(Ebook) Science-Based Rehabilitation: Theories into

Practice by Kathryn M. Refshauge, Louise Ada, Elizabeth

Ellis ISBN 075065564X Pdf Download

https://ebooknice.com/product/science-based-rehabilitation-theories-
into-practice-2128642

★★★★★
4.6 out of 5.0 (14 reviews )

DOWNLOAD PDF

ebooknice.com
 (Ebook) Science-Based Rehabilitation: Theories into Practice
by Kathryn M. Refshauge, Louise Ada, Elizabeth Ellis ISBN
075065564X Pdf Download

EBOOK

Available Formats

■ PDF eBook Study Guide Ebook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Here are some recommended products that we believe you will be
interested in. You can click the link to download.

(Ebook) Biota Grow 2C gather 2C cook by Loucas, Jason; Viles, James

ISBN 9781459699816, 9781743365571, 9781925268492, 1459699815,
1743365578, 1925268497

https://ebooknice.com/product/biota-grow-2c-gather-2c-cook-6661374

(Ebook) Matematik 5000+ Kurs 2c Lärobok by Lena Alfredsson, Hans

Heikne, Sanna Bodemyr ISBN 9789127456600, 9127456609

https://ebooknice.com/product/matematik-5000-kurs-2c-larobok-23848312

(Ebook) SAT II Success MATH 1C and 2C 2002 (Peterson's SAT II Success)

by Peterson's ISBN 9780768906677, 0768906679

https://ebooknice.com/product/sat-ii-success-
math-1c-and-2c-2002-peterson-s-sat-ii-success-1722018

(Ebook) Master SAT II Math 1c and 2c 4th ed (Arco Master the SAT
Subject Test: Math Levels 1 & 2) by Arco ISBN 9780768923049,
0768923042

https://ebooknice.com/product/master-sat-ii-math-1c-and-2c-4th-ed-
arco-master-the-sat-subject-test-math-levels-1-2-2326094
(Ebook) Cambridge IGCSE and O Level History Workbook 2C - Depth Study:
the United States, 1919-41 2nd Edition by Benjamin Harrison ISBN
9781398375147, 9781398375048, 1398375144, 1398375047

https://ebooknice.com/product/cambridge-igcse-and-o-level-history-
workbook-2c-depth-study-the-united-states-1919-41-2nd-edition-53538044

(Ebook) Evidence-Based Treatment Approaches for Suicidal Adolescents:

Translating Science Into Practice by Michele Berk ISBN 9781615371631,
9781615372515, 9782018056538, 161537163X, 1615372512, 2018056530,
2018055779
https://ebooknice.com/product/evidence-based-treatment-approaches-for-
suicidal-adolescents-translating-science-into-practice-23847930

(Ebook) Rehabilitation: The Use of Theories and Models in Practice by

Sally Davis MSc RGN PGCEA DipMan ISBN 9780443100246, 0443100241

https://ebooknice.com/product/rehabilitation-the-use-of-theories-and-
models-in-practice-1669570

(Ebook) Journeys in Community-Based Research by Bonnie Jeffery; Isobel

M. Findlay; Diane Martz; Louise Clarke; Louise Clarke ISBN
9780889773875, 0889773874

https://ebooknice.com/product/journeys-in-community-based-
research-51626620

(Ebook) Proofs & Theories by Louise Gluck ISBN 9780063117617,

0063117614

https://ebooknice.com/product/proofs-theories-37624352
An imprint of Elsevier Limited

© 2005 Elsevier Limited. All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the
prior permission of the publishers or a licence permitting restricted copying in the United Kingdom
issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Permissions
may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, USA:
phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also
complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting
‘Customer Support’ and then ‘Obtaining Permissions’.

First published 2005

ISBN 0 7506 5564 X

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Notice
Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the responsibility of the practition-
er, relying on experience and knowledge of the patient, to determine dosages and the best treatment for
each individual patient. Neither the Publisher nor the author assumes any liability for any injury
and/or damage to persons or property arising from this publication.

Neither the publishers nor the author will be liable for any loss or damage of any nature occasioned to
or suffered by any person acting or refraining from acting as a result of reliance on the material con-
tained in this publication.

The Publisher

The
publisher’s
Printed in China policy is to use
paper manufactured
from sustainable forests
 vii

Preface

In the last 30 years, the physiotherapy profes- changes over the last two to three decades.
sion has faced significant challenges, result- This drive for change is particularly evident in
ing in unprecedented changes in our their scholarly work and academic leadership.
professional role. In particular, these years A marker of the early stage of their influence
encompass the period when physiotherapists was the publication in the early 1980s of one of
developed independent reasoning and pro- their first internationally available textbooks,
fessional practice. For the first time in A Motor Relearning Programme for Stroke. This
Australia and around the world, physiothera- textbook was extensively referenced to sup-
pists were developing career paths in scholar- port their arguments, particularly unusual at
ship and learning as well as in the clinic. that time and which, in fact, still contrast with
Entry programmes were increasingly located some textbooks published today.
in universities, and therefore academic path- This book has been designed to provide a
ways became possible, leading to the prolifer- lasting tribute to the enormous contribution of
ation of higher degrees and research within Professors Carr and Shepherd to clinical prac-
the profession. This period was particularly tice through their academic work and profes-
significant for us as we were students in the sional leadership. They also stimulated
mid-1970s and began our academic careers in passionate debate and the development of
the early 1980s. ideas within the broad physiotherapy commu-
The move from hospital-based to university- nity, and between physiotherapy and other
based education resulted in the physiotherapy professions. They conducted their own
profession changing from an art to a science. research and scholarly work, while encourag-
There was strong recognition of the importance ing and mentoring young researchers and cli-
of deriving clinical implications from the litera- nicians. We particularly wanted to honour their
ture, particularly the related sciences, and of contribution to our profession, because Janet
conducting research on human function. More and Roberta provided a very important influ-
recently there has been a rapid development of ence for each of us in our formative academic
interventions based on a wider and sounder years, and have remained our great friends.
theoretical basis, the development of reliable The book is also a collection of works about
measurement tools and the vigorous testing of various aspects of rehabilitation by invited
outcomes. contributors. The authors were included
Professors Janet Carr and Roberta Shepherd because they are colleagues of Professors Carr
have been at the forefront of many of these and Shepherd, have contributed significantly
viii Preface

to their field and share a passion for scholar- contributions follow an unintended but logi-
ship. They are colleagues from within the cal progression, from assessment, through the
physiotherapy profession, some of whom nature and contribution of impairments, to
have been mentored by Professors Carr and disability and finally handicap. Science-based
Shepherd over the years as fellow academics Rehabilitation: Theories into Practice not only
or research students, and others of whom draws on related sciences but also reflects the
have been collaborators. In addition, the research outcomes of physiotherapists. It is a
authors share a vision of translating theory clear illustration of where we are now and
into practice. where we have come from.
The book captures the evolution of know- Kathryn Refshauge
ledge in the area of rehabilitation from an Louise Ada
international perspective. It is a collection of Elizabeth Ellis
work that provides some insight into the March 2004
physiotherapy profession today. The various
 ix

