefore, first the patients had to walk forward with support on the bars, to walk by stepping on obstacles, and to walk on the sides. In order to re-educate motion autonomy, we determined various paths with the patients, such as walking through pegs, walking by stepping on thresholds, walking on the sides, going up and down the stairs. Furthermore, in order to improve the spatio-temporal variables (step pace, step length, and distance covered per time unit), the patients walked on the treadmill. Within rehabilitation programs, we insisted on maintaining muscle elasticity, as well as on the muscles of triceps surae, and on the Achilles tendon. RESULTS We analyzed the results in SPSS, which provided us information regarding this study, by comparing the initial data on the sample of patients with the final results. We were interested in the step pace, the simple step length, the distance covered within two minutes, and the Get up and walk test. Table 1 analysis of initial and final results of the get up and walk test, step pace, simple step length, distance covered within 2 minutes, by arithmetic mean. Following this analysis, by comparing the initial and the final stage, we highlight a positive evolution of arithmetic mean of the four parameters of reference ( get up and walk test, step pace per minute, simple step length, distance covered within 2 minutes). Furthermore, concerning standard deviation, it is worth highlighting higher variation of results obtained in step pace per minute. Concerning the other areas of evaluation, standard deviations have close values. Table 2 differences between initial evaluation and final evaluation concerning the parameters of the get up and walk test, step pace, simple step length (cm), and distance covered within 2 minutes (m). 117
3 The statistical analysis allowed us to pinpoint significant differences between the initial and final evaluation of the get up and walk test (mean: 0.77); between the initial testing of step pace per minute and the final testing (mean: ); between the initial testing of simple step length (cm) and the final testing (mean: -6.41); between the initial evaluation of distance covered within 2 minutes (m) and between the final evaluation (mean: -8.80). This attests the efficiency and importance of kinetic activities in the rehabilitation of patients who suffered a stroke. The t test for independent samples in the Table above for p=0 argues this hypothesis statistically. Table 3 correlation between the variables of initial and final evaluation of the score for the get up and walk test. By analyzing the correlation between the initial evaluation variables of the get up and walk test score and the final evaluation of the get up and walk test score, we obtained the correlation coefficient r=0.79, a significance level p=0.0, and the number of subjects N=31. The significance level obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.79). Graph 1 correlation between the variables of initial and final evaluation of the score for of the get up and walk test. The correlation graph is an ascending cloud of points (from lower-left to upper-right) because the relation is positive or directly proportional. 118
4 Table 4 correlation between the variables of initial and final evaluation for step pace. By analyzing the correlation between the variables of initial testing evaluation for step pace/minute and the final testing for step pace/minute, we obtained the correlation coefficient r=0.90, a significance level p=0.0, and the number of subjects N=31. The significance level obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.90). Graph 2 correlation between the variables of initial and final evaluation for step pace. The correlation graph is an ascending cloud of points (from lower-left to upper-right) because the relation is positive or directly proportional. Table5 correlation between the variables of initial and final evaluation for simple step length (cm). By analyzing the correlation between the variables of initial testing for simple step length (cm) and the final testing a simple step length (cm), we underscore the correlation coefficient r=0.93, a significance level p=0.0, and the number of subjects N=31. The significance level obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.93). 119
