PM R 7 (2015) 105-112

www.pmrjournal.org

Original Research

Treatment Strategies for Genu Recurvatum in Adult Patients

With Hemiparesis: A Case Series
Malathy Appasamy, MD, Michelle E. De Witt, Nisha Patel, MD, Nancy Yeh, MD,
Ona Bloom, PhD, Anthony Oreste, MD

Abstract

Objective: To report our clinical experience and propose a biomechanical factorebased treatment strategy for improvement of
genu recurvatum (GR) to reduce the need for knee-ankle-foot orthosis (KAFO) or surgical treatment.
Design: Case series.
Setting: Outpatient clinic of a Department of Physical Medicine and Rehabilitation in an academic medical center.
Subjects and Interventions: Adult subjects (n ¼ 22) with hemiparesis and GR who received botulinum injections alone or in
combination with multiple types of orthotic interventions that included solid ankle-foot orthosis (AFO) " heel lift, hinged AFO
with an adjustable posterior stop " heel lift, AFO with dual-channel ankle joint " heel lift, or KAFO with offset knee joint.
Biomechanical factors reviewed included muscle strength, modified Ashworth score for spasticity, presence of clonus, posterior
capsule laxity, sensory deficits, and proprioception.
Outcome Measurements: Outcome factors were improvement or elimination of GR based on subjective assessment before and
after the interventions by the same experienced clinician.
Results: More than one biomechanical factor contributed to GR in all patients. Botulinum toxin A injection was used in patients
who had significant plantar flexor spasticity and/or clonus. Four types of orthotic interventions were used based on the biome-
chanical factor: solid AFO in patients with severe ankle dorsiflexion and plantar flexion weakness or clonus; hinged ankle joint
with adjustable posterior stop in patients with less severe ankle dorsiflexion weakness in the absence of clonus; AFO with a dual-
channel ankle joint for quadriceps weakness or severe proprioceptive deficits; and KAFO with offset knee joints in patients with
Achilles tendon contracture or severe proprioceptive deficits. Adjunctive options included the addition of heel lifts and toeplate
modifications. Combinatorial interventions of botulinum injection, modified AFOs, and heel lifts improved or eliminated GR and
avoided the need for cumbersome orthotics or surgical interventions.
Conclusions: GR in hemiparesis is multifactorial and can be successfully controlled by using a conservative biomechanical
factorebased approach and combined medical and orthotic interventions. An algorithmic approach and a prospective study design
is proposed to determine a combination of effective interventions to correct GR.

Introduction include cerebral palsy [4,5], multiple sclerosis, and

Genu recurvatum (GR) is an abnormal hyperextension
of the knee, operationally defined as greater than 5# of
hyperextension, characterized by the ground reactive
force (GRF) line being anterior to the axis of the knee
(Figure 1). Functionally, GR results in increased me-
chanical work of walking [1] and decreased gait velocity
[2,3]. GR is a progressive, disabling, acquired deformity
that occurs as a result of a wide variety of neuromus-
cular conditions, including upper motor neuron and
lower motor neuron pathologies. Some examples of
upper motor neuron pathologies that may cause GR
cerebrovascular accidents [4], where it has been re-
ported to occur in 40%-68% of patients [6-8]. Several
biomechanical factors have been enumerated as
causative factors in this patient population [6]. In
addition, GR may be caused by lower motor neuron
conditions including poliomyelitis [9] and cauda equina
syndrome [10].
Normally, full knee extension is accompanied by in-
ternal rotation of the femur on the tibial head. With GR,
knee hyperextension does not trigger the femur to
continue to roll anteriorly, and instead the femur tilts
forward, creating anterior compression between the

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106 Genu Recurvatum in Adults With Hemiparesis
Figure 1. Line drawings of ground reactive forces (GRF).
femur and tibia. This hyperextended position, in con-
junction with the normal femoral internal rotation, re-
sults in tension on the anterior cruciate ligament and
posterior structures of the knee, ultimately leading to
abnormal stretch of the posterior joint capsule and
posterior ligaments of the knee [11]. With repetitive
loading activities, especially activities of daily living
such as walking, posterior joint laxity can develop from
the tensile forces on the posterior capsule and struc-
tures, leading to knee joint instability [2,12].
