神經物理治療學及實習
PT for vestibular lesion
胡名霞
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Contents
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Introduction
Evaluation based on ICF model
Management based on ICF model
Meta-analysis Outcome and Guidelines
Summary
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眩暈定義
• 頭暈(dizziness): 頭重腳輕、昏昏的、或想吐
的感覺
• 眩暈(vertigo): 感覺自己在轉的頭暈症狀
• 目眩、轉動幻視(oscillopsia):覺得周遭景物在
轉、可伴隨景物模糊現象
• 發作週期:2-3年一次--2-3次/月
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Anatomy
• Cranial VIII nerve
– Vestibular
– cochlear
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內耳迷路(labyrinth)-三半規管
• 旋轉時角加速度變化的感覺
• Flexion：R’t front – L’t posterior
semicircular canal
• Side roll: R’t posterior-L’t anterior
• Rotation: horizontal
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耳石器
• 測知直線加速度
• 電梯上下感覺：卵形囊
– 調節肌肉張力(卵形囊→vestibular N→spinal
neuron)
• 電梯上升:flexion response, 眼球上吊
• 電梯下降:extension response, 眼球下降
– 搖baby睡覺(卵形囊→腦幹睡眠中樞之網狀結構)
• 海盜船左右搖擺感覺：球形囊
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眩暈種類
• 三大類
– 末梢性(周圍性)眩暈: 源於內耳的眩暈通常伴隨耳
鳴、重聽等症狀
– 中樞性眩暈
– 反射性眩暈:動暈症
• 先天性眼振：不會有眩暈，側頭視物、易脊柱
側彎
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Common Vestibular Diagnosis
• 美尼爾症：約佔眩暈之4%; 旋轉性眩暈
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內淋巴水腫
眩暈：激烈、自發、反覆
耳鳴
耳塞感
每次發作1-4小時，間隔數天至數月
好發於20-50歲;女>男
多次發作後聽力變差而失聰
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頭位性眩暈
• 良性陣發性頭位眩暈症 (BPPV)
– 最常見之眩暈原因，轉頭後2-5秒發生眩暈，持續小於30秒;
counter-rolling 現象
– 因耳石脫落;約3-6月可自癒
• 惡性陣發性頭位眩暈症(MPPV)
– 第四腦室腫瘤或小腦下蚓部出血
– 眩暈超過30秒且一直持續直至頭位回覆
• 頸性眩暈(cervicogenic vertigo)
• 耳石危相(Tumarkin catastrophy)
– 無先兆地突然跌倒但神智清醒，數日發作一回
– 耳石器─lateral vestibular nucleus─spine
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小兒眩暈症
• 兒童良性陣發性眩暈症(BRV, benign recurrent
vertigo)
– 4-15歲
– 每次持續約20分鐘
• 起立性調節障礙(O.D., Orthostatic dysregulation)
– 起立或久站後眩暈; BP或心跳差異>20
• 幼年性單側耳聾(JUTD, juvenile unilateral total
deafness)常於16-30歲發生眩暈
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動暈症
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狗最易發生
<2歲不暈
老年<年輕人
女性>男性
誘發因素: 過度搖動的交通工具、visual
stimulation、smell or auditory stimulation;
內因如感冒、疲勞、宿醉、空腹、過飽、不安
等
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Common Nonvestibular Diagnosis
• Cerebellar meningioma
• 其他伴隨因子
– 低血壓
– 高血壓
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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問診
• 與頭暈有關之症狀: 病人主訴症狀
– 我頭很暈：指走路漂浮，踏地不實在的感覺
– 天旋地轉：眩暈狀態
• 併發症所伴隨之症狀
– 耳鳴、指尖麻痺、頭痛、肌力等
• 探究原因和目的
– 職業、過敏、血壓、外傷、藥物、脖子痛、蛀牙、
其他疾病等
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Assessment
• 眼球運動檢查
• 眼振(nystagmus)方向：急速相的方向
• 病變側：徐緩相的方向
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Assessment
• 溫差反應檢查(Caloric test)
– Supine, head flexion 30°
– 50cc 30℃冷水左耳→30℃右耳→44℃左耳
→44℃右耳; 各間隔5分鐘以上
– 觀察灌水後15秒左右開始出現之眼振
– 灌冷水出現對側眼振;溫水為同側眼振;正常為3分
鐘
– 眼振少於1 min為該側內耳功能麻痺
– 眼振多於4 min表小腦障礙
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Assessment-ENG 眼振電圖
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眼角膜(+)、網膜(-)於眼球運動時之電位變動
記錄小腦與腦幹的腦波
向下垂直眼振：腦幹或小腦蚓部病變
向上垂直眼振：中腦或松果體病變
蹺蹺板眼振：後下小腦動脈阻塞
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Body function & structure evaluation
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History
Hallpike Dix maneuver
Motion sensitivity test
Cervical alignment/ pain
MMT screen
ROM screen
Observe
nystagmus
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Hallpike-Dix maneuver
• Liberatory Manoeuvre
– First Hallpike position to induce
symptom
– Rapid rotation to opposite ear
down position
– upright
• Epley manoeuvre
– Rapid straight back tilt with
symptomatic ear down
– Rotation to opposite ear
– upright