5 Graph 3 correlation between the variables of initial and final evaluation for simple step length (cm). The correlation graph is an ascending cloud of points (from lower-left to upper-right) because the relation is positive or directly proportional. Table 6 correlation between the variables of initial and final evaluation of the distance covered within 2 minutes (m). By analyzing the correlation between the variables of the initial evaluation of the distance covered within 2 minutes (m) and the final evaluation of the distance covered within 2 minutes (m), we highlight the correlation coefficient r=0.85, a significance level p=0.0, and the number of subjects N=31. The significance level obtained shows a strong connection between the variables used, because it exceeds 0.50 (r=0.85). Graph 4 correlation between the variables of initial and final evaluation for the distance covered within 2 minutes (m). 120
6 The correlation graph is an ascending cloud of points (from lower-left to upper-right) because the relation is positive or directly proportional. As illustrated in the Graphs below (5, 6, 7, 8), the results obtained within our research demonstrate and validate the theory of the improvement of assessed parameters, from the initial to the final evaluation. It is apparent that all parameters, without any exception, recorded progress. CONCLUSIONS Gait rehabilitation in adult hemiplegic patients represents a necessity because the family and socioprofessional reintegration depends upon their degree of independence. Hemiplegia involves a complex clinical picture, while the rehabilitation possibilities and limits are closely connected to the gravity of the lesion, the patient s age, his biological capacity, the moment of treatment debut, as well as certain objective factors. In this sense, we mention the patient s co-operation and his participation and scrupulosity in the application of therapeutic programs. A very important aspect is represented by kinesiotherapy at home, and mostly by the optimization of gait training under various and difficult environmental circumstances, which will help patients acquire more stability and safety during movement. Within this study, through the initial and final evaluation, we have noticed an improvement of the remaining functions of subjects. Through kinesiotherapy programs and daily walking, they improved their gait parameters significantly. 121
7 The final conclusion of this study highlights that the application of a therapeutic plan adapted to the particularities of adult hemiplegic patients and walking in different conditions lead to a more effective rehabilitation of locomotion. REFERENCES [1] Geraint Fuller, Neurological Examination Made Easy, Callisto, third edition. [2] Janet H. Carr, Stroke rehabilitation, Butterworth Heinemann, [3] Mariana Cordun, Medical Kinesiology, Axa Publisher, [4] Sbenghe Tudor, Prophylactic, Therapeutic and Rehabilitation Physical Therapy, Medical Publisher, Bucharest, [5] Tiberiu Vlad, Liviu Pendefunda, Recovery of hemiplegic adult patient, International Contact Publisher, Iaşi, PARTICULARITĂŢI ALE RECUPERĂRII MERSULUI LA BOLNAVUL HEMIPLEGIC ADULT Lucaci P. ¹, Neculăeş M.¹ ¹Universitatea Alexandru Ioan Cuza, Iaşi, România, Facultatea de Educaţie Fizică şi Sport lucacipaul91@yahoo.com REZUMAT Studiul efectuat îşi propune să evidenţieze importanţa procesului recuperator al mersului la bolnavul hemiplegic adult şi necesitatea individualizării tratamentului în funcţie de tipul de accident vascular cerebral, în funcţie de localizarea şi gravitatea acestuia. Studiul a fost realizat pe un lot de treizeci şi unu de pacienţi cu diagnosticul de hemiplegie, care au beneficiat de rezultate semnificative în ceea ce priveşte recuperarea mersului, în urma aplicării particularizate a programelor de reabilitare. Efectuarea îndelungată a programelor de recuperare şi interesul pacientului pentru recâştigarea independenţei, reprezintă motorul motivaţional şi pilonul principal în obţinerea rezultatelor propuse şi aşteptate. Datorită programelor efectuate, pacienţii au reuşit să efectueze mersul independent, iar prin realizarea locomoţiei în condiţii îngreuiate subiecţii au beneficiat de un grad crescut al autonomiei de deplasare. CUVINTE CHEIE: reeducare a locomoţiei, kinetoterapie, autonomie de deplasare, parametri. INTRODUCERE Asistența de recuperare a acordat dintotdeauna principala atenție sechelelor bolilor neurologice, iar în cadrul acestora hemiplegia s-a plasat pe primul loc, atât datorită frecvenței, cât și a rezultatelor deosebit de bune ce se pot obține prin reeducarea funcțională.