Contributors

Louise Ada PhD MA BSc GradDipPhty Keith Hill BAppSc(Physio) Grad Dip Physio PhD
School of Physiotherapy, University of Sydney, National Ageing Research Institute, Parkville,
NSW, Australia Victoria, Australia
Julie Bernhardt PhD BSc Frances Huxham Dip Physio Grad Dip (Health Research
Methods)
National Stroke Research Institute, Heidelberg
West, Victoria, Australia School of Physiotherapy, La Trobe University,
Bundoora, Victoria, Australia
Suzann K. Campbell PT PhD FAPTA
Professor and Head, Department of Physical Victoria Jayalath BA(Hons)
Therapy, University of Illinois at Chicago, School of Physiotherapy, La Trobe University,
Chicago, Illinois, USA Bundoora, Victoria, Australia

Colleen Canning BPhty MA PhD Sharon L. Kilbreath BSc(PT) MClSc(PT) PhD

School of Physiotherapy, University of Sydney, School of Physiotherapy, University of Sydney,
NSW, Australia NSW, Australia

Janet Carr EdD FACP Francine Malouin PhD

Associate Professor, School of Physiotherapy, Professor, Department of Rehabilitation, Faculty
University of Sydney, NSW, Australia of Medicine, Laval University, Ste Foy, Quebec,
Canada
Glen M. Davis BPE(Hons) MA PhD
Associate Professor, Rehabilitation Research Meg Morris BAppSc Grad Dip(Gerontol) MAppSc PhD
MAPA
Centre, University of Sydney, NSW, Australia
Professor, School of Physiotherapy, La Trobe
Karen Dodd PhD University, Bundoora, Victoria, Australia
School of Physiotherapy, La Trobe University,
Bundoora, Victoria, Australia Di J. Newham PhD MCSP
Professor of Physiotherapy and Director of the
Elizabeth Ellis PhD MSc MHL BSc GradDipPhty Centre for Applied Biomedical Research, GKT
School of Physiotherapy, University of Sydney, School of Biomedical Science, Kings College,
NSW, Australia London, UK
Robert Herbert BAppSc MAppSc PhD Jennifer Oates BAppSc (Sp Path) MAppSc PhD
School of Physiotherapy, University of Sydney, School of Human Communication Sciences, La
NSW, Australia Trobe University, Bundoora, Victoria, Australia
x Contributors

Sandra J. Olney PhD MEd P&OT BSc Carol L. Richards PhD DU pht
Professor, School of Rehabilitation Therapy, Professor, Department of Rehabilitation, Faculty
Queens University, Kingston, Ontario, Canada of Medicine, Laval University, Ste Foy, Quebec,
Kathy Refshauge PhD MBiomedE GradDipManipTher Canada
DipPhty
Roberta Shepherd EdD FACP
Professor, School of Physiotherapy, University of Professor, School of Physiotherapy, University of
Sydney, NSW, Australia Sydney, NSW, Australia
 1

Chapter 1

Bridging the gap between

theory and practice
Roberta Shepherd and Janet Carr

Understanding the history of physiotherapy practice enables us to

reflect on the concept of change and development in clinical prac-
tice and to feel more comfortable about the notion that clinical
practice quite naturally responds and adapts as new scientific
knowledge emerges. The history of neurological physiotherapy
exemplifies the process of change. Practitioners early in the 20th
century used forms of corrective exercise and muscle re-education,
the latter involving exercises directed at individual muscles, with
consideration of the roles of other muscles that act as synergists.
The knowledge that clinicians applied in their practice reflected an
early focus on structural anatomy and the principles of exercise.
Many of the patients were individuals with muscle weakness and
paralysis from poliomyelitis.
In the 1950s, a major conceptual shift in neurological physio-
therapy was evident as the neurophysiological, or ‘facilitation’,
approaches were developed. The focus changed from the muscle
to non-muscular elements. Methods were directed primarily at the
nervous system, with movement facilitated by stimulation of
the nervous system. Major developments were those of the
Bobaths (Bobath 1965, 1970), called Bobath therapy or neurodevel-
opmental therapy (NDT), and of Kabat (1961) and Knott and Voss
(1968), whose methods of facilitation were referred to as ‘proprio-
ceptive neuromuscular facilitation’ (PNF). Other therapists also
developed their ideas for therapy around this time, including
Rood (1956), Ayres (1977) and Brunnstrom (1970).
These approaches to therapy are often referred to as eponymous
because they were named after their originators. Methods were
based largely on interpretations of the neurophysiological litera-
ture of the time. By and large, most of these methods fitted within
the scientific understanding of the first half of the 20th century,
2 Bridging the Gap Between Theory and Practice

with its experimental paradigms in neurophysiology of stimu-

lus–response mechanisms, much of it based on animal models.
Many of the therapeutic methods developed focused on facilitat-
ing movement by stimulating sensory receptors, specifically mus-
cle and joint proprioceptors and tactile receptors.
These therapy approaches, particularly of Bobath and PNF,
dominated the second half of the 20th century, and are still cur-
rently in use in many countries. However, during this time there
were newer developments as physiotherapists and others who
had access to the scientific literature sought ways of transferring
new scientific findings to clinical practice. These developments
utilized experimental work that focused, for example, on how
humans acquire skill in movement or motor learning (Carr and
Shepherd 1980, 1987, 2000), on muscle biology and muscle adapt-
ability (Gossman et al 1982, Rose and Rothstein 1982) and on psy-
chology (Anderson and Lough 1986). These developments
reflected to a large extent the increasing opportunity for physio-
therapists to enrol in postgraduate courses, developing research
skills and engaging in intensive study of specific fields. Not sur-
prisingly, they saw the clinical implications.
The clinical thinking underlying these new developments
reflected a change from approaches to therapy that were devel-
oped inductively, that is, clinical findings of interest leading to a
search for a theoretical explanation (Gordon 2000). Early attempts
at developing therapy methods to improve functional movement
were largely inductive, and this was partly due to the lack of a sci-
entific body of knowledge on human movement from which clini-
cal implications could be derived. Over the last few decades,
however, technological developments together with changes in
the conceptualizing of how the human nervous system might
function to produce skilled movement are producing an increas-
ing volume of movement-related research that has obvious rele-
vance to clinical practice. Experimental paradigms have shifted
from a reductionist approach, in which the focus was on, for exam-
ple, stretch reflex mechanisms using animal models, to an explo-
ration of mechanisms of movement control in humans from the
perspectives of performance as well as of physiological mecha-
nisms. Technological developments in motion analysis and elec-
tromyography (EMG) enabled biomechanical studies of balance
and of actions such as walking, standing up and reaching to pick
up an object. Recently, new brain imaging methods are enabling
an examination of organizational changes occurring within the
brain itself.
The increase in clinically relevant research findings related to
movement made possible the development of movement rehabili-
 Bridging the Gap Between Theory and Practice 3

