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609414

research-article2015
CRE0010.1177/0269215515609414Clinical RehabilitationCabanas-Valds et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

The effect of additional core 2016, Vol. 30(10) 10241033


The Author(s) 2015
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DOI: 10.1177/0269215515609414

dynamic sitting balance and trunk cre.sagepub.com

control for subacute stroke


patients: a randomized
controlled trial

Rosa Cabanas-Valds1, Caritat Bagur-Calafat1,


Montserrat Girabent-Farrs2,
Fernanda M Caballero-Gmez3,
Montserrat Hernndez-Valio4
and Gerard Urrtia Cuch5

Abstract
Objective: To examine the effect of core stability exercises on trunk control, dynamic sitting and standing
balance, gait, and activities of daily living in subacute stroke patients.
Design: A randomized controlled trial.
Setting: Inpatient rehabilitation hospital in two centres.
Subjects: Eighty patients (mean of 23.25 (16.7) days post-stroke) were randomly assigned to an
experimental group and a control group.
Interventions: Both groups underwent conventional therapy for five days/week for five weeks and the
experimental group performed core stability exercises for 15 min/day. The patients were assessed before
and after intervention.
Main measures: The Trunk Impairment Scale (Spanish-Version) and Function in Sitting Test were used
to measure the primary outcome of dynamic sitting balance. Secondary outcome measures were standing
balance and gait as evaluated via Berg Balance Scale, Tinetti Test, Brunel Balance Assessment, Postural
Assessment Scale for Stroke (Spanish-Version), and activities of daily living using Barthel Index.

1Department of Physiotherapy, Faculty of Medicine and 5Centro


Cochrane Iberoamericano, Institut dInvestigaci
Health Sciences, Universitat Internacional de Catalunya (UIC) Biomdica Sant Pau, CIBERESP, Barcelona, Catalonia, Spain
Barcelona, Catalonia, Spain
2Department of Physiotherapy (Biostatistics Unit), Faculty of Corresponding author:
Rosa Cabanas-Valds, Department of Physiotherapy, Faculty
Medicine and Health Sciences, Universitat Internacional de
of Medicine and Health Sciences, Universitat Internacional de
Catalunya, Barcelona, Catalonia, Spain
3Physical Medicine and Rehabilitation, Parc Taul Sabadell Catalunya (UIC) Josep Trueta street, E-08195 Sant Cugat del
Valls Barcelona, Catalonia, Spain.
Hospital Universitari, Sabadell, Catalonia, Spain
4Department of Physiotherapy, Parc Sanitari Pere Virgili, Email: rosacabanas@uic.es
Barcelona, Catalonia, Spain
Cabanas-Valds et al. 1025

Results: The experimental group showed statistically significant differences for all of the total scale scores
(P<0.05), except for the sitting section of the Brunel Balance Assessment. The mean (SD) difference
between groups in Trunk Impairment Scale total score was 3.40 (4.12) points, and its subscale dynamic
sitting balance was 2.28 (3.29). The Berg Balance Scale was 14.54 (18.19) points, and the Barthel Index
was 13.17 (25.27) points. Collectively, these results were in favour of the experimental group.
Conclusions: Core stability exercises in addition to conventional therapy improves trunk control,
dynamic sitting balance, standing balance, gait and activities of daily living in subacute post-stroke patients.

Keywords
Hemiplegia, activities of daily living, core stability, stroke, trunk control

