Download The Efficacy of the ROM Dance Program for Adults With Rheumatoid

The Efficacy of the ROM
Dance Program for
Adults With Rheumatoid
Arthritis
Julia Van Deusen, Diane Harlowe
Key Words: exercise therapy. health
education. relaxation techniques
This study examined the efficacy of an exercise and
relaxation program fOl adults with rheumatoid arthritis. The program integrates principles of occupational therapy and rai-Chi Ch 'uan and was expected to be more effective than traditional exercise
and rest regimens because of its expressive and
pleasurable elements. There were Significant differences between 17 experimental and 16 control subjects on two categories of dependent variables after
the former group's participation in the experimental
program. These dependent variables were range of
motion measures and subject self-reports offrequency, enjoyment, and benefits of home exercise
and rest routines. Pretest, posttest, and 4-month follow-up data were analyzed.
Program participants showed signz/icantly
greater upper extremity range of motion 4 months
after completing the program although the reported
frequency of exercise and rest was greater in the
control group. Postprogram reports of enjoyment
were Significantly higher for experimental than for
control subjects. If these initial results are confirmed
in further studies, the efficacy of the use ofpurposeful activity for exercise and rest will be supported.
This study also supports the integration of Eastern
and Western frames of reference in the treatment of
patients with chronic illness.
c
Julia Van Deusen. PhD, OTR, is Associate Professor, De·
partmenr of Occupational Therapy, College of Health Related Professions, Box J -164, J. HiJlis MiJler Health Center,
University of Florida, Gainesville, Florida 32610
Diane Harlowe, JVIS, OTR, is Director, Occupational Therapyand Speech Services, Sr. Marys Hospital Medical Center, Madison, Wisconsin.
T
herapists and physicians typically recommend
a balance between rest and exercise to patients
with rheumatoid arthritis (Harlowe & Yu, 1982;
Melvin, 1982), but the research on the efficacy of
exercise and rest programs is sparse. Nordemar (Nordemar, 1981, ordemar, Ekblom, Zachrisson, & Lundquist, 1981) found better disease outcomes for rheumatoid arthritiS patients in long-term physical training
programs than for control subjects Achterberg,
MacGraw and Lawlis (1981) obtained positive results
on the effectiveness of relaxation and biofeedback
training for patients with rheumatoid arthritis.
Nonpharmacological relaxation procedures have
been shown to promote relaxation, increase pain tolerance, and reduce stress. Harlowe and Yu (1984)
cited a variety of these studies.
A review of the literature showed no studies on
adherence to home rest programs, but three studies
described compliance of arthritis patients with home
exercise regimens (Carpenter & Davis, 1976; Parker
& Bender, 1957; Treusch & Krusen, 1943). Treusch
and Krusen (1943) found 67% of 216 patients complied with home exercise programs for 3 months with
a drop to only 25% after 1 year. Parker and Bender
(1957) found that 50% of their 56 patient sample
complied for 1 year, and Carpenter and Davis (1976)
reported only 555% of their sample of 54 were compliant at 4-month follow-up. These compliance rates
are low relative to the 65% compliance rate found by
investigators for other types of self-administered medical treatment (Davis, 1966; Davis, 1967; Feinberg &
Brandt, 1981; Maddock. 1967: Oakes, Ward, Gray,
Kauber, & Moody, 1970). A number of explanations
have been offered for the lower compliance rate for
exercise programs: the dearth of efficacy information,
pain, interference with daily routine, and boredom
(Harlowe & Yu, 1984; Blach.rwell, 1973).
The question of how to facilitate increased involvement in daily exercise and rest regimens for
individuals with rheumatoid arthritis is worthy of investigation. Mayo reported in 1978 that patient education has been studied as a means to increase compliance with medical recommendations. Although education was found to increase patients' knowledge
about their diseases and treatment, it did not have an
effect on compliance _ The later literature does not
negate the continuing need for increasing compliance
(Dimonte & Hollis, 1982; Feinberg & Brandt, 1984;
Lenker, Lorig, & Gallagher, 1984; Lorig, Laurin, &
Gines, 1984; Parker et a!, 1984; Robinson, Haldeman,
Imrie, & Neubauer, 1980).