[4] Studiile clinice, datele anatomopatologice împreună cu dezvoltarea tehnicii neuroimagistice moderne permit evidențierea fiziopatologiei hemiplegiei, oferind premisele înțelegerii procesului biologic normal și patologic în scopul acordării unei terapii cât mai eficiente. Mersul presupune o acţiune coordonată care necesită integrarea corespunzătoare a funcţiilor senzitivă şi motorie.[1] Pentru a putea efectua mersul hemiplegicul folosește la maximum forțele musculare restante, ceea ce atrage după sine modificarea structurii pasului. Afectarea fazei de sprijin și fazei de balans se datorează următoarelor fenomene: reacția pozitivă de suport, reacția negativă de suport, reflexul de extensie încrucișat. [3] În efectuarea mersului, membrul inferior plegic se menţine rigid şi descrie o mişcare de circumducţie fiind proiectat spre înainte prin balansul bazinului. Kinetoterapeutul trebuie să înveţe pacientul să efectueze mersul, mai întâi între barele paralele, apoi cu ajutorul bastonului şi în final independent. Tot kinetoterapiei îi revine şi rolul principal de a imprima mersului stabilitate, printr-o cât mai apropiată egalizare a deprinderilor motrice simetrice din plan frontal şi o cât mai bună succesiune a acestora în plan sagital, totul în raporturi optime faţă de poligonul de susţinere.[5] Coordonarea unei mişcări, scria Bernstein, reprezintă procesul de control a multiplelor posibilităţi de mişcare, caracteristice oricărui organism în mişcare, mai precis, conversiunea acestor mişcări într-un sistem disciplinat. Multiplele posibilităţi de mişcare pot fi reduse prin conexiunea muşchilor cu articulaţiile aşa încât ele să acţioneze împreună ca un tot unitar sau ca o sinergie, scopul final fiind simplificarea 122
8 coordonării mişcării. O astfel de conexiune este ilustrată în mod relevant în cooperarea dintre forţa musculară de la şold, genunchi şi gleznă pentru a produce o forţă de sprijin care să menţină în siguranţă deplină piciorul.[2] Mersul implică un model de bază al locomoției care este adaptat la cerințele mediului înconjurător și la obstacolele pe care acesta le poate prezenta: borduri, trepte etc. Ca și modalități pentru hemiplegic de a face față condițiilor variabile ale mediului și pentru a-și îmbunătăți performața mersului, el poate executa: mersul pe un hol aglomerat, mersul cu o viteză care să permită traversarea străzii în condiții de siguranță, urcatul și coborâtul scărilor, mersul prin ușile automate, mersul pe dedesuptul sau pe deasupra obstacolelor, urcatul pe rampe, peste borduri, mersul în condiții variabile de lumină. Pacientul trebuie să practice aceste tipuri de exerciții pentru a identifica potențialele pericole și pentru a-și construi propriile strategii de rezolvare a unor situații mai dificile. Abilitatea de a merge repede sau de a depăși obstacolele reprezintă un factor foarte important pentru securitatea hemiplegicului. Mersul este un factor important pentru reîntoarcerea hemiplegicului în societate, care nu este deloc facilă și nu se realizează direct, necesitând o etapă de familie, la rândul ei condiționată de starea bolnavului: dacă este suficient de autonom, dacă starea sa psihică este corespunzătoare, pentru a nu risca o catastrofă dacă este lăsat singur, dacă la nivelul familiei există un aparținător liber care să îl preia, să îl ajute și să îi desăvârșească nivelul de recuperare realizat până la acel moment. METODE Studiul s-a realizat pe un lot de treizeci şi unu de pacienţi hemiplegici adulţi, care aveau indicaţia de efectuare a kinetoterapiei, cu antrenarea continuă a locomoţiei. Prin intermediul testului de mers Tinetti, am făcut analiza câtorva componente ale mersului: inițierea mersului, lungimea pasului, continuitatea pasului, devierea traseului mersului, mișcarea trunchiului, distanța dintre călcâie în mers. Pentru evaluarea mersului am realizat testarea