Causes of GR are complex and multifactorial, and
their relative contributions are debated [1,13-16]. In
patients with hemiparesis, both proximal and distal
biomechanical factors can occur individually or in
combination [1]. Proximal factors that may drive muscle
imbalance at the knee joint are quadriceps spasticity,
which converts a normal eccentric quadriceps contrac-
tion to control knee flexion at heel strike to an abnormal
hyperextension force [1], or weak hamstring muscles
[13], which allow abnormal extension. Distal factors
include equinovarus synergistic motor patterns, plantar
flexor or posterior compartment spasticity [14,15], and
restricted ankle dorsiflexion [17]. All of these biome-
chanical factors drive the GRF line anteriorly [7]
(Figure 1C). The most commonly reported combination
has been equinovarus synergistic motor patterns and
quadriceps spasticity [15]. Loss of lower extremity
proprioception, which can occur in stroke patients, is
also associated with GR, because patients intentionally
drive their knee into hyperextension either during late
swing phase, to lock in extension, or by leaning their
trunk forward at heel strike, to prevent the joint from
collapsing [18]. This mechanism is similar to that of
patients with lower motor neuron quadriceps weakness
(ie, poliomyelitis and lumbar plexopathy).
Long-term consequences of GR stem from its pro-
pensity toward stretching the posterior capsule and
ligaments of the knee, causing instability. GR also has
 M. Appasamy et al. / PM R 7 (2015) 105-112 107

been shown to lead to degenerative joint disease and
chronic knee pain [11]. Additional reasons to correct GR
include improved gait symmetry, cosmetic appearance,
and reduced energy expenditure during ambulation
[19-21]. Therefore, GR should be reduced or
eliminated.
No standard algorithm currently exists to determine
treatment for patients with GR, and strategies to
manage GR vary widely. Reported strategies to
ameliorate GR in the heterogeneous stroke population
include medical, orthotic, and rehabilitation-based
approaches, and in a small number of patients, surgi-
cal approaches [1,7,16,17,22-25]. Medical therapy,
which includes injection of botulinum A toxin into
quadriceps or triceps surae, is common for hemiplegic
gait abnormalities. Orthotics are arguably the most
conservative treatment option for GR, but little infor-
mation is available about the suitability of various
subtypes of orthotics to manage GR. Three studies
evaluating orthotics to manage GR used knee-ankle-
foot orthoses (KAFOs) and Swedish knee cages [26];
however, ankle-foot orthoses (AFOs) are used
extensively for treatment of other gait abnormalities in
hemiplegic patients [20,25,27]. The rationale for using
AFOs to treat GR stems from their ability to cause the
ground reactive force line to be driven posteriorly and
thereby influence the knee. Another motivation for
using AFOs to manage GR stems from the notion that
they also correct for insufficient dorsiflexion [28,29]. In
a gait analysis study of 46 patients who had sustained a
stroke, knee hyperextension and weak dorsiflexion
were often associated [3]. Therefore a treatment
strategy with the potential to correct both factors, such
as an AFO, is superior to treatment of each gait ab-
normality individually.
Here, we summarize our clinical experience re-
garding the benefit of a variety of orthotic options
(Figure 2) intended to address the biochemical factors
causing GR in persons with spastic hemiparesis. We have
had successful outcomes with a conservative, biome-
chanical factorebased approach that utilizes botulinum
toxin injections, heel lifts, and solid or articulated
AFOs. These interventions, when combined with other
treatment modalities, improve management of GR while

Figure 2. Examples of orthotics used to manage genu recurvatum. (A) A solid ankle-foot orthosis (AFO). (B) An AFO with an adjustable posterior
stop. (C) Dual channel and ankle joint. (D) Knee-ankle-foot orthosis (KAFO, left); KAFO with offset knee joint (right).