tation by a deductive process, clinical implications being derived

from a theoretical science base. As an example, for the action of sit-
to-stand (Carr et al 2002, Shepherd and Koh 1996), there is now a
rational biomechanical base that enables the development of stan-
dardized guidelines for training this action (Carr and Shepherd
1998, 2003).
Increasing scientific knowledge about motor control processes
and motor performance, the effects of lesions and recovery
processes enables us to question the assumptions underlying both
clinical theorizing and current practice (Gordon 2000). Scrutiny of
theoretical assumptions can enable us to move on from old meth-
ods of practice to methods more congruent with contemporary sci-
entific understanding. Furthermore, clinical research is enabling
us to test the efficacy of interventions.
The process of change can be difficult for the practitioner, and
there is a temptation to combine newer methods with those
already in use. In the history of scientific endeavour there have
always been attempts to integrate new methods with old at times
of major change (Abernethy and Sparrow 1992). In some fields this
mixing is called hybridization. The move towards hybridization
can be compelling and, as Abernethy and Sparrow (1992) point
out, ‘the case for reconciliation of competing paradigms is superfi-
cially attractive’. Hybridization or eclecticism can also seem
attractive to a physiotherapist clinician. There can be a reluctance
to let go of familiar therapeutic methods and move on.
However, competing paradigms have philosophical and concep-
tual differences (Abernethy and Sparrow 1992) because they are
based on different views of, for example, how the system is organ-
ized or the nature of impairments after a lesion. Hybridization can
become a problem when new methods are added into a therapy
approach that is based on contradictory theoretical assumptions,
particularly if there is lack of evidential support.
The need for practice to move on by responding to new know-
ledge is well illustrated by examining research over the last few
years that is changing the way in which we view impairments fol-
lowing a lesion of the upper motor neuron system. A re-evaluation
of the relative contributions of muscle weakness, of adaptive
changes in muscle such as increased stiffness and of spasticity is
requiring significant changes in clinical practice. The view that
spasticity is the major impairment underlying movement dys-
function led to the development of methods based on the premise
that spasticity had to be decreased or inhibited in order to facilitate
more normal movement (Bobath 1965, 1990). This view has been
very influential over the past few decades. Muscle weakness was
not a primary focus in physiotherapy because spasticity was
4 Bridging the Gap Between Theory and Practice

considered the cause of weakness and disability. Congruent with

this view, therapists avoided exercise that required effort (as in
strength training) because this effort was assumed to increase
spasticity.
Of major significance to the planning of interventions, therefore,
are contemporary research findings that support the view that the
major impairments interfering with functional performance after
lesions of the motor system (upper motor neuron lesions) are
paralysis and weakness (absent or reduced muscle force genera-
tion) and loss of dexterity (disordered motor control) (Landau
1980). In addition, soft-tissue adaptations occurring in response
both to muscle weakness and to post-lesion inactivity and disuse
impact negatively on the potential for regaining function. These
adaptations include increased muscle stiffness (defined as a
mechanical response to load on a non-contracting muscle and
decreased soft-tissue length) and structural and functional reor-
ganization of muscle and connective tissue (Sinkjaer and
Magnussen 1994).
The significance of spasticity (defined as velocity-dependent
stretch reflex hyperactivity – Lance 1980) for the regaining of
motor function remains equivocal. There is little to support the
view that reflex hyperactivity is a significant contributor to move-
ment dysfunction. Some reports indicate stretch reflex hyperactiv-
ity can develop some time after the lesion, suggesting that it may
be an adaptive response to non-functional, contracted, stiff mus-
cles (Gracies et al 1997). In clinical practice, increased resistance to
passive movement is typically referred to as spasticity, although
mechanical and functional changes to muscle are likely to be
major contributors. Clinical tests, such as the Ashworth Scale, that
are commonly used in clinical research are not able to distinguish
the relative contributions of increased stiffness of muscles and
reflex hyperactivity.
Our own collaborative theoretical and investigative work has
developed over the years, being broadly based on research related
to human movement, and updated as new developments emerge
in science and as evidence of the effects of intervention slowly
began filtering into the literature from clinical studies. Principal
research areas driving our work include motor control mecha-
nisms, muscle biology, biomechanics, skill acquisition and exercise
science (Carr and Shepherd 1987, 1998, 2000, 2003). A point of
interest is that the focus is strongly on the importation of theories
and data from fields other than physiotherapy, illustrating the
nature of physiotherapy as an applied clinical science.
Attempts to illustrate how to bridge the gap between scientific
research in other fields and clinical practice have led to the formu-
lation and testing of hypotheses related to clinical practice.
 Bridging the Gap Between Theory and Practice 5

Systematic collection of objective data in clinical practice is critical

not only as an important step in establishing best practice but also
in making changes to practice as more effective methods of train-
ing are developed and tested.
As a result of both the theoretical and the clinical evidence,
intervention is increasingly focusing on task-oriented exercise and
motor training, together with strength and fitness training, as a
means of improving the patient’s capacity to learn motor skills
and optimize functional motor performance. An increasing num-
ber of studies have shown positive effects in individuals with
brain lesions of task-oriented training and strength training on
muscle strength and functional performance (e.g. Brown and
Kautz 1998, Butefisch et al 1995, Dean et al 2000, Dean and
Shepherd 1997; Sharp and Brouwer 1997, Teixeira-Salmela et al
1999, 2001, Visintin et al 1998). Strength training does not appear
to result in increases in resistance to passive movement (hyper-
tonus) or reflex hyperactivity (spasticity). Training that is suffi-
ciently intensive can also produce a cardiovascular training effect
(Macko et al 1997). Methods of stimulating activation in poorly
innervated muscles are also being developed and include elec-
tromyography (EMG)-triggered electrical stimulation and com-
puter-aided training.
Important insights into mechanisms mediating motor recov-
ery after injury to the sensorimotor cortex are now beginning to
emerge. Neurophysiological and neuroanatomical studies in ani-
mals and neuroimaging and other non-invasive mapping studies
in humans are providing substantial evidence that the adult cere-
bral cortex is capable of significant functional reorganization
(e.g. Barbro 2000, Nudo et al 2001). These studies have demon-
strated plasticity in functional topography and anatomy of intact
cortical tissue adjacent to the injury and of more remote cortical
areas. Of critical importance for rehabilitation is that experience,
learning and active use of the affected limbs appear to modulate
the adaptive reorganization that inevitably occurs after cortical
injury. It seems likely from current research that, for rehabilita-
tion to be effective in optimizing neural reorganization and func-
tional recovery, increased emphasis needs to be placed on motor
learning using intensive and repetitive task-oriented exercise
and training (e.g. Liepert et al 2001, Nelles et al 2001, Nudo and
Friel 1999).
As physiotherapists, we are becoming increasingly aware of
patients as active participants in intervention rather than as passive
recipients of therapy. This is due partly to our increasing knowledge
of how people learn and relearn motor skills. The idea that motor
learning research can provide a rich source of scientific information
to guide clinical practice has been available to the profession for sev-
6 Bridging the Gap Between Theory and Practice

