Balance and gait improved in patients with MS after physiotherapy based on the Bobath concept

Physiotherapy Research InternationalPhysiother. Res. Int. 11(2) 104–116 (2006)Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pri.327

104

Physiother. Res. Int. 11: 104–116 (2006)Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pri

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Balance and gait improved in patients with MS after physiotherapy based on the Bobath concept

TORI SMEDAL National Multiple Sclerosis Competence Centre, Department of Neurology, and Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway

HILDEGUNN LYGREN Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway

KJELL-MORTEN MYHR National Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland University Hospital, Bergen and Department of Clinical Medicine, Section for Neurology, University of Bergen, Norway

ROLF MOE-NILSSEN Department of Public Health and Primary Health Care, Section for Physiotherapy Science, University of Bergen, Norway

BENTE GJELSVIK Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway

OLAV GJELSVIK Department of Physiotherapy, Haukeland University Hospital, Bergen, Norway

LIV INGER Strand Department of Public Health and Primary Health Care, Section for Physiotherapy Science, University of Bergen, Norway

ABSTRACT Background and Purpose. Patients with multiple sclerosis (MS) tend to have movement difficulties, and the effect of physiotherapy for this group of patients has been subjected to limited systematic research. In the present study physiotherapy based on the Bobath concept, applied to MS patients with balance and gait problems, was evaluated. The ability of different functional tests to demonstrate change was evaluated. Method. A single-subject experimental study design with ABAA phases was used, and two patients with relapsing–remitting MS in stable phase were treated. Tests were performed 12 times, three at each phase: A (at baseline); B (during treatment); A (immediately after treatment); and A (after two months). The key feature of treatment was facilitation of postural activity and selective control of movement. Several performance and self-report measures and interviews were used. Results. After intervention, improved balance was shown by the Berg Balance Scale (BBS) in both patients, and improved quality of gait was indicated by the Rivermead Visual Gait Assessment (RVGA). The patients also reported improved balance and gait function in the interviews and scored their condition as ‘much improved’. Gait parameters, recorded by an electronic walkway, changed, but differently in the two

Physiotherapy in MS 105


patients. Among the physical performance tests the BBS and the RVGA demonstrated the highest change, while no or minimal change was demonstrated by the Rivermead Mobility Index (RMI) and Ratings of Perceived Exertion (RPE). Conclusion. The findings indicate that balance and gait can be improved after physiotherapy based on the Bobath concept, but this should be further evaluated in larger controlled trials of patients with MS. Copyright © 2006 John Wiley & Sons, Ltd.

Key words: balance, gait, multiple sclerosis, physical performance tests, physiotherapy, the Bobath concept

INTRODUCTION

Gait and balance disturbance caused by weakness, spasticity and ataxia are com-monly seen in patients with multiple sclero-sis (MS) and may lead to problems in activities of daily living (Oligati et al., 1998; Rodgers et al., 1999; Thompson, 2001). Gehlsen et al. (1986) reported reduced range of motion in the lower legs and walking with slow speed and short, quick steps in a study of 11 MS patients. The probability of manag-ing without walking aids after 15 years is about 70% (Myhr et al., 2001).

The large heterogeneity of the disease requires comprehensive management by a multidisciplinary rehabilitation team (Ko Ko, 1999; Freeman, 2001). Different types of interventions are recommended at differ-ent stages of the disease (Thompson, 2001). Physiotherapy is commonly recommended, and tentative evidence suggests that it may be helpful to improve physical functioning or prevent deterioration (Lord et al., 1998a; Solari et al., 1999; Freeman and Thompson, 2001; Wiles et al., 2001). There is, however, limited evidence to guide the therapist in choosing the most effective approach (Freeman and Thompson, 1997; Lord et al., 1998a).

There are methodological challenges when undertaking rehabilitation trials of patients with MS. When designing interven-tion studies, homogeneity of study popula-

tion and intervention is usually recommended. However, the heterogeneous manifestations and unpredictable course of MS call for an intervention tailored to each individual (Freeman and Thompson, 1997). In line with the World Health Organization (WHO) International Classification of Functioning, Disability and Health (WHO, 2001) the choice of outcome measures should also be carefully considered to capture various aspects of functioning and disability.