108 Genu Recurvatum in Adults With Hemiparesis
minimizing the use of more cumbersome orthotics or the
need for surgical approaches. The description of our
clinical approach is provided to stimulate discussion of
the management of patients with spastic hemiplegia
and GR and to highlight the need for prospective clinical
trials to determine a reasonable and consistent
treatment algorithm for GR.
Methods
Subjects
A retrospective chart review was performed for pa-
tients with a diagnosis of GR who were treated in an
outpatient clinic of an academic medical center from
January-December 2011. Inclusion criteria required that
patients be 18 years or older and have a diagnosis of
hemiparesis (ie, ICD-9 codes 342.11, 342.12). A total of
22 patients met these criteria. Patient characteristics
are provided in Table 1. GR was diagnosed by clinical
observation of a patient in stance phase by an experi-
enced board-certified physiatrist. A physiatrist recorded
manual muscle strength testing in the lower extremity
of all patients, specifically in quadriceps, hamstrings,
ankle dorsiflexors, and plantar flexors. All patients were
evaluated for spasticity using the modified Ashworth
scale (MAS) in the quadriceps, hamstrings, ankle dorsi-
flexors, and plantar flexors [30]. Associated factors,
such as the presence or absence of clonus, along with
proprioception in the affected lower extremity, were
documented. Table 2 presents the contributing causes
of GR (proprioception deficit, muscle weakness, and
spasticity/clonus) and the medical or orthotic inter-
ventions received by individual subjects.
Results
Interventions and Outcomes
A combination of orthotic and medical interventions
was used to treat GR in patients with spastic hemi-
paresis. Specifically, the use of an AFO was aimed at
enhancing dorsiflexion (DF) at the ankle or foot to drive
the GRF line posteriorly toward the knee (Figure 2A, B).
If spasticity was considered to be a significant biome-
chanical factor and/or hindered the fit of the orthosis,
botulinum toxin A injections to the gastrocnemius,
Table 1
Subject demographics (N ¼ 22)
Variable
Median age, y (range) 49 (17-89)
Males, N (%) 13 (59)
Females, N (%) 9 (41)
Mean time to presentation, y (range) 3.8 (0.5-17)
Mean follow-up, mo (range) 23.9 (4-72)
soleus, and/or tibialis posterior muscles were provided
as an adjunctive treatment.
Four primary types of orthotic interventions were
used to treat GR, based on the biomechanical factors
involved. In the setting of severe ankle plantar flexion
(PF) weakness or ankle clonus, a solid ankle-foot
orthosis (SAFO) was beneficial (Figure 2A). A hinged
AFO, which allows free DF, may be problematic in these
patients, because it can elicit excessive ankle clonus.
For subjects who presented with a pre-existing SAFO
and continued to demonstrate GR, additional orthotic
modifications were made: the addition of a heel lift
(Figure 1D) to provide “pseudo dorsiflexion,” and/or
cutting of the footplate proximal to the metatarsal
heads (Figure 1E) to influence the GRF line further
posteriorly. A SAFO was prescribed for 9 subjects, 6 of
whom had ankle clonus.
The second orthotic option is a hinged AFO with an
adjustable posterior stop (APS), which was our preferred
orthosis, especially in the setting of less severe ankle
weakness and the absence of ankle clonus (Figure 2B).
This type of orthotic not only limits ankle PF like the
SAFO but also has the ability to place the footplate into
additional DF, thereby further driving the GRF line pos-
teriorly (Figure 1B). Adjunctive orthotic modifications
such as the addition of heel lifts and cutting the foot-
plate proximal to the metatarsophalangeal joint are also
available. Of the 12 patients who were prescribed a
hinged AFO with an APS, 6 had ankle dorsiflexion (ADF)
strength $3/5 motor power and 5 patients an ADF %4/5
motor power, and 8 patients had ankle clonus.