• Each position maintain > 2 min or
until symptom subside
• Repeat until no symptoms (Epley)
(Herdman, Phys Ther, 70:381-88, 1990)
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Motion sensitivity test
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• Motion sensitivity test
– 可伴用Frenzel’s lenses
– 搖頭眼振檢查(head shake): head flexion 30°, 2
次/秒，30次。70%的眩暈患者及14%的正常人出
現搖頭眼振。正常人出現搖頭眼振是預測眩暈的
最佳方法。
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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Assessment-Postural Control
• Romberg
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– 睜眼時搖晃懷疑中樞障礙, 閉目時搖晃懷疑內耳或
dorsal column障礙
Tandem walk
Sensory Organization Test
Postural muscle responses
Limits of Stability
Fukuda test
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Fukuda test (原地踏步檢查)
• 50 steps in-place
eyes closed, arms
raised
• Normal: < 1m
– 50 steps, < 30°
– 100 steps, < 45°
• Newton, Brain Injury, 1989
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Motor coordination: strategies
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Balance - Sensory organization
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Dizzy and Disequilibrium
(林桑伊等，2001)
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DGI-FGA test
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(Wrisley et al., 2004)
動態步態指標 Dynamic Gait Index
1.平整路面行走步態 Gait Level Surface
2.改變行走速度 Change in gait speed
3.行走時同時水平頭部轉動 Gait with horizontal head turns
4.行走時同時垂直頭部轉動 Gait with vertical head turns
5.快速轉身 Gait and pivot turn
6.跨越障礙物 Step over obstacles
7.繞過障礙物 Step around obstacles
8.上下樓梯 Stairs
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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Dizziness Handicap Inventory
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抬頭向上看是否會使你的頭更暈？
你會因為頭暈而感到挫折（做事不順心）？
你是否因為會頭暈就不去遠行，不論是因公出差或是去旅行？
當你在逛百貨公司或是大賣場的時候是不是會使你的頭更暈？
你是否會因為頭暈而讓你在上床下床的時候覺得很困難？
你頭暈的問題是否嚴重地影響了你去參加社交活動的意願（例如:去餐館吃
飯、去看電影、跳舞或是參加聚會）？
頭暈是否會使你在讀書或看報時感到困難？
當你在做一些比較劇烈的活動，例如運動、跳舞、做家事（掃地、洗碗盤、
收碗盤）是不是會讓你的頭更暈？
你是不是會因為頭暈的關係就不敢一個人獨自出門？
你會不會因為頭暈就在別人面前覺得很不好意思？
如果你的頭做一些快速移動的動作是不是會使你的頭更暈？
你是不是因為會頭暈就盡量避免去站在高處？
當你在床上翻身的時候是不是會覺得頭更暈了？
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Dizziness Handicap Inventory
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你是否因為頭暈而使你在做較費力的家事時會感到困難？
你會不會因為自己覺得頭暈而怕別人以為你是喝醉酒？
你是否因為頭暈的關係而覺得自己一個人去散步是困難的？
當你走在人行道上時，是否會加劇你的暈眩？
你會不會因為頭暈而使你無法專心？
你會不會因為頭暈而無法在不開燈的情況下在家中行走？
你是否會因為頭暈的關係就不敢一個人待在家裡？
你使否因為會頭暈就覺得自己的身體是有障礙的？
你頭暈的問題對於你和你的家人或是朋友的相處是否有造成任
何的壓力？
• 你是否因為頭暈的關係就覺得沮喪？
• 你頭暈的情形是否對於你的工作或是家務事造成干擾？
• 當你彎腰低頭時會不會增加頭暈的情形？
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Disability rating scale
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0: 症狀很輕,可忽略
1: 被症狀所困擾
2: 工作照常,但戶外活動症狀明顯
3: 症狀影響工作和戶外活動
4: 需用藥減輕症狀或必須換工作
5: 症狀嚴重，超過一年無法工作
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Management based on ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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基本概念
• 治療方法：運動和吃藥
• 治療時機：越早開始越好
• 治療內容：前庭運動、平衡運動
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Recovery Mechanisms
• spontaneous recovery
• vestibular adaptation
– changing the gain, timing, or direction
• substitution
– of other sensory inputs
– of alternative motor responses
central compensation
peripheral restoration
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Unilateral vestibular neuritis (Strupp et al., 1998)
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Benigh paroxysmal positional
nystagmus and vertigo (Horak, 1994)
pre
post
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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Steps to take
• 1. Is it BPPV?