Program Description
Harlowe and Yu (1984) hypothesized that adults with
rheumatoid arthritis would better adhere to a home
exercise-rest program if it were enjoyable and per-
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90
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ceived to have intrinsic value. Therefore, they developed a health education program which employed
the basic occupational therapy principle of addressing
goals through the use of purposeful, meaningful activities which facilitate creativity and self-expression
in a supportive environment. Their program was
named the ROM Dance Program (ROM is pronounced
ram and stands for range of motion). Program goals
include the following:
1. To assist participants in following any medical
recommendations provided by their personal physicians and therapists for involvement in daily exercise
and rest routines
2. To increase the frequency, enjoyment, and
perceived benefit of involvement in daily exercise
and rest
3. To enhance the ability to cope with stress and
pain through the use of relaxation techniques
4. To prOVide a forum for group interaction concerning personal health care management
5. To prOVide selected health education experiences
6. To improve body awareness
7. To promote an experience of well-being
The program's use of an expressive dance form
for maintaining range of motion reflects occu pational
therapy principles more fully than does routine exercise It emphasizes the creative use of relaxation
and pain management techniques during prescribed
rest periods to increase the benefits and perceived
value of rest as a claily activity
The group instruction format was chosen for the
program to proVide a forum for peer interaction and
support. Brief occupational therapy patient education
materials (Harlowe & Yu, 1984; Harlowe & Black,
1984) were included as a focus for discussion Topics
covered included coping with arthritis, the relaxation
response, energy conservation, work simplification,
and the use of adaptive equipment and splints. The
program was designed to be proVided in a series of
eight, 90-minme, weekly health education classes
with 15 to 25 participants. Each class included a
repetition of the ROM Dance sequence, a gUided
relaxation experience, and a group discussion]
The ROM Dance sequence is a flOWing progression of dance-like movements, which incorporates
joint motion in ranges usually recommended for persons with rheumatoid arthritis (Harlowe & Yu, 1984).
The 7-minute sequence is accompanied by a poem
and music, both of which are provided to participants
in an audiotape cassette (ROM Dance, 1984) for home
J Instructional materials for the ROM Dance Program (book, audio
olape, and videotape) can be purchased from St Marys Services,
1011 Erin Street, Madison, WI 53715 (Telephone: 608-258-5700).
use. Illustrated instructions are also provided (Harlowe & Yu, 1984)
In a holistic approach to maintaining function,
the occupational therapy principles and techniques
described here were integrated with those from an
ancient Chinese exercise form, Tai-Chi eh'uan,
which stresses slow, relaxed movement together with
an awareness of postural alignment and breathing.
The ROM Dance routine differs from rai-Chi in that
it presents pleasant images of warm water, sunshine,
and friendship rather than being oriented to the martial arts A sample from the poetry to which the
expressive movements are performed follows (Barlowe & Yu, 1984, p. 23)
I gather the sun's warmth down over me
Bathing me in a shining light
My 11ands feel warm
And a sunbeam shines between them
Then shines back to the sun.
The relaxation component of the ROM Dance
Program includes a wide variety of methods (Harlowe
& Yu, 1984), which are introduced in a graded sequence Emphasis is placed on individual experimentation with the presented techniques. Simple biofeed
back devices are introduced, and relaxation audiotape
cassettes are provided for home use (ROM Dance,
1984)
Results of a pilot study by Harlowe and Yu (984)
of 17 adults with rheumatoid arthritis showed an
increase in the reported frequency of exercise, r'st,
and perceived benefit after participation in the ROM
Dance Program. Subjects also reported that the pro·
gram was beneficial in increasing their ability to cop
with arthritis.
The purpose of the pI/'sent study was to ascertain
if there were significant differences on the dependent
variables between experimental subjects in the RO.!
Dance Program and control subjects on traditional
exercise and rest regimens (a) immediately after tbe
8 week program and (b) 4 months after the comple·
tion of the program. The dependent variables were
range of motion measures and subject self-reports of
the frequency, enjoyment, and benefits of home e. ercise and rest programs as operationally defined by
scores on the scales shown in Figure 1
Method
Subjects
Ambulatory adults with rheumatoid arthritis who had
medical recommendations for home rest and exercise
and no prior ROM Dance experience were recruJ(' :d.