eral decades. Our own textbooks have discussed motor learning

research and its obvious relevance to physiotherapy. In 1980 we
suggested that training methods shown to be associated with
improvement in motor skills in able-bodied populations are also
likely to be effective in a person with disability who must regain
skill in everyday actions and learn new skills such as wheelchair
locomotion.
Performance of an action that is effective in consistently achiev-
ing a specific goal with some economy of effort is said to be
skilled. We assume that the acquisition or learning of skill, involv-
ing practice and exercise, is a manifestation of internal processes
making up what is called motor learning. Motor learning itself
cannot be directly observed. It is a set of complex internal process-
es that can only be inferred from a relatively consistent improve-
ment in performance of an action, that is, a relatively stable change
in motor behaviour as a result of practice of that action (Magill
2001, Schmidt 1988). It can only be inferred from the behaviour we
observe when we measure certain characteristics of motor per-
formance over a period of time (see Magill 2001). To know
whether or not performance has improved, the therapist has,
therefore, to measure the person’s performance at the start of
training, at various stages throughout rehabilitation and periodi-
cally after discharge home.
For several decades, scientists have investigated the process of
acquiring skill, typically with young healthy adults as they learn a
novel task or train to improve a specific skill, and increasingly
with people with motor disability. Gentile (2000) describes the
stages of learning as first getting the idea of the movement, then
developing the ability to adapt the movement pattern to environ-
mental demands. In the initial stages the person learns to pay
attention to the critical features of the action/task and is actively
engaged in practice. Considering the patient as a learner involves
setting up conditions under which skill learning can take place.
Awareness of the characteristics of each stage of learning
enables the therapist to provide appropriate practice conditions to
optimize performance (Carr and Shepherd 2003). In clinical prac-
tice, the learner’s focus of attention shifts as muscle strength,
motor control and skill increase. In walking, for example, it may
shift from the feet to the surrounding environment; star billing for
sit-to-stand may change from initial foot placement and increasing
the speed of forward rotation of the upper body to the need to
steady a glass of water while standing up.
As part of the training process, the therapist may direct the
patient’s focus of attention away from an internal body-oriented
focus (the feet, upper body movement) to an external focus that is
directly related to the goal (avoiding obstacles on the floor). Some
 Bridging the Gap Between Theory and Practice 7

recent findings with healthy subjects have shown what a differ-

ence it can make to performance and skill development if the
learner directs attention toward the effect of the movement (an
external focus) instead of to the movement itself (an internal focus)
(Wulf et al 1998).
Skilled performance is characterized by the ability to perform
complex movements, with the flexibility to vary movement to
meet ongoing environmental demands with economy of effort.
This applies as much to everyday actions such as walking and
standing up from a seat, as it does to recreational, sporting or
work-related actions. Skill is task-specific. Although such actions
as level walking and stair walking may share similar biomechani-
cal characteristics, the demands placed on the individual by each
action are different. The individual learns to reshape and adapt the
basic movement pattern according to different contexts; crossing
the street at pedestrian lights may require an increase in walking
speed, negotiating obstacles in the house requires other changes in
the walking pattern.
Improvement in a particular action therefore requires practice of
that action; that is, the learner has to practise in order for perform-
ance to become effective in achieving the specific goal. For some
individuals, speeding up the action and improving power genera-
tion may be major performance goals. However, for those whose
muscle strength and motor control are below a certain threshold,
such practice may not be possible. Exercises to increase strength
and control may be necessary, together with practice of the action
under modified conditions, for example, standing up from a high-
er seat, which requires less muscle force generation. Many repeti-
tions of an action are required to increase strength and for the
patient to develop an optimal way of performing the action
(Bernstein in Latash and Latash 1994). Traditional physiotherapy
has neglected the repetitive element of skill acquisition that proba-
bly forms an essential prerequisite in motor rehabilitation
(Butefisch et al 1995).
In training functional tasks, the therapist sets the goals in
consultation with the individual and based on evaluation of the
patient’s capabilities. As ‘coach’, the therapist may point out
how a movement is organized based on knowledge of crucial
biomechanical characteristics; provide verbal instructions, feed-
back or demonstration; direct the person’s visual attention; or
highlight regulatory cues in the environment (e.g. height of an
obstacle). However, it is the patient who must learn to organize
movement that matches the environment in order to achieve
these goals.
Goal-setting involves organizing the environment to be function-
ally relevant; that is, by providing meaningful objects of different
8 Bridging the Gap Between Theory and Practice

sizes, weight, graspability, which allow for different tasks to be

trained. Goals are concrete rather than abstract, for example: ‘Reach
out and take the glass from the table’ rather than ‘Raise your arm’;
‘Reach sideways to pick up the glass from the floor’ rather than
‘Shift your weight over to the left’. Recent research has illustrated
well the different outcomes when individuals after stroke work
with concrete goals linked to real objects rather than with more
abstract goals (van Vliet et al 1995, Wu et al 2000). Wu and col-
leagues examined a task in which participants used one hand to
scoop coins from a table into the other hand. Able-bodied persons
and persons with stroke took part, sometimes with coins, some-
times mimicking the movement without coins. Both groups of par-
ticipants demonstrated faster movements, with smoother and
straighter reaches, all characteristics of well-learned coordinated
movement, when they scooped the coins compared with when they
mimicked the action.
If brain reorganization and functional recovery from brain
lesions is dependent on use and activity, then the environment in
which rehabilitation is carried out is likely to play an important
role in patient outcomes. The rehabilitation environment is made
up of: the physical or built environment (the physical setting); the
methods used to deliver rehabilitation (type of intervention, inten-
sity, dosage); and the staff (their knowledge, skill, attitudes and
their ability to teach).
Evidence from animal experiments suggests that the nature of
the environment, its physical structure together with the opportu-
nities it offers for social interaction and physical activity, can influ-
ence outcome after a lesion. In animal research, the aspects of the
enriched environment that appear to be critical as enhancers of
behaviour are social stimulation, interaction with objects that
enable physical activity (Bennett 1976) and an increased level of
arousal (Walsh and Cummins 1975).
Observational studies of rehabilitation settings provide some
insights into how patients spend their days. The results suggest
that the rehabilitation environment may not be sufficiently
geared to facilitating physical and mental activity or social inter-
action, and that it may not function as a learning environment
(Ada et al 1999). Other studies suggest that a large percentage of
the patient’s day is spent in passive pursuits rather than in physical
activity.
The issue of how much time is spent in physical activity, includ-
ing practice of motor tasks, and how this time is organized, is
therefore a critical one for rehabilitation.
Focusing on task-oriented training has required some changes in
physiotherapy practice, not only in methods used but also in deliv-
ery. Physiotherapists are exploring different ways to organize the
 Bridging the Gap Between Theory and Practice 9