– Left Hall-Pike position test, 觀察nystagmus 以及主觀症
狀
– Right Hall-Pike position test
• 2. Decide if posterior or horizontal canal
– Posterior: 通常只有一邊Hall-Pike test 為positive
– Horizontal: 較少見，可能兩側都出現nystagmus
• 3. If posterior: do modified Epley (參下頁及影片)
• 4. If horizontal: do canalith reposition (參page 3)
• 5. Patient education & other exercises (pages 47)
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Modified Epley for L Post Canal BPPV
(Radtke et al., 2004;Neurology)
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Start by sitting on a bed with your head turned 45° to the left. Place a
pillow behind you so that on lying back it will be under your shoulders.
Lie back quickly with shoulders on the pillow, neck extended, and head
resting on the bed. In this position, the affected (left) ear is
underneath. Wait for 30 seconds.
Turn your head 90° to the right (without raising it), and wait again for
30 seconds. 4. Turn your body and head another 90° to the right, and
wait for another 30 seconds.
Sit up on the right side.
This maneuver should be performed three times a day. Repeat this daily
until you are free from positional vertigo for 24 hours.
(For right ear BPPV, the procedure has to be performed in the opposite
direction, starting with the head turned to the right side.)
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Brandt-Daroff exercise:
for posterior canal
1. Is first positioned
sitting
2. Rapidly moves into
side-lying (stays until
1,3,5
vertigo stops, waits 30
sec)
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4
3. Sits up (“rebound
effect”), remains for
30 sec
• Repeats the entire maneuver 5~ 20 times, depending on the
tolerance or until vertigo no longer occurs 4. Rapidly moves into the
• Repeats the entire sequence 3 times a day untilmirror-image
without vertigo
position 41
in 2 consecutive days
Canalith repositioning maneuver :
for horizontal canal
Turns head
toward the
affected side
& moves
quickly
into supine
• The head should be flexed slightly
• If the patient experiences nystagmus or vertigo, stop the movement until the s/s
stops
• Must keep the head upright for 48 hours
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前庭訓練- passive
• 旋轉椅訓練: 4秒/圈，with visual target at
1.2 m; CCW and CW 各10圈
• 旋轉鼓追蹤訓練: 注視黑線; 4秒/圈，CW,
CCW 各15秒
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前庭訓練(2)
• 鐘擺追蹤訓練: 1.2 m距離, 4秒一往復; 先只用
眼睛動作;再加上頭部動作
• 傾斜板訓練
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Occulomotor test/ exercise
• Whitney, Clin Manage, 1991
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Vestibular habituation exercises
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Vestibular Electrical Stimulation
• The first step of physical therapy
• Aimed to reduce antigravity failure and to increase
proprioceptive cervical sensory substitution.
• TENS; on paravertebral muscle opposite to the affected
side and on the trapezius of the affected side.