cadenţei paşilor, lungimea pasului şi distanţa parcursă în intervalul de două minute. Cadenţa paşilor şi distanţa au fost testate cu ajutorul pedometrului Omron Walking Style Pro, care calculează viteza medie de deplasare, distanţa şi numărul de paşi pe unitatea de timp. Pentru calcularea lungimii pasului, subiecţii au călcat pe pudra de talc pentru a li se putea imprima pe sol amprenta plantară. După ce aceştia au efectuat un număr de zece paşi, am măsurat distanţa parcursă, apoi am împărţit la zece şi astfel am stabilit o lungime medie a pasului pentru fiecare pacient. Am început exerciţiile de reeducare a mersului între barele paralele. Astfel pacienţii au efectuat mai întâi mersul înainte cu sprijin pe bare, mersul păşind peste obstacole, mersul în lateral. Pentru reeducarea autonomiei de depasare, am realizat cu pacienţii diferite trasee de mers cum ar fi mersul printre jaloane, mersul cu păşirea peste praguri, mersul în lateral, urcatul şi coborâtul scărilor. De asemenea pentru îmbunătăţirea variabilelor spaţio-temporale (cadenţa paşilor, lungimea pasului, distanţa parcursă în intervalul de timp, pacienţii au realizat mersul pe covorul rulant. În cadrul programelor de recuperare s-a insistat şi pe menţinerea elasticităţii musculare, un accent deosebit fiind pus pe musculatura tricepsului sural şi pe tendonul achilian. REZULTATE Analiza rezultatelor s-a efectuat cu ajutorul programului SPSS care ne-a oferit informaţii cu privire la studiul realizat prin compararea datelor iniţiale obţinute pe lotul de pacienţi cu rezultatele finale, indicii vizaţi fiind: cadenţa paşilor, lungimea pasului simplu, distanţa parcursă de subiecţi în intervalul de două minute, testul Ridică-te şi mergi. Tabel 1 - analiza rezultatelor iniţiale şi finale ale testului ridică-te şi mergi, cadenţa paşilor, lungimea pasului simplu, distanţa parcursă în intervalul de 2 minute, prin efectuarea mediei aritmetice. 123
9 În urma analizei efectuate, comparând etapa inițială cu etapa finală, se observă în primă instanță o evoluție pozitivă a mediei aritmetice a celor patru parametri de referință (test "ridică-te și mergi", cadență pași pe minut, lungime pas simplu (cm), distanța parcursă în intervalul de 2 minute). De asemenea, privind deviația standard se observă o variație mai mare a rezultatelor înregistrate cu privire la cadența pașilor pe minut. Referitor la celelalte zone de evaluare, deviațiile standard sunt apropiate ca și valoare. Tabel nr.2 diferenţele rezultate de la evaluarea iniţială la evaluarea finală a parametrilor testului ridică-te şi mergi, cadenţa paşilor, lungimea pasului simplu (cm) şi distanţa parcursă în intervalul de 2 minute (m). Analiza statistică realizată a permis identificarea unor diferențe semnificative între evaluarea inițială și cea finală a testului "ridică-te şi mergi" (mean: 0,77); între testarea inițială a cadenţei pașilor pe minut și testarea finală (mean: -13,29); între testarea inițială a lungimii pasului simplu (cm) și testarea finală (mean: - 6,41); între evaluarea inițială a distanței parcurse în intervalul de 2 minute (m) și între evaluarea finală (mean: -8,80) fapt ce demonstrează eficiența și importanța activităților kinetice în recuperarea bolnavilor ce au suferit un accident vascular cerebral. Testul t pentru eșantioanele independente din tabelul de mai sus pentru p=0 argumentează statistic această ipoteză. Tabel nr.3 corelaţia dintre variabilele evaluării iniţiale şi finale a scorului testului ridică-te şi mergi. Analizând corelația dintre variabilele evaluarii iniţiale a scorului la testul "ridică-te şi mergi" și evaluarea finală a scorului la testul "ridică-te şi mergi" observăm coeficientul de corelație r=0,79, pragul de semnificație p=0,0 și numărul de subiecți N=31. Pragul de semnificație obținut arată o legătură puternică între variabilele folosite, fiind peste 0,50 (r=0,79). 124