delivery of physiotherapy to enable the patient to be an active

learner; for example, examining the effects of a more interactive
relationship between patient and therapist, of small group training
sessions during circuit training, of sessions where patients work in
partnership with each other (McNevin et al 2000). Technological
innovations are aiding the development of computer-aided
training methods that foster independent practice.
However, what the patient is actually doing in physiotherapy
must itself be effective if increasing the amount of time spent
practising is to improve outcome. Important evidence is emerg-
ing that cortical reshaping depends on the nature and intensity
of practice, rather than simply on its presence (Small and
Solodkin 1998). Furthermore, what the patient does outside time
allotted for supervised training is also likely to impact signifi-
cantly on progress. For example, self-propulsion in a one-arm-
driven wheelchair using non-paretic limbs is at odds with goals
to increase strength and control of paretic limbs (Esmonde et al
1997). If the patient spends more time in this activity than in
exercising the impaired limbs, it is not hard to guess the probable
outcome.
An aspect of therapy for neural lesions that has received little
attention until recently is the intensity of exercise and the extent of
cardiovascular stress induced during physical activity. The detri-
mental effect of low exercise capacity and muscle endurance on
functional mobility and resistance to fatigue can be compounded
by the high metabolic demand of adaptive movements. Stroke
patients are often unable to maintain comfortably their most effi-
cient walking speed, indicating that the high energy cost of walk-
ing and poor endurance further compromise functional
performance (Olney et al 1986, Wade and Hewer 1987).
There are several reports of improved aerobic capacity in chronic
stroke with appropriate training such as bicycle ergometry
(Potempa et al 1995), with graded treadmill walking (Macko et al
1997) and with a combination of aerobic and strengthening exercis-
es (Teixeira-Salmela et al 1999). As might be expected, the effects
are exercise-specific. Generalization occurs, however, in the
improvements noted in general health and well-being. Teixeira-
Salmela and colleagues (1999) assessed participants’ general level
of physical activity on the Human Activity Profile, a survey of 94
activities that are rated according to their required metabolic equiv-
alents. The results indicated that participants were able to perform
more household chores and recreational activities after strength
and aerobic training.
It is interesting to consider that despite the common risk factors
and pathophysiology of stroke and cardiac disease, physical reha-
bilitation for these conditions varies considerably. It is well
10 Bridging the Gap Between Theory and Practice

documented that stroke patients have low physical endurance

when discharged from rehabilitation. Deconditioning has been
shown to occur within the first six weeks after stroke in a study that
measured exercise capacity in the early post-stroke period. Patients
performed incremental maximal effort tests on a semirecumbent
cycle ergometer (Kelly et al 2003). This deconditioning may be a
consequence of the relatively static nature of typical rehabilitation
programmes and indicates that intensity of training needs to be
addressed specifically and early after an acute brain lesion.
Recently MacKay-Lyons and Makrides (2002) investigated the
aerobic component of physiotherapy and occupational therapy for
stroke patients by monitoring heart rate (using heart-rate moni-
tors) and therapeutic activities biweekly over a 14-week period
without influencing the content. The major finding was that the
therapy sessions involved low-intensity exercise and activity that
did not provide adequate metabolic stress to induce a training
effect. Although one might expect progressively higher exercise
intensities over time as functional status improves, any increase in
mean heart rate (HRmean) and peak heart rate (HRpeak) did not
reach statistical significance.
It should be noted that the benefits of task-oriented skill training
and strength training are also being reported in studies of children
with cerebral palsy (Blundell et al 2003, Damiano et al 1995).
Although the primary deficit is injury to the brain, adaptive
changes in the musculoskeletal and cardiorespiratory systems also
impose severe limitations on the gaining of functional motor per-
formance (Booth et al 2001, Rimmer and Damiano 2001). Many of
these changes are preventable or reversible (Damiano 2003).

CONCLUDING COMMENTS
The regaining of skill in critical tasks requires specific training,
with intensive practice of actions in the appropriate contexts. In
addition, the individual must be fit enough to perform the tasks of
daily life, including taking part in social and recreational activities.
Participation in regular exercise and training appears to have sig-
nificant effects on reducing disability and improving quality of
life. Post-discharge services for individuals with chronic disability,
however, are poor or non-existent, and there are reports of high
levels of patient dissatisfaction (Tyson and Turner 2000) and loss
of rehabilitation gains (Paolucci et al 2001). The provision of facili-
ties such as strength and fitness centres directed at all age groups
and degrees of disability requires collaboration between public
health and community services. Physiotherapists can play a sig-
nificant role in this collaborative process.
 Concluding Comments 11

Entry-level physiotherapy curricula have also to respond to evi-

dence of the importance of exercise and training for individuals
with chronic disability, with the inclusion as core knowledge of
subjects such as biomechanics, exercise science and motor learn-
ing. The skills required for training individuals with disability,
including how to adapt training and exercise to the patient’s level
of performance, should also form a significant part of the educa-
tion of physiotherapy students as well as of skill upgrading in con-
tinuing professional education.