• At 1 hr per day at least
• The first half hour: p’t lye on the SS, in the light, and
try to keep their eyes open
• The other half hour: practice activities in upright
position and walking during VES
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Heat and Cervical traction
• 頸性眩暈, 基底動脈循環不良或突發性耳聾、
Whiplash
• 7-9kg, 10 min→10 kg,…14kg 10 days; rest 10 days,
traction 10 days, rest 10 days until 30 days of traction
• Manual traction by therapist
• Self home traction
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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Cawthorne-Cooksey Exercise
A in bed
1. Eye movements: slow-quick
2. Head movements: slow-quick, eyes open-closed
B. sitting
1, 2. as above
3. shoulder shrugging and circling
4. bending and picking up object from floor
C. standing
1, 2, 3. as above
4. standing up: eyes open-closed
5. throwing balls from hand to hand
6. standing up while turning around
D. moving about
1. walk a circle while passing a ball to a person in the center
2. walk across room: eyes open-closed
3. walk up and down slop/stairs: eyes open-closed
4. game activities
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Foam and dome exercise
(Shumway-Cook
and Horak, 1985)
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Balance - Limits of stability
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ICF Model
Health Condition
Body Function
& Structure
Environmental
factors
Activities
Participation
Personal
factors
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Patient education
• 急性症狀發作:
閉眼
減少光線、聲音刺激
放鬆心情
減少頭部動作
• Effective habituation
Effective range
intensity
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time
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Red flags to stop exercise
•突然失聰
•耳內壓力增加及腫脹感
•耳中流出液體
•嚴重耳鳴
•嚴重嘔吐
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Exercise Prescription Principles
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adaptation or compensation
3-5 exercise items
moderate tolerable intensity
moderate repetition
twice every day
modify with progression
resume functional activities
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Contents
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Evaluation based on ICF model
Management based on ICF model
Meta-analysis Outcome and Guidelines
Summary
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Outcome
(Hillier, 2009)
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Outcome
(Hillier, 2009)
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Outcome
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Outcome
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Outcome
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Influencing factors (Herdman, 1997)
Positive influences
Negative influences
Customized, supervised
exercises
Generic, unsupervised
exercises
Stable unilateral vestibular
loss
Fluctuating disorders
Symptoms provoked by
movement
Less severe initial disability
Recent onset
Head injury
Mixed central and
peripheral lesion
Vestibular suppressant
medications
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Special considerations for BPPV
• recommendations against
– radiographic imaging, vestibular testing, or both in
patients diagnosed with BPPV
– routinely treating BPPV with vestibular suppressant
medications such as antihistamines or benzodiazepines.
• Options
– should differentiate BPPV from other causes of
imbalance
– should question patients for factors that modify
management including impaired mobility or balance, CNS
disorders, lack of home support
– reassess patients within 1 month
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Summary
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Desensitize vestibular system
Coordinate eye-head movement
Improve balance and walking
Education: learn about condition and cope
or become active
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references
• Schubert MC, Herdman SJ. Vestibular rehabilitation. In SB O’Sullivan and
TJ Schmitz. Physical Rehabilitation: Assessment and Treatment, 4th ed.
Philadelphia: FA Davis, 2001:821-843.
• Allison L. Balance Disorders. In Umphred DA, Neurological Rehabilitation,
3rd ed. St Louis: Mosby, 1995:802-837.
• Herdman SJ. Vestibular Rehabilitation. Davis:Philadelphia, 1994.
• Jacobson GP, Newman CW, Kartush JM. Handbook of Balance Function
Testing. St. Louis: Mosby, 1993.
• 楊怡祥。眩暈招待。台北：時報文化，1995。
• 楊怡和。現代人的文明病-眩暈。台北：健康世界雜誌，1996 。
• (板)田英治。(沈永嘉譯)。頭暈是健康的警訊。台北：金菠羅，1998。
• 胡名霞、蕭淑芳、黃靄雯。眩暈病人的物理治療原則。中華物療誌
1995;20:182-196。
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References
• Acute phase after resection of acoustic neuroma
(Herdman et al., 1995)
• Unilateral vestibular loss (Mruzek et al., 1995; Strupp
et al., 1998)
• Bilateral vestibular loss (Krebs et al., 1993)
• Central involvement, head injury (Godbout, 1997)
• BPPV (Ford-Smith, 1997; Banfield et al., 2000)
• Cervical vertigo (Bracher et al., 2000)
• Mixed patient type (Horak et al., 1992; Tilian Y
Shepard, 1996)
• BPPV Clinical Guidelines (Bhattacharyya, 2008)
• Vestibular rehabilitation cochrane review (Hillier & 68
Holohan, 2009)