The third orthotic option used was an AFO with dual-
channel ankle joints (Figure 2C). This orthosis may be
indicated in the setting of quadriceps weakness or for
patients with significant proprioceptive deficits. These
patients are susceptible to knee buckling if the GRF line
is driven too far posteriorly. Just a few degrees of
excessive ankle DF may cause their knee to buckle, and
a few degrees of excessive ankle PF may cause GR. The
dual-channel ankle joint allows one to lock the foot-
plate at an appropriate angle to prevent or minimize
both issues. Five subjects had quadriceps weakness on
clinical examination, but the dual-channel ankle joint
was prescribed for only one subject. The other 4 pa-
tients responded well to either a SAFO or a hinged AFO
with an APS. We speculate that the severity of quadri-
ceps weakness is a risk factor for knee buckling; how-
ever, spasticity and apraxia play a role in mitigating that
risk. Consequently, it is necessary to evaluate a patient
with a stock SAFO to assess the degree of GR and/or
knee buckling prior to committing to an AFO with dual-
channel ankle joints.
Adjunctive modifications to the aforementioned or-
thotics included the addition of heel lifts and toeplate
modifications. The addition of a heel lift to an AFO will
balance the foot and drive the GRF line posteriorly,
similarly to dorsiflexing the footplate at mid stance
 M. Appasamy et al. / PM R 7 (2015) 105-112
Table 2
Summary of biomechanical factors and orthotic interventions
Biomechanical Factor Solid AFO Hinged AFO With APS
ADF strength $3/5 (n ¼ 15) 9 6
ADF strength %4/5 (n ¼ 4) 0 4
Quadriceps strength $4/5 (n ¼ 5) 2 2
Spasticity " clonus (n ¼ 15) 6 8
Decreased proprioception (n ¼ 3) 0 2
AFO ¼ ankle-foot orthosis; APS ¼ adjustable posterior stop; KAFO ¼ knee-ankle-foot orthosis; ADF ¼ ankle dorsiflexion.
(Figure 1D). Because the footplate angle is not actually
changed, we describe this as “pseudo dorsiflexion.”
Heel lifts up to 3/8 inch will easily fit inside a patient’s
shoe. Heel lifts greater than ½ inch must be added to
the outer sole, and equal height must be added to the
contralateral shoe. Heel lifts were used as an adjunctive
modification with an AFO in 17 of the subjects.
All the orthotics prescribed here were ordered with a
full footplate and flexible toeplate. A flexible toeplate
allows toe DF to occur and will influence the GRF line
posteriorly (Figure 1E). A rigid toe plate is contra-
indicated because it prevents toe DF, enhancing GR by
influencing the GRF line anteriorly (Figure 1C). In addi-
tion, a flexible toeplate tends to be more comfortable
for the patient. We used an additional orthotic modifi-
cation to promote toe DF: cutting of the footplate just
proximal to the metatarsal heads (not shown). A total of
4 subjects had the footplate cut proximal to the meta-
tarsal heads to reduce GR.
If the aforementioned measures did not adequately
manage the patient’s GR, a KAFO with offset knee joints
was provided to control the knee and prevent GR
(Figure 2D). The offset knee joint was chosen because it
is extremely durable and able to handle the potentially
severe moment of force into extension, which may
compromise other orthotic knee joints. The offset knee
joint does not lock and has the added benefit of free
knee flexion during transfers. Authors of previous
studies have recommended that a KAFO be used for
persons who have GR with sagittal plane deviations of
more than 20# [31]. Here, a KAFO was prescribed when
the aforementioned interventions had failed to
adequately reduce GR and placed the subject at risk for
the development of sagittal plane deviations in the
future. One subject who had a severe Achilles tendon
contracture required a KAFO after GR failed to improve
with botulinum toxin A injections and distal orthotic
modifications, including heel lifts. A second subject
required a KAFO after a hinged AFO with an APS failed to
reduce GR in the setting of a severe proprioceptive
deficit at the knee.