The aim of the present study was to investigate whether physiotherapy based on the Bobath concept could improve gait and balance for two patients with MS. We also wanted to evaluate the usefulness of differ-ent functional tests.

METHOD

Study design

A single-subject experimental study design, with ABAA phases, was used to get thor-ough and repetitive information about the patients. Several registrations at baseline and during treatment make it possible to evaluate whether treatment has an effect beyond normal variability in the condition, and each patient was, accordingly, their own control. The patients received individualized tailored physiotherapy and were followed closely by assessments once a week, in four three-weeks periods:

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• A: baseline (weeks 1–3).• B: treatment (weeks 4–6).• A: early follow-up (weeks 7–9).• A: late follow-up (weeks 15–17).

All assessments were undertaken in the same sequence and at the same time of day by an independent physiotherapist. During the treatment period, the patients had phys-iotherapy for one hour a day, five times a week. Patients were treated by different physiotherapists, one patient each. Written, informed consent was obtained, and the regional ethics committee approved the study.

Subjects

Two patients with MS were recruited from the National Multiple Sclerosis Competence Centre, Norway. Inclusion criteria were relapsing–remitting MS without any new relapses during the last year, gait problems attributed to spastic paraparesis or ataxia and capability of walking for 10 minutes, with pauses if needed. Exclusion criteria were progressive MS or cognitive dysfunc-tion and excessive fatigue that could pre-clude the testing procedures. Mrs A was a 48-year-old woman diagnosed with MS at the age of 20, and Mr B was a 32-year-old man diagnosed at the age of 17.

Intervention

The intervention was based on the Bobath concept (Lennon, 1996; Lennon, 2001; Gjelsvik, 2002) as interpreted and applied by two International Bobath Instructors Training Association (IBITA) approved Bobath instructors. Treatment was individu-ally tailored to the patients, based on the physiotherapists’ examination. In this approach, reduced postural control, abnor-

mal co-ordination of movement patterns, weakness and abnormal tone are considered the main cause of the movement problem for people with central nervous system (CNS) disease. The treatment aims to improve function through motor learning, emphasiz-ing the individual’s own control. Hands-on therapy is used when necessary, to enhance an optimal postural alignment and thereby muscle function. Analysis of movement in functional activity determines which com-ponent of movement dysfunction (impair-ment) is most central to the patient’s limitation of activity. The principle underly-ing treatment is that the CNS has the capac-ity to learn. ‘Neuroplasticity’ refers to the ability of the CNS to change both its struc-ture and function as a response to changing demands (Nudo, 2003).

Mrs A had Expanded Disability Status Scale (EDSS) (Kurtzke, 1983) equal to 6.0. She had pronounced spastic paraparesis and ataxia, and was depending on visual fixation for balance. Based on functional assessment, treatment was focused on postural stability and orientation. The aim was to improve adaptability of the patient’s feet in relation to the base of support, alignment of the trunk in relation to the pelvis, and recruitment of trunk and pelvic activity. The patient was treated in different postures and through transfers (for example, sitting to standing) to allow the experience of demands from changing relationships between the body and the environment.

Mr B had EDSS equal to 6.0. He had spastic paraparesis and trunk instability consistent with weakness of trunk muscles. He had clawing of toes in standing, inver-sion of feet in walking and hypersensitivity to muscle stretch (clonus) during floor contact. The treatment was focused on mobi-lization of ankles, feet and toes in order to prepare for weight-bearing and facilitate



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abdominal and low back muscles to activate selective activity against gravity.

Assessments

Physical performance measures, as follows.

• The Berg Balance Scale (BBS) consists of 14 standardized sub-tests scored on five-point scales (0–4), with a maximum (best) score of 56 (Berg et al., 1992). Reliability and validity have been dem-onstrated in elderly people (Berg et al., 1989; Berg et al., 1992; Berg et al., 1995), and scores below 45 may indicate increased risk of falling for elderly people (Thorban and Newton, 1996).