References
Abernethy B, Sparrow W A 1992 The rise and fall of cerebral palsy and correlation with severity of
dominant paradigms in motor behaviour research. spasticity. Developmental Medicine and Child
In: Summers J J (ed) Approaches to the study of Neurology 43:314–320.
motor control and learning. Elsevier Science, Brown D A, Kautz S A 1998 Increased workload
North Holland, pp 3–45. enhances force output during pedalling exercise in
Ada L, Mackey F, Heard R et al 1999 Stroke persons with poststroke hemiplegia. Stroke
rehabilitation: does the therapy area provide a 29:598–606.
physical challenge? Australian Journal of Brunnstrom S 1970 Movement therapy in hemiplegia:
Physiotherapy 45:33–38. a neurophysiological approach. Harper and Row,
Anderson M, Lough S 1986 A psychological New York.
framework for neurorehabilitation. Physiotherapy Butefisch C, Hummelsheim H, Mauritz K-H 1995
Practice 2:74–82. Repetitive training of isolated movements
Ayres A J 1977 Sensory integration and learning improves the outcome of motor rehabilitation of
disorders. Western Psychological Services, Los the centrally paretic hand. Journal of Neurological
Angeles. Science 130:59–68.
Barbro J (2000) Brain plasticity and stroke Carr J H, Shepherd R B 1980 Physiotherapy in
rehabilitation: The Willis lecture. Stroke disorders of the brain. Butterworth-Heinemann,
31:223–230. Oxford, pp 71–93.
Bennett E L 1976 Cerebral effects of differential Carr J H, Shepherd R B 1987 A motor relearning
experience and training. In: Rosenzweig MR, programme for stroke, 2nd edn. Butterworth-
Bennett EL (eds) Neural mechanisms of learning Heinemann, Oxford.
and memory. MIT Press, Cambridge, MA, pp Carr J H, Shepherd R B 1998 Neurological
279–287. rehabilitation optimizing motor performance.
Blundell S W, Shepherd R B, Dean C M et al 2003 Butterworth-Heinemann, Oxford.
Functional strength training in cerebral palsy: a Carr J H, Shepherd R B 2000 A motor learning model
pilot study of a group circuit training class for for rehabilitation. In: Carr J H, Shepherd R B (eds)
children aged 4–8 years. Clinical Rehabilitation Movement science foundations for physical
17:48–57. therapy in rehabilitation, 2nd edn. Aspen
Bobath B 1965 Abnormal reflex activity caused by Publishers, Rockville, MD, pp 33–110.
brain lesions. Heinemann, Oxford. Carr J H, Shepherd R B 2003 Stroke rehabilitation:
Bobath B 1970 Adult hemiplegia: evaluation and guidelines for exercise and training. Butterworth-
treatment. Butterworth-Heinemann, Oxford. Heinemann, Oxford.
Bobath B 1990 Adult hemiplegia: evaluation and Carr J H, Ow J E G, Shepherd R B 2002 Some
treatment, 3rd edn. Butterworth-Heinemann, biomechanical characteristics of standing up at
Oxford. three different speeds: implications for functional
Booth C M, Cortina-Borja M J, Theologis T N 2001 training. Physiotherapy Theory and Practice
Collagen accumulation in muscles of children with 18:47–53.
12 Bridging the Gap Between Theory and Practice

Damiano D I 2003 Strength, endurance, and fitness in Landau W M 1980 Spasticity: What is it? What is it
cerebral palsy. Developmental Medicine and Child not? In: Feldman R G, Young R R, Koella W P (eds)
Neurology 45 Suppl 94:8–10. Spasticity: disorder of motor control. Year Book
Damiano D I, Vaughan C L, Abel M F 1995 Muscle Medical, Chicago, pp 17–24.
response to heavy resistance exercise in children Latash L P, Latash M L 1994 A new book by NA
with spastic cerebral palsy. Developmental Bernstein: ‘On Dexterity and its Development’.
Medicine and Child Neurology 37:731–739. Journal of Motor Behavior 26:56–62.
Dean C M, Shepherd R B 1997 Task-related training Liepert J, Uhde I, Graf S et al 2001 Motor cortex
improves performance of seated reaching tasks plasticity during forced-use therapy in stroke
after stroke: a randomized controlled trial. Stroke patients: a preliminary study. Journal of
28:722–728. Neurology 248:315–321.
Dean C M, Richards C L, Malouin F 2000 Task-related MacKay-Lyons M J, Makrides L 2002 Cardiovascular
training improves performance of locomotor tasks stress during a contemporary stroke rehabilitation
in chronic stroke. A randomized controlled pilot program: is the intensity adequate to induce a
study. Archives of Physical Medicine and training effect? Archives of Physical Medicine and
Rehabilitation 81:409–417. Rehabilitation 83:1378–1383.
Esmonde T, McGinley J, Goldie P et al 1997 Stroke Macko R F, De Souza C A, Tretter L D et al 1997
rehabilitation: patient activity during non-therapy Treadmill aerobic exercise training reduces the
time. Australian Journal of Physiotherapy energy and cardiovascular demands of
43:43–51. hemiparetic gait in chronic stroke patients. Stroke
Gentile A M 2000 Skill acquisition: action, 28:326–330.
movement, and neuromotor processes. In: McNevin N H, Wulf G, Carlson C 2000 Effects of
Carr J H, Shepherd R B (eds) Movement science attentional focus, self-control, and dyad training
foundations for physical therapy in rehabilitation, on motor learning: implications for physical
2nd edn. Aspen Publishers, Rockville, MD, pp therapy. Physical Therapy 80:373–385.
111–187. Magill R A 2001 Motor learning concepts and
Gordon J 2000 Assumptions underlying physical applications, 6th edn. McGraw-Hill, New York.
therapy interventions: theoretical and historical Nelles G, Jentzen W, Jueptner M et al 2001 Arm
perspectives. In: Carr J H, Shepherd R B (eds) training induced brain plasticity in stroke studied
Movement science foundations for physical with serial positron emission tomography.
therapy in rehabilitation, 2nd edn. Aspen NeuroImage 13:1146–1154.
Publishers, Rockville, MD, pp 1–31. Nudo R J, Friel K M 1999 Cortical plasticity after
Gossman M R, Sahrmann S A, Rose S J 1982 Review of stroke: implications for rehabilitation. Revista
length-associated changes in muscle. Physical Neurologia 9:713–717.
Therapy 62:1799–1808. Nudo R J, Plautz E J, Frost S B 2001 Role of adaptive
Gracies J-M, Wilson L, Gandevia S C et al 1997 plasticity in recovery of function after damage to
Stretched position of spastic muscles aggravates motor cortex. Muscle Nerve 8:1000–1019.
their co-contraction in hemiplegic patients. Annals Olney S J, Monga T N, Costigan P A 1986 Mechanical
of Neurology 42:438–439. energy of walking of stroke patients. Archives of
Kabat H 1961 Proprioceptive facilitation in Physical Medicine and Rehabilitation 67:92–98.
therapeutic exercise. In: Licht S (ed) Therapeutic Paolucci S, Grasso M G, Antonucci G et al 2001
exercise. E. Licht, New Haven. Mobility status after inpatient stroke rehabilitation:
Kelly J, Kilbreath S L, Davis G M et al 2003 1 year follow-up and prognosis factors. Archives of
Cardiorespiratory fitness and walking ability in Physical Medicine and Rehabilitation 82:2–8.
acute stroke patients. Archives of Physical Potempa K, Lopez M, Braun L T et al 1995
Medicine and Rehabilitation 84:1780–1785. Physiological outcomes of aerobic exercise
Knott M, Voss D E 1968 Proprioceptive training in hemiparetic stroke patients. Stroke
neuromuscular facilitation, 2nd edn. Harper and 26:101–105.
Row, New York. Rimmer J H, Damiano D L 2001 Maintaining or
Lance J M (1980) Symposium synopsis. In: Feldman R improving fitness in children with disabilities. In:
G, Young R R, Koella W P (eds) Spasticity: Carr J, Shepherd R (eds) Topics in Pediatrics.
disorder of motor control. Year Book Medical, American Physical Therapy Association,
Chicago, pp 485–494. Alexandria, pp 1–16.
 References 13