As mentioned previously, orthotic interventions were
also combined with botulinum toxin A injections
(100-320 units) to manage equinovarus synergy pat-
terns, excessive PF spasticity, and ankle clonus in 9
subjects. Injections were provided for 3 subjects with
109
Orthotic Interventions
AFO With Dual-Channel Ankle Joint KAFO
0 0
0 0
1 0
0 1
0 1
PF spasticity, 3 subjects with ankle clonus, and 3 sub-
jects with both PF spasticity and clonus. Targeted
muscles for injection were the gastrocnemius, soleus,
and tibialis posterior muscles to decrease ankle PF tone
and ankle inversion. Decreasing ankle PF tone not only
reduces the force with which the patient actively
plantar flexes but also enhances stretch on the Achilles
tendon. We found that botulinum toxin A injections
allowed us to stretch the heel cord and place the hinged
AFO into more DF as needed. In addition, it allowed
subjects to tolerate more DF in their AFOs and reduce
ankle clonus. An AFO with a hinged ankle joint not only
has the advantage of providing maximal DF of the
footplate but also allows the Achilles tendon to stretch
during weight bearing, thereby increasing range of mo-
tion into DF and influencing the GRF line posteriorly.
Botulinum toxin A injections preferentially enhance
these benefits and made the hinged AFO our preferred
orthotic. Subjects with the following orthotic in-
terventions received botulinum toxin A injections: SAFO
(N ¼ 2), hinged AFO (N ¼ 6), and AFO with dual-channel
ankle joints (N ¼1).
All subjects experienced improvement, which ranged
from mild to complete elimination of GR based on sub-
jective assessment before and after the interventions
by the same experienced clinician. More importantly, in
our experience, carefully identifying the underlying
biomechanical factor avoided the use of cumbersome
knee immobilization or surgical interventions. The goal
of the distal interventions at the ankle was to influence
the knee into less GR by driving the GRF line posteriorly,
thereby reducing the moment of force into extension at
the knee.
Discussion
GR is an often overlooked effect of stroke that should
be studied further because of its prevalence in about half
of hemiplegic stroke survivors [7]. If untreated, GR causes
change in joint loading conditions, which has been
implicated in chronic knee pain and knee instability, as
well as in the development of osteoarthritis (OA) [32-35].
Although improvement of hemiplegic gait is a widely
discussed topic, effective management of GR, which is
common in persons with hemiplegia, is less well studied.
In fact, specific assessment or correction of GR is rarely
110 Genu Recurvatum in Adults With Hemiparesis
discussed in these patients [1]. Indeed, a search of
PubMed for “hemiplegic,” “gait,” and “stroke” yields 773
results, whereas “knee hyperextension” and “stroke” or
“genu recurvatum” and “stroke” yields 12 and 4 results,
respectively.
Treatment approaches for GR that have not incor-
porated the underlying biomechanical etiologic factor
have had mixed results. For example, in a retrospective
study of GR (N ¼ 6 subjects), 2% lidocaine was used to
achieve a rectus femoris nerve block, but this inter-
vention did not result in significant improvement in knee
hyperextension [16]. In a case cohort study of acute and
chronic phase stroke patients with PF spasticity, injec-
tion of botulinum into the triceps surae resulted in a
trend toward decreased knee hyperextension, but this
trend was not significant [17]. Other proposed treat-
ment modalities for GR include specialized technology-
based gait retraining techniques that are designed to
improve upon conventional physical therapy, which in-
cludes overground gait retraining and verbal feedback
to improve gait [7,24].