• Gait parameters were assessed by GAITRite; a 5-metre long computerized electronic mat for automated measure-ment of gait parameters. Maximum gait velocity, step-length (SL) and double stance phase (DS) (percentage of gait cycle) were registered when walking on the mat. Walking was performed three times at different speeds: normal, slow and maximum. SL and DS were regis-tered for each speed. By interpolation, a point estimate was calculated for each of the two variables at a normalized speed representative for that subject. Thus com-parisons between test occasions could be done without the confounding effect of walking speed (Moe-Nilssen, 1998). Before testing, the patients walked once on the mat to get comfortable with the test. Results from the GAITRite have shown strong test–retest reliability and concurrent validity for healthy adults (Bilney et al., 2003).

• ‘Timed Up & Go’ (TUG) measures the time while the patient stands up from a standard arm chair, walks a distance of 3 metres, turns, walks back and sits down

again. Performance of the test in less than 20 seconds has been suggested to indicate independent mobility (Podsiadlo and Richardson, 1991). The test has been shown to be reliable and valid for elderly people (Podsiadlo and Richardson, 1991).

• The Rivermead Visual Gait Assessment (RVGA) consists of two observations of the arms at swing and stance phases of gait and 18 observations of the trunk and lower limb: 11 observations during stance phase and seven during swing phase. The assessor watches the patient during walking. A four-point scale is used to quantify the degree of abnormality for each of the component items. A global score is calculated by summing the total numbers of scores, which range from 0 (normal gait) to 59 (grossly abnormal gait). The RVGA can be applied to measure change over time for patients with neurological disease and is sensitive to gait impairment. Reliability and valid-ity has been shown in patients with MS (Lord et al., 1998b), and it is suggested that a six-point change on the global score is clinically relevant (Lord et al., 1998a).

Self-report measures, as follows.

• Visual analogue scale (VAS): the patients estimated their perceived amount of gait problem on a scale from 0 mm to 100 mm, anchored by ‘No problem’ and ‘Worst imaginable problem’. A mean reduction of 10 on a scale from 0 to 100 has previ-ously been proposed as a clinically sig-nificant improvement (Kaasa and Lode, 2004).

• Ratings of perceived exertion (RPE) was scored after walking four times on the GAITRite mat, by a 15-point graded scale from 6 (no exertion) to 20 (maximal

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exertion) (Borg, 1970). The scale values correlate well with exercise variables such as heart rate, ventilation, percentage VO2 max and workload (ACSM, 1998).

• The Rivermead Mobility Index (RMI) is a measure of activity domain with focus on body mobility. It consists of 14 ques-tions and one observation of the ability to perform activities, from turning in bed (as the easiest) to running (as the most advanced) (Collen et al., 1991). Increase by two points or more has been regarded as clinically significant (Lord et al., 1998b).

• The Patient Global Impression of Change (PGIC) or the Clinical Global Impression of Change (CGIC) are graded on a seven-point scale, from 1 (very much improved) to 7 (very much worse). A score of 4 means no change (Farrar et al., 2001).

Interviews

Semi-structured interviews were used focusing on bodily function, activities of daily living (ADL), experiences in the body and comments from family and friends. The interviews were tape-recorded and transcribed.

The PGIC was applied once after the treatment and the follow-up periods, and the CGIC was applied after the treatment period. The interviews were done once after treat-ment, once three weeks after and once two months after. The other tests were used at each assessment. The tests were performed once before baseline, to reduce the learning effect. Before each testing, the patients were asked to report special events that could have influenced their functioning.

The tests have been validated for other populations, but almost none for patients with MS. However, many of them have been used in studies with MS patients.

Data analysis

Visual analysis of the graphs was used. The 2 SD deviation band method was also used, defining a statistically significant change if at least two consecutive data points after the baseline phase fell outside the 2 SD range (Noubakhsh and Ottenbacher, 1994). Calcu-lation of effect size, (mean change) / [(SD follow-up + SD baseline) / 2] was used to compare sensitivity to change in the different measures as effect size is a unit-less term, allowing direct comparison between mea-sures. A summary of the semi-structured interviews was made.