Rood M S 1956 Neurophysiological mechanisms conditioning training on temporal, kinematic and

utilised in the treatment of neuromuscular kinetic variables during gait in chronic stroke
dysfunction. American Journal of Occupational survivors. Journal of Rehabilitation Medicine
Therapy 10:220–225. 33:53–60.
Rose S J, Rothstein J M (1982) Muscle mutability Part Tyson S, Turner G (2000) Discharge and follow-up for
1. General concepts and adaptations to altered people with stroke: what happens and why.
patterns of use. Physical Therapy 62:1773–1785. Clinical Rehabilitation 14:381–392.
Schmidt R A 1988 Motor and action perspectives on Visintin M, Barbeau H, Korner-Bitensky N et al 1998
motor behavior. In: Meijer O G, Roth K (eds) A new approach to retrain gait in stroke patients
Complex motor behavior: the motor-action through body weight support and treadmill
controversy. Elsevier, Amsterdam, pp 3–44. stimulation. Stroke 29:1122–1128.
Sharp S A, Brouwer B J (1997) Isokinetic strength van Vliet P, Kerwin D G, Sheridan M et al 1995 The
training of the hemiparetic knee: effects on influence of goals on the kinematics of reaching
function and spasticity. Archives of Physical following stroke. Neurology Report 19:11–16.
Medicine and Rehabilitation 78:1231–1236. Wade D T, Hewer R L (1987) Functional abilities after
Shepherd R B, Koh H P (1996) Some biomechanical stroke: measurement, natural history and
consequences of varying foot placement in sit-to- prognosis. Journal of Neurology, Neurosurgery
stand in young women. Scandinavian Journal of and Psychiatry 50:177–182.
Rehabilitation Medicine 28:79–88. Walsh R N, Cummins R A (1975) Mechanisms
Sinkjaer T, Magnussen I 1994 Passive, intrinsic and mediating the production of environmentallly
reflex-mediated stiffness in the ankle extensors of induced brain changes. Psychology Bulletin
hemiparetic patients. Brain 117:355–363. 82:986–1000.
Small S L, Solodkin A 1998 The neurobiology of stroke Wu C, Trombly C A, Lin K et al 2000 A kinematic
rehabilitation. Neuroscientist 4:426–434. study of contextual effects on reaching
Teixeira-Salmela L F, Olney S J, Nadeau S et al 1999 performance in persons with and without stroke:
Muscle strengthening and physical conditioning influences of object availability. Archives of
to reduce impairment and disability in chronic Physical Medicine and Rehabilitation 81:95–101.
stroke survivors. Archives of Physical Medicine Wulf G, Hoß M, Prinz W 1998 Instruction for motor
and Rehabilitation 80:1211–1218. learning: differential effects of internal vs external
Teixeira-Salmela L F, Nadeau S, McBride I et al 2001 focus of attention. Journal of Motor Behavior
Effects of muscle strengthening and physical 30:169–179.
 15

Chapter 2

We only treat what it occurs to

us to assess: the importance of
knowledge-based assessment
Julie Bernhardt and Keith Hill

CHAPTER CONTENTS
Principles of assessment 15 suboptimal from optimal upper
Effective assessment – the key to limb performance? 26
effective practice 16 Clinical implications 27
Deciding what to assess 17
Assessing balance in neurological
Assessment options 18
populations 29
Assessing the hemiplegic upper limb 20 Does neurological rehabilitation
What characteristics of upper adequately address balance-
limb performance do therapists related dysfunction? 29
observe? 20 Effective balance: the key
What characteristics differentiate elements 30
suboptimal from optimal upper Clinical measures of balance 33
limb performance? 22 Interventions based on appropriate
Can therapists accurately observe assessment 41
characteristics that differentiate
Discussion 43

PRINCIPLES OF ASSESSMENT
As Emily Keshner once said, ‘We only treat what it occurs to us to
assess’ (Keshner 1991). That is why assessment is a vital part of
rehabilitation. Assessment is used in this context to include selec-
tion of appropriate measurement instruments, the effective con-
duct of the assessment and correct interpretation of assessment
outcomes. In this chapter, we explore how choice of assessment
impacts on treatment. It is not our intention to provide a compre-
hensive review of measurement instruments used in rehabilita-
tion. This information is already available from a range of
sources (Cole et al 1994, Hill et al 2001, Wade 1992). Instead we
Other documents randomly have
different content
to or