Of 110 potential subjects contacted 46 agreed to
participate in the project and were randomly assigned
to experimental and control groups with 23 subjects
each. All control subjects were informed that they
could participate in a future program as experimental
The Americanjoumal a/Occupational Therapy
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91
Figure 1
Exercise-Rest Self-Report Scales
Please complete the following statements by putting a check next
Table 1
Demographic Data: 46 Subjects (Experimental and
Control) Versus 32 Nonsubjects
to the most appropriate response (choose only one). Please read
all responses carefully since they are not in any particular order
Exercise Scales
A People often have difficulty following advice [0 schedule regular
exercise periods during the day. On the whole, I do my recommended home exercises
S daily
- 4 - three [0 five times a week
_3_ once or twice a week
1 less than once a week
2 once or twice a momh
B~erms of enjoymem, I can say that 1
S almost always enjoy my exercise periods
4 usually enjoy my exercise periods
_2_ get almost no enjoymem from my exercise periods
_3_ occasionally enjoy my exercise periods
_1_ hate haVing [0 take exercise periods
C. I feel that my home exercise program is of
4 much benefit
- 1 - no benefit
-S- tremenl10us benefit
~ little benefit
_3_ some benefit
Rest Scales
A I am able [0 sit qUietly and rest my joints
S once or twice daily
-4- three [0 five times a week
- 2 - once or twice a month
- 1 - less than once a month
3 once or twice a week
B~el that rest periods are of
2 little benefit
- 1 - no benefit
-4- much benefit
-S- tremendous benefit
-3- some benefit
C-:rnterms of enjoymem, I can say that I
_3_ occasionally enjoy my rest periods
4 usually enjoy my rest periods
- 2 - get almost no enjoyment from rest periods
1 hate having to take rest periods
_S_ almost always enjoy my rest periods
No/e. Numbers are for use in scoring and were not on forms
filled out by subjects.
subjects. A physician's permission to participate was
obtained for all subjects.
Demographic data collected on the 46 participams and on a random selection of 32 nonparticipants
were comparable with the exception of age (see Table
1). The average age was greater for the nonpartiCipants than for the subjects.
Instrumentation
Exercise-rest rating scales (see Figure 1) were developed on the basis of the self-report scales in the pilat
study questionnaire (Harlowe & Yu, 1984). These
scales were used to obtain data on the reported frequency, benefits, and enjoyment of rest and exercise.
Scale items were randomly placed to rule out position
habits in response patterns.
92
Variable
Number of medications
Age
Number of surgeries
Sex
Years since onset
Whether or not devices are
used
Chi
Square
F
927
df
S
469
020
036
0.17
180
1
1
1
1
1
P
009
0.03'
066
O.5S
0.68
0.18
, Significant at or beyond the .OS level.
Standard goniometry as described by Trombly
(1983) was used by four occupational therapists to
measure selected joint ranges (see Table 2). Prior to
the study, a generalizabi!ity coefficient (Berk, 1979)
of 83 had been obtained for the four therapists'
goniometry measurements shOWing a relatively high
degree of agreement among the therapists' measurements.
Procedures
Using the instruments discussed above, we collected
pretest data from all subjects in the experimental and
control groups. Demographic data and medical histories were also obtained through questionnaires. Potentially confounding variables were examined by
chi-square analyses and analysis of variance (F test)
to determine if there were significant differences
between the control and experimental subjects on
variables that might influence the results of the study.
The 23 experimental subjects were encouraged
to practice the ROM Dance sequence on a daily basis
at home in addition to any specific exercises recommended by their physician or therapist. They were
also encouraged to practice relaxation techniques
during daily periods of rest. All 23 control subjects
received a brochure which explained the ROM Dance
Program and the research project. They were not
given any specific instructions concerning exercise
and rest at home.
Posttest data were collected with the same instruments immediately after the 8-week ROM Dance Program. By this time, because of illness, geographical
move, or other reason, the number of experimental
subjects had gone down to 22 and the number of
control subjects to 17. Demographic data on these
subjects are presented in Table 3.