RESULTS

Both patients were stable, without new relapses during the study period, and EDSS improved from 6.0 to 5.5 for both. However, Mrs A experienced gastrointestinal symp-toms during the first half of the study period and Mr B experienced a short period of fatigue at the time of first testing during late follow-up. Test data (mean, SD) of both patients are shown in Table 1.

Mrs A

The BBS scores at baseline (<45) indicated increased risk of falling, but significant improvement was shown in connection with treatment (Figure 1). The RVGA scores, reflecting quality of movement during gait, also improved (Figure 2). Maximum gait velocity assessed by GAITRite was low at baseline: 0.5 m/s (normal reference value 2.10 m/s; Bohannon, 1997), but improved somewhat during treatment. Double stance (DS) as well as step-length (SL) increased. Some clinical important improvement was demonstrated by the TUG test as <20 s is suggested to be the limit for independent



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Smedal et al.110


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FIGURE 1: Berg Balance Scale (BBS) for Mrs A at baseline, treatment, early follow-up and late follow-up. Level for risk of falling is shown in the diagram. Note that the y axis differs from Figure 3.

38

40

42

44

46

48

50

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54

56

erocS

Risk of falling

+ 2 SD

– 2 SDMean

Baseline(1–3 weeks)

Treatment(4–6 weeks)

Early follow-up(7–9 weeks)

Late follow-up(15–17 weeks)

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

erocS + 2 SD

– 2 SDMean





FIGURE 2: Rivermead Visual Gait Assessment (RVGA) for Mrs A at baseline, treatment, early follow-up and late follow-up. Low scores indicate improvement.



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walking (Podsiadlo and Richardson, 1991). The change was, however, not statistically significant.

Substantial gait problems were reported at baseline, but the scores were improved from 60.3 (VAS) at baseline to 26.3 (VAS) at late follow-up. Minor exertion was reported on RPE during baseline and almost no change was demonstrated during the study. Similarly, no change was demon-strated by the RMI. The PGIC was reported as ‘much improved’, ‘very much improved’ and ‘much improved’ after treatment and at early and late follow-up, respectively. Simi-larly the physiotherapists reported ‘much improved’ (CGIC).

Mr B

The BBS scores at baseline indicated increased risk of falling. Improved BBS scores after baseline were demonstrated, but the mean change was not statistically signifi-

cant (Figure 3). The RVGA data, reflecting quality of movement during gait, showed improvement (Figure 4). Maximum gait velocity was low at baseline: 1.26 m/s (normal reference value 2.46 m/s; Bohannon, 1997), but improved somewhat during treatment. DS was decreased, and there was almost no change in SL. Some improvement was dem-onstrated by TUG, but the change was not statistically significant.

The scores of self-reported gait problems were reduced from 29.3 (VAS) at baseline to 12.0 (VAS) at early follow-up. The mean VAS score at late follow-up was not different from baseline (29.7), possibly due to increased fatigue symptoms during weeks 15 and 16. The VAS score at week 17 was again mark-edly reduced (20.0). Minor exertion on RPE was reported during baseline, and almost no change was demonstrated during the study. Similarly, no change was demonstrated by the RMI. The PGIC was reported as ‘much improved’ after treatment and at both follow-

26

28

30

32

34

36

38

40

42

44

46

48

50

52

54

56

erocS

Risk of falling

+ 2 SD

– 2 SD

Mean





FIGURE 3: Berg Balance Scale (BBS) for Mr B at baseline, treatment, early follow-up and late follow-up. Level for risk of falling is shown in the diagram. Note that the y axis differs from Figure 1.

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ups. Similarly, the physiotherapists reported ‘much improved’ (CGIC).

For both patients the BBS and RVGA demonstrated most changes, whilst no

change was demonstrated by RMI and almost none by RPE (Table 2).