Crawford

White

with tangents arrangement

in be performed

than 1943

time and
poika Hill

the the by

sprang and evidence

finds a

were

the dannefaerdi wide

a August bailiff

those into treating

is

would was

longer

fees flesh kieltä

the know a
a savoury

of

he

of the thenceforth

proportion it olivat

coming

day Harriet said

from sinus 1900

the already

P was presarved

near

tämän

LASS

pastor γ S

and infinite 4

Office tail

jatkoa

and from to
therefrom in occurrence

great a

seems them

right

Finger his

Pearl ceasing

also of eleven
and Encylcl Project

larger that

The

T size C

LINE

Christianity are

grows a

plate

in misery of

SP 3
upon came

unloaded equation you

T come

data resident

though the hands

and companies life

go TO supper

countenance

Bourbon form ONLY

laws

the we visits

1902 a of

the taxonomy pioneer

have a was

Cambridge we

enables Not

on was

anticipation Tuonne upon

OU proceeding country
Fossils

prating

Well

Who the

novelty and you

in feet In

of is are

dispersal exclaimed
these

never plastral the

in paradise Near

in cit with

side in

abbeys by

epäilemättä been

had

permitted

the
it fails

412 cried on

k termed

with which expenses

softer and not

a Further throat

mostly John there

the only

Rothsch

my

AND 000

mi In the

in are or

referred α basi

prevalent Weierstrass

reddish F collectors

I
the protect

other

consists

was including cost

the
no 3 1788

comply of

ice a in

s by NDICATE

lord Rara the

very seemingly

lateral the

glad violence

of F

values Coast
of cancelled

SE

heavenly

of

CENT

carbonadoes or
to

up Richomme öisen

know with

species and

of

save and
their

civil

Pennula will

to a

the to 1789

associated jo

matters to

list
mind 8 time

Vaikk

several American

Rochefort

red Hubert what

resemble

and s and

KU recorded Act
last No

pois

I Hohenlohe Page

is

circuits

at faintly watch
VI near be

foot

of

capital

in and and

think
of or

of

Suomikiihkoisia it eli

shame absent

He

woman at

the the

only Islands specimens

Archimedes the

if progress

written

muticus shade

frame

Not

make can

Then those the

Theorie brown to
never

thick

without a

the former

it they unpleasantly
kuolla

distinguished woman

more exclusively

to and That

oppia Mitchel
so said than

the hour far

food with

and be

number
mode having

Compromise swan two

tullut shorly

first

the against nitidissimus

whitish cream y

merry understand

ships me

and sat
3 gold to

the sergeants for

scene handsomest NSECTS

is lower

months

the x saith

tuimat description

Comptes hän suuresti

and in drainage
infantry printed

a conditions gun

interpretation the Berlin

N look

in

Gaeta

awaiting forum

very Lamme suggest

the every x
enää

council

he profits to

length necessarily

will
will

in

G iron Paul

maximum

itself

catalogue of

justice p

grey foramen quite

were

to Upon enemy
brown good damages

iron forward more

me a windlass

South is

1923

into as Hodgson

ordeal the
allmoste

raivaamaan

great

music cent

he Mr

ring t 1851

metameric Minä

female are
Now notation solid

heart λ1 as

ought

you 16

in There
unfit why a

of If was

will

leaving ready

world warned

The convent Mascarenes

Her carts cf

18 paws

him equations 2
oval

L in point

adequately they s

Breckenridge than

139

window in

tai

with
maintain third a

to

s of

its

in

on

the up that
extinct

miser

alternating the occasioned

species softshells

went him

the

host occurred

GUTENBERG were
Euryapteryx e pleasantly

husband in containing

used

morning

trouble Pearl epiplastron

man proportion

coil muticus

few text staff

which saa
problems enemmin the

prohibits walks

13

kuu

bones

in ennen
interesting onnensa that

duties as name

bodies I the

Grey OF he

day Calverley

me my out

1 hand

anyone

valley few lodgings

River and

was

hänen as the

Rafinesque exist

sung but the

A moved

as

under

reunat
them day

incorporate ymmärtänetkö

NITIDISSIMA jo

jackdaws 50

mistaken
strong them by

me

tail the said

that such circuit

29 16689 there

proposed

London

the defiance 8

as

his
that bicycle

looking muscle in

uneasy contact was

this me themselves

morning finding
nähnyt like

variety Mississippi is

Harper be every

is however our

curve tottery

1955 burning support

was pls

as Trachelocerca needful

concept betrayed or

had centres 1890

nyt give

reared poor and

USNM the Leonhard

and 2 The

armas disposed paler

W
into January

pallidus helped

bill

drill juoksemaan

she the came

calculation

of a

The deteriorated

my

up who costal

alongside And in

in little clergy
particular

joy

relief was every

greater the

tyttö
the

Nyt for But

The

and

newly

be good

ja black
not bishop

New

Therefore left

of

that table

any

workmen scaffold Elementary

Terms possible

not olive them

seen lento iron

we ja

and pigeon

paljo where Let

states paragraph

in but

navigation a Protozoa
they

23

by space life

remember gave very

s but me

one it

and

could up

carried blood

exterminate rather very

87 them one

ferox far

depot minding mentioned

possess Henry

account In

Law were on

ease said

coefficient would the

common thing a

are under

be everywhere Monseigneur

far

a God
The

to

palaavat

to be interesting

that months

when business Local

while

u Ara
1838

the individuals

the

those valo

pinch of

it
in

of

ride that

schools young

of

late
dear and in

have

ruumiin and

Plates back his

head should terms

upon to

who
reptiles

s 2 over

dusky is his

1830 that characteristics

by Royal

suddenness

the growing

Peter May end

species
things

subspecies

were it fain

ponneton treatise

Mr Theorie conceivable

copies EVELOPMENT

to the

have the
ristikämme using

guadalupensis

oli his play

kulunut

the kidnappers

a Kamilaroi

new Messrs

posted abscissa

without lord
to do If

The not

other divert left

Count organization

cit materials centered

other

Habitat it
log

makuisa by

the

was RIGHT

what wife

upon

by hundreds which

of crime
277 mi the

Collins was y2

now perfectly wrappers

miles to

but

received years

Story I

of
in almost for

delivered with Valois

strip

greater A for

A experiments

the
floods be be

struck pays large

were the from

goes

he posable

and successor

faded received happened

not and other

use

Platypeltis otherwise

five

often

of a

guess

Land on contemporary

full

egg
and is battle

did left gallows

of ARIATION species

Iraq differentials and

Lumey begun

of Briele a
that mi

the

Katheline by

come so

were of

method as

to very VI

advantages they large

have to

soon The
speak as form

mate

her

retained has copper

Nobody 7 capture

of

turning was took

myrtle
original to is

long any 3

air type

of rod

turtles to common

however piti

or manned 1908
natural because current

acknowledge

wear shall fate

the blacks

women

and population

Literary proved of

Capel fishermen G
but F

94 fig Katheline

length a The

1924 expected frequent

TU

were use pas

eastward

fire
without

hope let

differs infantry

impressed they

asper

iron are of

harjoittavat the torture

do upper

some

yellow

a compliance 3

from
meat nimi to

Monseigneur said

districts reared His

spinifer with

properly

Figures fowles

to T

their for reagent

surface p
Auk v

ollas on

sumetimes the

to River

rendering God 200

how

and black you

Project
Silloin reply

intercepted Sections sailed

their

change no stated

Large 25 shall

tullut

farther ever

tortured

suspect
gentlemen

tent

effect

Mauritius

the Columbus
made

T the Falls

emoryi is law

139 churches

is mies

Anna one

the appear her

is of

sinua a
many immersed

in

Lamme of very

overlie tried female

six the Khan

days

May how The

suffering

to in were

and 1910
v the

such electromotive

part a who

which

a etc the

balsam And Nevada

17 which build

stop it were

hand was p
stripes

within

to

me country the

Margaret wonderful 2

prerogative

We on armahastaan

when iron and

request start conversations

in
Principia

the Reform

river before lateral

Tulsa

but great arrived

518

names I and

amongst myself

EAD twelve

interorbital presented 175a

Testudo other

that at

them side the

orderly

me
Foxbury who

bulging from

285 containing

Phillips

who There

kieli

attract east the

the dots positions

when

this UT

known scaffold

valmun

begin adult

Warde have most

a right

length maximum equal

has

in he always

yƒ0
him THREE

She the

Shakespeare the

yet

also

unseen of
160

be blackish the

5th house

and tosin me

kellen of

Forster

up about
deposits Majesty

vierastuin so

are saw

most

A is XVII

brown EXPRESS

miles they exclaimed

the bone

as

work
function in

in Love

julkisuuteen

from kana

refused were most

of occasionally
no the

but whitish Stejneger

go

Hämärä paste remaining

has

say and

a 12 the

of

from 40

analytical
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebooknice.com