Data on range of motion measures and the selfreport scales were again collected 4 months after the
cessation of the ROM Dance Program. These followup data were obtained for 17 experimental subjects
and 16 control subjects. Scaled data were analyzed by
the median test, range of motion data by analysis of
variance (F test). On one variable (lower extremity
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Table 2
Range of Motion: Differences Between 17 ROM Dance Participants and 16 Control Subjects
Mean
dl
SD
P
Experimemal
Control
Experimental
Control
0.11
073
0.02-
291
270
75
30
B. Shoulder internal and external rotation
3.22
Pretest
Postlest
114
4-month follow-up
533
0.08
029
003-
290
248
81
65
C. Wrist extension
Pretest
Posttest
4-momh follow-up
0.81
082
046
899
843
232
96
Variable
F
A. Shoulder flexion
Pretest
Postlest
4-momh follow-up
2.64
013
565
006
005
056
D. TOlalupper extremity combined: Above ranges plus elbow flexion and wriSt l1exion
0.42
068
1
Pretest
POStleSl
4-month follow-up
069
4.22
1
1
0.77
0.048-
E. MetarcaL'pal phalangeal flexion-five digits
Pretest (n = 34)
2.00
Posttest (11 = 32)
0 15
4-month follow-up
013
072
F. Ankle plamar flexion
Pretest
Posttest
4-month follow-up
039
003'
025
114
90
35
25
0.020.04051
487
453
36
32
G
017
0.70
076
496
135
Lower extremity flexion: Hip, knee. ankle dorsal flexion
Pretest
5.83
1
POStleSl
4.79
1
4 -momh follow·up
0.45
1
• Significant at or beyond the 05 level.
fleXion) significant pretest differences were observed
and analysis of covariance was used to determine
posttest and follow-up differences. To reduce the
number of variables for appropriate statistical analYSiS,
left and right limb range of motion scores were combined as well as various other scores (see Table 2)
volvement in occupational therapy or physical therapy, number of medications currenrly taken, number
of years since onset of the arthritiS, and current use
of assistive devices. The only demographic variable
shOWing significant differences was age, with control
subjects being older (X = 60) than experimental
subjects (X = 52) Pretest data were also compared
for experimental and control subjects by the same
methods See Tables 2 and 4 for differences
Table 4 shows the results of the analyses for the
Results
The pmentially confounding variables examined were
age, sex, number of arthritis-related surgeries, in-
Table 3
Demographic Data on the 39 SUbjects at Posttest
Variable
No of
SubjeGs
Years since onset
Number of surgeries
Number of medications
Age
Sex
Had OT
HaJ PT
Uses device
38
9
37
39
39
37
38
37
Mean
SDof Mean
Minimum
Maximum
1092
268
2.14
55.91
217
88
.18
2.60
0
0
1
29
38
8
4
80
Frequencies
Male = 7
Yes = 12
Yes = 27
Yes = 18
Tbe American Journal of Occupational Tberapy
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Female
No
No
No
= 32
= 25
= 11
= 19
93
Table 4
Differences Between ROM Dance Participants and
Control Subjects on Self-Reports for Exercise and Rest
(Combined)
Variable
Frequency
a Pretest
b Posttest
b 4-month follow-up
Enjoyment
a Pretest
b Posttest
b 4-month follow-up
Benefit
a Pretest
b Posttest
b 4-month follow-up
Chi-~quare
df
p
1.59
0.24
374
021
062
0.05'
1.07
374
0.05
030
005"
083
0.18
0.94
0.40
0.67
033
0.53
Control group of 14 subjects and experimental group of 17 subjects. b Control group of 16 subjects and experimental group of 17
subjects.
, Controls significantly greater at the 05 level. " Experimentals
significantly greater at the .05 level.
a
self-report data. There were no significant differences
on pretests between control and experimental subjects At the 4-month follow-up evaluation, the control
subjects reported significantly higher frequencies of
exercise and rest than did the experimental subjects_
The other significant difference in the 4-month evaluation was that the experimental subjects reported
greater enjoyment than did control subjects immediately after the 8-week ROM Dance Program.
More significant differences between experimental and control measures appeared in the goniometf)'
data. (See Table 2.) There were no significant differences between control and experimental subjects on
the finger measures. Three of the four analyses of
upper extremity showed significant differences at the
4-month follow-up evaluation whereas lower extremity differences were significant only at the posttest.
In all of these analyses where significant differences
were observed, the ROM Dance Program participants
showed better scores in range of motion than did the
control subjects
Discussion
In analYZing results, it is important to consider the
combined effect of all program elements that differ
markedly from traditional approaches_
Since the ROM Dance incorporates a variety of
occupational therapy and T'ai-Chi principles, it may
be more satisfying than routine exercise. This notion
is supported by the significantly greater enjoyment of
exercise and rest reported by the experimental group
immediately after the completion of the ROM Dance
Program. That the reported differences in enjoyment
were no longer evident at the 4-month follow-up may
indicate that group involvement was the effective
component.