In the interviews neither Mrs A nor Mr B reported that they had had any anticipation

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

erocS

+ 2 SD

– 2 SDMean





FIGURE 4: Rivermead Visual Gait Assessment (RVGA) for Mr B at baseline, treatment, early follow-up and late follow-up. Low scores indicate improvement.

TABLE 2: Change in scores on different tests from baseline to treatment, early follow-up and late follow-up using effect sizes* for comparisons

Test Change in Mrs A Change in Mr B

Treatment Early Late Treatment Early Late follow-up follow-up follow-up follow-up

BBS 5.2 5.9 3.4 1.8 2.7 3.0Maximum gait velocity 1.1 1.5 1.8 2.0 -0.3 -0.6Double stance phase 1.3 1.9 4.8 0.6 -1.3 -1.0Step-length 6.0 1.4 1.9 0.0 -0.2 1.3TUG -2.6 -2.4 -2.2 -1.3 -2.1 -1.5RVGA -5.3 -8.0 -8.0 -3.3 -5.3 -2.1Experienced gait -2.5 -0.4 -3.8 -3.1 -6.7 0.1 problem (VAS)RPE -1.2 0.0 0.0 -4.0 -2.2 -0.9RMI 0.0 0.0 0.0 0.0 0.0 0.0

* (mean change) / [(SD follow-up + SD baseline) / 2].BBS = Berg Balance Scale; TUG = Timed Up&Go; RVGA = Rivermead Visual Gait Assessment; VAS = visual analogue scale; RPE = ratings of perceived exertion; RMI = Rivermead Mobility Index.



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concerning the effect of physiotherapy. However, both patients reported improve-ments in connection with treatment. Mrs A found it easier to walk and to dress. Family and friends had noticed that she walked better, and they did not find it necessary to ‘give her a hand’. When starting treatment Mrs A walked with a crutch outdoors, but after treat-ment she walked with a cane. Mr B experi-enced better ability to walk and improved balance after treatment. He found it easier to dress and ‘to take the pizza in and out of the oven’, and his legs felt stronger. He reported an increased feeling of well-being and refresh-ment in his body, and family and friends commented that he walked much better. Both patients reported that the improvement still lasted two months after the treatment.

DISCUSSION

We have shown that physical functioning improved after individualized physiotherapy based on the Bobath concept for two patients. Both patients had BBS scores <45 at base-line, indicating increased risk of falling. After treatment, the scores were >45. This improvement of balance seems to be clini-cally significant (Thorban and Newton, 1996). Improvement in quality of movement during walking was demonstrated in both patients by the RVGA. The patients also reported improved balance and gait function in the interviews, and reported much improvement on the PGIC, confirmed by the therapist’s evaluations using the CGIC.

Both patients had more than a six-point improvement on the RVGA scale, which has been suggested to indicate a clinically rele-vant change (Lord et al., 1998a). The RVGA focuses on impairments consistent with the focus of the Bobath concept. This may explain why the RVGA was the most respon-sive to change among the assessment scales.

However, the BBS scores improved indicat-ing that the patients achieved better function in the activity domain as well. Thus improve-ment after physiotherapy based on the Bobath concept seemed to be related to the domain of activity, as well as the domain of impairment.

After treatment, Mr B had reduced maximum gait velocity walking on the mat. However, he walked faster when performing the TUG test, which appears to be a contra-dictory result. Walking on the mat seemed to make Mr B focus on achieving correct footsteps, whereas he concentrated more on walking at a fast speed when performing the TUG test, knowing that the tester used a stopwatch.

Mrs A had ataxic gait with short step-length (SL) during the baseline phase. After treatment velocity increased, and she reported better balance and ability to walk, as well as demonstrating increased SL and double stance (DS). The longer steps accom-panied by longer DS may possibly be explained by improved postural control, reducing the ataxia and thereby lengthening the DS. It is plausible that changes in RVGA and gait parameters after treatment for both patients is a result of changed underlying motor control strategies. If this is the case, the patients may have learnt new movement strategies. The changes seemed to imply long-term learning as they lasted beyond the immediate effect of treatment (Shumway-Cook and Wollacott, 2000).