10 Grafic nr.1 corelaţia dintre variabilele evaluării iniţiale şi finale a scorului testului ridică-te şi mergi. Graficul corelaţiei este un nor de puncte crescător (de la stânga-jos la dreapta-sus) deoarece relaţia este pozitivă sau direct proporţională. Tabel nr.4 - corelaţia dintre variabilele evaluării iniţiale şi finale a cadenţei paşilor. Analizând corelația dintre variabilele evaluării testării iniţiale a cadenţei paşilor/minut și testarea finală a cadenţei paşilor/minut observăm coeficientul de corelație r=0,90, pragul de semnificație p=0,0 și numărul de subiecți N=31. Pragul de semnificație obținut arată o legătură puternică între variabilele folosite, fiind peste 0,50 (r=0,90). Grafic nr.2 - corelaţia dintre variabilele evaluării iniţiale şi finale a cadenţei paşilor. Graficul corelaţiei este un nor de puncte crescător (de la stânga-jos spre dreapta-sus) deoarece relaţia este pozitivă sau direct proporţională. 125
11 Tabel nr.5 - corelaţia dintre variabilele evaluării iniţiale şi finale a lungimii pasului simplu (cm). Analizând corelația dintre variabilele testării iniţiale a lungimii pasului simplu (cm) și testarea finală a lungimii pasului simplu (cm) observăm coeficientul de corelație r=0,93, pragul de semnificație p=0,0 și numărul de subiecți N=31. Pragul de semnificație obținut arată o legătură puternică între variabilele folosite, fiind peste 0,50 (r=0,93). Grafic nr.3 - corelaţia dintre variabilele evaluării iniţiale şi finale a lungimii pasului simplu (cm). Graficul corelaţiei este un nor de puncte crescător (de la stânga-jos spre dreapta-sus) deoarece relaţia este pozitivă sau direct proporţională. Tabel nr.6 - corelaţia dintre variabilele evaluării iniţiale şi finale a distanţei parcurse în intervalul de 2 minute (m). Analizând corelația dintre variabilele evaluării iniţiale a distanţei parcurse în intervalul de 2 minute (m) și evaluarea finală a distanţei parcurse în intervalul de 2 minute (m) observăm coeficientul de corelație 126
12 r=0,85, pragul de semnificație p=0,0 și numărul de subiecți N=31. Pragul de semnificație obținut arată o legătură puternică între variabilele folosite, fiind peste 0,50 (r=0,85). Grafic nr.4 - corelaţia dintre variabilele evaluării iniţiale şi finale a distanţei parcurse în intervalul de 2 minute (m). Graficul corelaţiei este un nor de puncte crescător (de la stânga-jos spre dreapta-sus) deoarece relaţia este pozitivă sau direct proporţională. Așa cum este vizibil în graficele de mai jos (5, 6, 7, 8), rezultatele obținute în cadrul cercetării demonstrează și validează teoria îmbunătățirii parametrilor zonelor de evaluare de la evaluarea inițială la evaluarea finală. După cum se poate vedea nu există cazuri unde să nu se fi înregistrat progrese ale parametrilor testați. Grafic nr. 5 Grafic nr. 6 Grafic nr. 7 Grafic nr
13 CONCLUZII Recuperarea mersului la bolnavul hemiplegic adult reprezintă o necesitate deoarece reintegrarea familială și socio-profesională depinde de gradul de independență al acestora. Hemiplegia conturează un tablou clinic complex, iar posibilitățile și limitele de recuperare sunt strâns legate de gravitatea leziunii, vârsta pacientului, capacitatea biologică a bolnavului, momentul instituirii tratamentului, precum şi de unii factori subiectivi: cooperarea pacientului, participarea şi conștiinciozitatea în efectuarea programelor terapeutice. Un aspect foarte important îl reprezintă continuarea kinetoterapiei la domiciliu și mai ales optimizarea antrenamentului mersului în condiții de mediu diversificate și îngreuiate, care îi va ajuta pe aceştia să capete o mai bună stabilitate şi siguranţă în timpul deplasării. În cadrul acestui studiu am constatat, prin intermediul evaluării iniţiale şi finale o îmbunătăţire a restantului funcţional al subiecţilor care prin efectuarea programelor de kinetoterapie şi prin realizarea mersului zilnic şi-au îmbunătăţit în mod evident parametrii mersului. Concluzia finală a acestui studiu evidenţiază faptul că aplicarea unui plan terapeutic adaptat la particularităţile pacientului hemiplegic adult şi efectuarea mersului în condiţii variate, conduc la o recuperare mai eficientă a locomoţiei. BIBLIOGRAFIE [1] Graint Fuller, Examinarea clinică neurologică, ed. Medicală Callisto, ediţia a treia [2] Janet H. Carr, Stroke rehabilitation, ed.butterworth Heinemann, 2004 [3] Mariana Cordun, Kinetologie medicală, ed. Axa, 1999 [4] Sbenghe Tudor, Kinetoterapie profilactică, terapeutică și de recuperare, Ed. Medicală, București, 1987 [5] Tiberiu Vlad, Liviu Pendefunda, Recuperarea bolnavului hemiplegic adult, ed. Contact Internațional, Iași,
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