A number of explanations can be provided for
94
the significantly better upper extremity mobility status of the experimental groups 4 months after the
completion of the program. The ROM Dance sequence involves "total body" range of motion,
whereas subjects' prescribed exercises may have been
limited to specific joints or to the lower extremities_
The emphasis placed on slow, relaxed movement in
the ROM Dance may enhance the benefits of exercises for range of mOtion. The weekly instruction and
reinforcement for learning proVided by the program
may have affected the participants' ability to perform
the motions accurately and to full range. It is interesting to note that the only reported upper extremity
ranges that did not show significant differences at the
4-month follow-up test were wrist extension and
metacarpal phalangeal flexion. One possible explanation for this finding is that these ranges are more
likely to be affected by joint fusion than others reported in the study. Therefore, they may have been
less likely to show changes in range. Another explanation for the lack of significant differences in these
ranges is that both control and experimental subjects
would tend to maintain wrist and finger range through
their ordinary daily activities.
The finding that the significant differences between groups for lower extremity ranges occurred
only at the posttest is difficult to interpret. One possible explanation is that the ROM Dance sequence
places more emphasis on upper extremity motion.
During classes, however, the lower extremity motions
are repeated frequently for instructional purposes,
which could have had an initial influence That there
were no lasting differences could be due to the fact
that ambulatory adults perceive the maintenance of
upper extremity ranges to be more essential to function and, consequently, intensify effofts in this area
during home exercise.
Another interesting finding is that control subjects reported a higher frequency of exercise and rest
than did the ROM Dance participants at the 4-month
follow-up. One possible explanation is that the program repeatedly emphasizes tbe daily practice of
range of motion exercise. Control subjects may have
thought that any exercise, such as walking, would
qualify for frequency, whereas the experimental subjects, having been specifically oriented to the program, would have been more cognizant of the intent
of the questions on the self-report scale. On the other
hand, a basic initial assumption was that an increased
frequency of exercise and rest would promote the
desired results. If tbe self-report data are accurate,
this could be a faulty assumption and hence it would
not necessarily be true that more exercise and rest
means better exercise and rest.
If these initial results are confirmed in future
studies, the efficacy of the ROM Dance Program and
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the value of integrating Eastern and Western frames
of reference 10 the treatment of some chronic disease
patients will be supported.
Limitations
There were a number of limitations in this study. For
ethical reasons, subjects had [0 sign either control or
experimental consent forms, and the potentially motivating effects of study participation could not be
avoided. Because of scheduling problems and the fact
that experimental subjects talked about their involvement, the evaluators were occasionally aware of which
subjects were in the experimental group and which
were in the control group. This limitation could have
affected the results of the study.
Another limitation is the large drop-out rate of
28% at the 4-month follow-up. An added problem was
that because of the low number of subjeCtS it was
necessary to decrease the number of dependent variables for statistical reasons Therefore, groups of goniometry measures were made. A lack of data on the
exact home exercise procedures used by the control
subjeCts was a further limitation.
A final limitation was the fact that measurement
tools lacked rigorous validity and had not been tested
with the population under consideration. The current
study, however, can help alleviate this limitation by
contributing reliability and construct validity data
Acknowledgments
We extend our appreciation to Kenneth Ottenbacher, PhD,
OTR, for statistical consultatiOn, the occupational therapy
students at the University of Wisconsin-Madison for reo
search assistance, and the Sr. Marys Hospital Medical Center
and professional participants Patricia Yu, Andrea Alder,
Becky Black, Mary Jahnke-Hanson, and Nancy Walker for
data collection
The National Arthritis Foundation funded this research
through an Arthritis Health Professional Research Grant.
The development of the ROM Dance was funded in part by
a grant from the Arthritis Foundation, Wisconsin Chapter
References
Achterberg,]., McGraw, P., & Lawlis, F. (1981) Rheumatoid arthritis: A study of relaxation and temperature biofeedback training as an adjunctive therapy. Biofeedback and
Self-RegUlation, 6, 207-223.