Physiotherapy research needs to include assessment tools at different functional domains, and the relationship between them should be investigated (Jette, 1995). The present study included outcome measures of impairments as well as of activities. While the BBS measures ability to perform various physical activities that demand balance, the RVGA registers quality of performance.

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From our results, it seems likely that improved balance in daily activities is associated with improved quality of movement. However, this needs to be further investigated.

The intention was also to examine which assessment scales were the most sensitive to change. Among the physical performance tests, the BBS and RVGA showed the great-est change. However, a substantial effort was made to obtain a sufficient inter-rater reli-ability of RVGA scores prior to the study.

The single-subject experimental study design (SSED) is considered appropriate to assess the effectiveness of individualized treatment (Figoni, 1990; Ko Ko, 1999). Using results from randomized controlled studies may not always be helpful to guide treatment of individual patients (Mant, 1999). It was decided therefore to use SSED where treatment was tailored to the individ-ual’s needs (Ottenbacher, 1992; Ko Ko, 1999). Because of the variable and unpre-dictable nature of MS, the opportunity to follow each patient thoroughly and fre-quently through different phases is a great advantage of this design (Figoni, 1990; Blair et al., 1996; Polit and Hungler, 1999).

The visual analysis of the graphs is insen-sitive to weak treatment effects (Nourbakhsh and Ottenbacher, 1994), ensuring that only treatment effects with obvious changes were reported. We further used the two-standard deviation band method, which is reported to be sensitive to changes in variability across phases of a SSED study, although the few data in each phase made it impossible to confirm normality in distribution (Nourbakhsh and Ottenbacher, 1994). This method made it possible to evaluate whether change during treatment superseded vari-ability in a non-treatment phase.

Self-report measures and physical perfor-mance tests with different degrees of objec-tivity were employed. Although the gait

parameters are more objectively registered using the GAITRite system, the RVGA is dependent on the testers’ subjective opinion. It was impossible to blind the tester. The results showed, however, the same tendency in most tests containing different aspects of objectivity. In addition, what the patients reported, confirmed positive functional changes after treatment.

If the tests had been done more than three times at each period, we would have more thorough data, but we found this too strenu-ous for the patients. A treatment period of three weeks may also seem short, but this was in accordance with rehabilitation stays in our department.

The demonstrated improvement may be attributed to the effect of treatment, but might also be explained by multiple testing. However, analysis showed that most of the baseline data were rather stable. Thus it is likely that the observed changes during treatment were not simply due to repetitive assessments. The improvement could also be explained by an eventual spontaneous improvement. However, we would not expect this, as the patients had had their diagnosis for many years without any new relapses the last years.

Although the present study shows that physical functioning in two patients with MS improved after individualized Bobath treat-ment, the results cannot be generalized to a broad population of MS patients, and the effect should therefore be further examined in larger MS samples. Further validation of balance and gait measures is needed in neurological disorders (Perennou et al., 2005), and this seems particularly applicable in MS.

IMPLICATIONS

The implication of the present study is that balance and gait in patients with MS may



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improve after physiotherapy based on the Bobath concept. However, more research is needed to examine the validity of our results in a larger sample of patients with MS. Reli-ability and validity of outcome measures should be further established for the MS population.

ACKNOWLEDGEMENTS

This study was financially supported by The Norwe-gian Fund for Post-graduate Training in Physiother-apy. The authors wish to thank the two patients who participated in the study.

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American College of Sports Medicine. Resource Manual for Guidelines for Exercise Testing and Prescription. Philadelphia, PH: Lea & Febiger, 1988.

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Address correspondence to: T Smedal, Department of Physiotherapy, Haukeland University Hospital N- 5021 Bergen, Norway (E-mail: [email protected]).

(Submitted June 2005; accepted November 2005)

Balance and gait improved in patients with MS after physiotherapy based on the Bobath concept

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