In a study of acute stroke patients, the majority wore
hinged or double-adjustable AFOs, which may have
contributed to beneficial effects of locomotor training
[24]. The use of a KAFO in chronic postecerebrovascular
accident hemiplegic subjects (N ¼ 11) resulted in a
significant reduction in knee hyperextension angle when
measured with gait analysis [20]. However, KAFOs are
bulky and noticeable, and although they are effective in
controlling the knee, they have a significant weight,
cosmetic drawbacks, and lack of patient compliance
[1]. In a small study of patients with GR who received an
AFO for poststroke hemiplegia, use of an AFO with a PF
stop decreased hyperextension angle, although this
trend was not statistically significant [25]. Heel lifts
alter the GFR line by altering the angle of the tibia
relative to the floor, placing the tibia into relative
dorsiflexion [36,37]. Thus, it has been suggested that
use of heel lifts may improve hyperextension during the
stance phase. In a pilot study examining AFO modifica-
tions and their effect on GR in hemiplegic gait, heel lifts
and shortened foot plates were included, but neither
promoted a significant effect on knee hyperextension
[25]. Of these orthotic interventions, many are
cumbersome (KAFOs), invasive (tibial neurotomies), or
difficult to implement outside of academic medical
centers (locomotor gait training).
We are unaware of a study that has prospectively
evaluated effective treatments in a significant number
of hemiplegic patients with GR who have diverse clinical
etiologies (eg, spasticity, hamstring weakness, and loss
of proprioception) or that has tested a stepwise,
comprehensive treatment approach. The advantages
and disadvantages of using various AFO types to treat GR
are not well studied, and evidence-based indications for
various types of AFOs are lacking. In this study, the
successful use of AFOs with specific modifications based
on the biomechanical factor involved in GR management
supports the notion that many etiologies may promote
GR [1]. The indications for a specific type of AFO may be
complex and may need to be individualized, because
biomechanical factors that alter gait in hemiplegic pa-
tients may be multifactorial and beyond those tradi-
tionally considered.
AFOs can be rigid/solid, have a hinged/articulated
ankle joint, be made of metal or plastic, and have
modifications such as heel height or shortened foot-
plates (extending to the metatarsal head rather than the
full length of the foot; Figures 2B, C). The most common
AFO type used to support walking in hemiplegic gait is a
rigid AFO [38]. A solid AFO positions the ankle in a fixed
position at the talocrural, subtalar, and midtarsal joints
and is suited for subjects who lack sufficient strength in
both ankle dorsiflexors and plantar flexors. Some ankle
range of motion with ankle DF and PF is needed for use
of hinged AFOs [36]. An articulated AFO with a posterior
stop, also known as a PF stop, allows use of ankle
plantar flexors but supports ankle dorsiflexion, which is
necessary for foot clearance in the swing phase [36].
Hence, we suggest that AFOs with specific modifica-
tions individualized and custom made to the predomi-
nant biomechanical factor may be useful as a primary
starting point for correction of GR in patients with
hemiplegia. AFOs offer the advantage of being a con-
servative treatment option and have improved weight
and cosmesis compared with KAFOs, and their use has
field familiarity.
Future Research Implications
Although our assertion is supported by experience
presented here with a small number of subjects from a
diverse patient population and by the use of simple
clinical outcome measures such as manual muscle
strength testing, both of these limitations reflect real-
istic and common treatment settings for GR. Given the
success of our approach and pilot study data from
Fatone and colleagues [25], we are certain that a pro-
spective clinical trial of AFOs as an option to treat GR
would be informative.