Berk, R. (1979). Generalizability of behavioral observations: A clarification of interobserver agreement and interobserver reliability. American Journal of lvlental Deji'ciency, 83,460-472.
Blackwell, B (1973) Patient compliance. New EnglandJouma/ of Medicine, 289, 249-252
Carpenter,]., & Davis, L. (1976). Medical recommendation followed or ignored I Factors influencing compliance
in arthritis. Archives of Pbysical Medicine and Rehabilitation, 57, 241-246.
Davis, M (1966) Variation in patients' compliance
with doctors' orders. Journal of Medical Education, 41,
1037-1048.
Davis, M (1967). Predicting noncompliant behavior.
Journal of Health and Social BehaVior, 8, 265-271.
Dimonte, P., & Hollis, L. (1982). Pathomechanics, gait
deviations and treatment of the rheumatoid foot. Pbysical
Therapy, 62, 1148-1156
Feinberg, ], & Brandt, K. 0 (1981) Use of resting
splints by patients with rheumatoid arthritis. Americanjournat of Occupational Therapy, 35,173-178
Feinberg, J. R., & Brandt, K. D. (1984). Allied health
team management of rheumaroid arthritis patients. American journal 0/ Occupational Therapy, 38, 613-620.
Harlowe, D., & Black, B (1984) [19-minute slide-tape]
Helping hands: Splints for early rheumatoid arthritis. Madison, WI: St. Marys Hospital Medical Center.
Harlowe, D., & Yu, P (1984) The ROM dance. Madi·
son. WI: Board of Regents of the University of Wisconsin,
Sr. Marys Hospital Medical CeOler.
Lenker,S., Lorig, K., & Gallagher, D. (1984). Reasons
for the lack of association between changes in health behavior and improved health status: An exploratory study.
Patient Education and Counseling, 6, 69-72.
Lorig, K., Laurin, J., & Gines, G. (1984) Arthritis selfmanagement, a five-year history of a patient education program. Nursing Clinics ofNorth America, 19,637-645
Maddock, R. (1967) Patient cooperation in taking
medication. journal of tbe American Medical Association,
199,169-172
Mayo, N (1978). Patient compliance: Practical implications for physical therapists. Pbysical Tberapy, 58, 10831090
I\'lelvin, J (1982) Rheumatic disease. Occupational
therapy and rehabilitation. Philadelphia: Davis.
Nordemar, R (1981) Physical training in rheumatoid
arthritis: A controlled long-term study: II. Functional capacity and general attitudes. Scandinavian Journal of Rheumatology, 10, 25-30
Norclemar, R, Ekblom, B., Zachrisson, & LundqUist, K.
(1981). Physical training in rheumatoid arthritiS A controlled long-term study. Scandinavian journal of Rbeumatology, 10, 17-23
Oakes, T., Ward,], Gray, R.. Klauber, M., & Moody, P
(1970) Family expectations and arthritis patient compliance to a hand resting splint regimen. journal of Cbronic
Diseases, 22, 575-764
Parker, J C, Singsen, B. H, Hewett. J E, Walker, S.
E., Hazelwood, S. E, Hall, P]., Halston, D. ], & Radon, C.
M. (1984) Educating patients with rheumatoid arthritis A
prospective analysis Arcbives of Pbysical Medicine and
Rebabilitation, 65,771-774.
Parker, L, & Bender, L. (957). Problem of home
treatment in arthritis Arcbives of Pb)'sical Medicine and
Rehabilitation, 38, 392-394.
Robinson, H, Haldeman,]., Imrie, ], & Neubauer, P
(1980) Evaluation of a province-wide physiotherapy monitoring service in an arthritis control program. journal of
Rbeumatology, 3, 387-389
ROM Dance Audio-Cassettes. (1984) Madison, WI:
University of Wisconsin, St Marys Hospital Medical Center.
Treusch, j., & Krusen, F. (1943) Physical therapy applied at home for arthritis. Archives of Internal Medicine,
72, 231-238
Trombly, C. (Ed) (1983). Occupational therapy for
physical dysfunction (2nd eeL) Baltimore: Williams & Wilkins. (p. 127)
The American Journal of Occupational Therapy
Downloaded From: http://ajot.aota.org/pdfaccess.ashx?url=/data/journals/ajot/930392/ on 06/15/2017 Terms of Use: http://AOTA.org/terms
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