Ideally, in such a study, subjects would be adult
stroke hemiplegic patients who were ambulatory prior
to sustaining a stroke and currently in the chronic phase
(>6 months) of recovery. A proposed algorithm based on
our observation is presented in Figure 3. Exclusion
criteria should include comorbid neuromuscular im-
pairments. Outcome measures have been recommended
by the StrokEDGE Taskforce of the American Physical
Therapy Association (2011), which reviewed available
outcome measures and ranked them, using an ordinal
grading system based on clinical utility and psycho-
metric properties. Based on these recommendations, a
clinical diagnosis of GR should be confirmed by goni-
ometer or gait analysis. Evaluation of muscle spasticity
 M. Appasamy et al. / PM R 7 (2015) 105-112
Figure 3. Study design for examination of strategies to manage genu
recurvatum (GR). AFO ¼ ankle-foot orthosis; DF ¼ dorsiflexion;
KAFO ¼ knee-ankle-foot orthosis; MAS ¼ modified Ashworth score;
PF ¼ plantar flexion; PT ¼ physical therapy.
should be assessed with the MAS, and muscle strength
should be measured by hand dynamometry. MAS has
good reliability for overall body measurement in stroke
[39]. It has level 4 recommendations for patients with
chronic effects of a stroke, which indicates good clinical
utility and excellent psychometric properties, and it is
recommended for use in research. Hand-held dyna-
mometry has high intrarater reliability, as well as good
test-retest reliability in stroke and traumatic brain
injury patients [40]. It has a grade 3 recommendation
for patients with chronic effects of a stroke, which in-
dicates good clinical utility and good psychometric
properties, and it is recommended for use in research
[39]. For comparison, a group of control subjects would
be patients who receive physical therapy alone, repre-
senting the most conservative treatment strategy. Pri-
mary outcome measures would include correction of
GR, as measured by multicamera gait analysis of peak
knee hyperextension. Secondary outcomes could
include validated, established instruments recom-
mended by StrokEDGE as appropriate for research in
stroke patients and commonly used in the literature
[7,13,20,38]. These outcomes include the time to
complete the 10-Meter Walk Test using a static start at
normal walking speed, to assess gait velocity, taking
into account critiques of the 10-Meter Walk Test
described by the National Institute of Neurological Dis-
orders and Stroke [39]. Ideally, subjects would consent
to be contacted for long-term follow-up assessments,
111
because we need to understand the impact of GR
treatment on long-term outcome measures, including
incidence and time course of the development of OA at
the knee, as previously described. Additional subjective
measures, such as subject-reported knee pain, should
also be included.
Conclusions
Custom-made AFOs with modifications based on the
underlying biomechanical factor can help to improve or
eliminate GR in hemiplegic patients. Treatment of GR
may prevent or lessen many long-term changes pro-
moted by GR. For example, what would happen to the
incidence of OA among stroke survivors if GR was
treated? The potential to prevent or lessen long-term
changes promoted by GR is a compelling motivation to
investigate the causes, treatment, and implications of
GR in the stroke survivor population.
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Disclosure
M.A. Department of Physical Medicine and Rehabilitation, Hofstra North Shore
Long Island Jewish Health System, Manhasset, NY. Address correspondence to:
M.A.; 2014 Reserve Dr, Philadelphia, PA 19145; e-mail: apmala01@gmail.com
Disclosure: nothing to disclose
M.E.D. Department of Physical Medicine and Rehabilitation, Hofstra North Shore
Long Island Jewish Health System, Manhasset, NY
Disclosure: nothing to disclose
N.P. Adventist Rehabilitation Hospital, Rockville, MD
Disclosure: nothing to disclose
N.Y. Department of Physical Medicine and Rehabilitation, Hofstra North Shore
Long Island Jewish Health System, Manhasset, NY
Disclosure: nothing to disclose
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O.B. Feinstein Institute for Medical Research Manhasset, NY; Department of
Physical Medicine and Rehabilitation, Hofstra North Shore Long Island Jewish
School of Medicine, Manhasset, NY
Disclosure: nothing to disclose
A.O. Department of Physical Medicine and Rehabilitation, Hofstra North Shore
Long Island Jewish Health System, Manhasset, NY
Disclosure: nothing to disclose
Preliminary data from this study were presented in a poster at the American
Academy of Physical Medicine & Rehabilitation Annual Assembly, November
15-17, 2012, Atlanta, Georgia.
Submitted for publication December 18, 2012; accepted October 12, 2014.