Received: 28 March 2015; accepted: 5 September 2015

Introduction
Impairments in balance can be a consequence of and dynamic sitting balance. Additionally, this
changes in the sensory and integrative aspects of study aimed to determine whether core stability
motor control.1 More than 80% of subjects who exercises might also positively affect standing bal-
have suffered a first-time stroke have balance dis- ance, gait and activities of daily living in sub-acute
ability in the sub-acute phase.2 post-stroke patients.
Trunk impairment, restricted balance, and
impaired postural control in patients with stroke
are correlated3 with increasing risk of falls and
Methods
impaired mobility.4 This creates disability and Trial design
dependency in their activities of daily living.
The core is central to almost all kinetic chains in A blinded-assessor randomized controlled trial
the body. Control of core strength, balance, and with two parallel groups were performed in two
motion maximizes all kinetic chains of upper and centres. Patients were recruited from the Parc
lower extremity function,5 which is essential to pro- Sanitari Pere Virgili (Barcelona, Spain) and Parc
viding a solid base to exert or resist force.6 A stable Taul Sabadell Hospital Universitari (Sabadell,
and strong core may contribute to more efficient use Spain) between October 2012 and March 2014.
of the lower limbs.7 Core stability is defined as the All patients (age 18 years or older) who had
ability of the lumbopelvic-hip complex to prevent experienced their first stroke, whether ischaemic or
buckling of the vertebral column and return it to haemorrhagic (not requiring surgery), within the
equilibrium following perturbation.8 last three months were eligible for inclusion. The
A systematic review9 has shown that imple- stroke diagnosis was based on the World Health
menting core stability exercises may be a viable Organization guidelines and was confirmed by clin-
strategy for improving trunk performance and ical examination and magnetic resonance imaging.
dynamic sitting balance, standing balance, and gait Exclusion criteria included significant disability
in post-stroke patients. However, common meth- prior to stroke as evidenced by a score of >3 on the
odological limitations in the design and the report- modified Rankin scale,10 a Barthel Index11 score 75,
ing of these studies included in the review justified and a Spanish Version of Trunk Impairment Scale
the need for further well-designed studies. 2.012,13 score 10. Other exclusion criteria included
Given the importance of core stability with bal- orthopaedic or neurological impairments that could
ance, this study aimed to investigate the effect of influence sitting balance, inability to understand
including additional core stability exercises to con- instructions as assessed by a Mini Mental State
ventional therapy on improving trunk performance Examination score 24, apraxia, and hemineglect.
1026 Clinical Rehabilitation 30(10)

Information on patients age, days post-stroke, treatment programme was patient-specific and
stroke severity as assessed by National Institutes of consists mainly of physiotherapy, such as tone
Health Stroke Scale, and the side and location of facilitation, stretching, passive mobilization, and
the lesion was collected from medical records. range-of-motion exercises for the hemiparetic side,
Participants were asked to sign an informed con- walking between parallel bars, and occupational
sent before participating. therapy and nursing care. Additionally, activities of
The ethical committee from Parc Taul Sabadell the trunk integrated in postural control and task-
Hospital Universitari gave approval. The study was directed movement were performed.
carried out as per the standards set by the In addition, patients in the experimental group
Declaration of Helsinki. performed core stability exercises for 15 minutes
The number of patients required for this study daily, totalling 6.15 hours. All physiotherapists
was calculated taking into consideration the score were neurology experts and received one day of
variable dynamic sitting balance subscale on the education on training in specific exercises by the
Spanish Version of Trunk Impairment Scale 2.0. A principal investigator. The physiotherapists per-
standard deviation of 2.3 was assumed in both formed the therapy with their hands on the patient
groups based on our results in the validation study to ensure proper quality of movement and did not
for this scale performed prior to the trial. participate in the patients evaluation.
We also assumed a type I error of 5% and a two- Adequate rest periods were allowed between
tailed t-test with 80% power. We estimated that 37 exercises. The core stability exercises were selec-
patients would need to be included in each study tive, repetitive movements and involved tasks
arm in order to detect a 1.5-point improvement, without resistance to improve strength, endurance,
yielding a total of 74 patients. To offset any possi- and coordination of the core.
ble dropouts estimated at <10%, the final sample The specific programme used in this study was
size was set at 80 patients. inspired by an analysis of the interventions used in
Study participants were randomly allocated to the trials included in the systematic review.9 The
either an experimental group or control group by programme was divided into three steps based on
means of a random computer-generated list spe- the level of difficulty (see Supplementary Figures
cific to each centre. The randomization was man- 1-2). Training was determined by the patients abil-
aged by an external person uninvolved in the ity to undertake easy exercises and progress to
treatment or follow-up of patients. The method of more challenging exercises. They did not move on
allocation was concealed in sequentially num- to higher levels until they had mastered the exer-
bered, sealed, opaque envelopes. cise they were engaged in.
The principal investigator sequentially enrolled When the individuals were unable to sit unsup-
patients and communicated the decision to the
ported, they performed core stability exercises in
physiotherapists (a total of eight), who then
step 1. Step 1: the exercises were performed in a
assigned patients to an intervention (control or
supine position on a plinth or bed (see
experimental group) according to the content of the
Supplementary Figure 1). When the patient was
envelopes. The principal investigator did not par-
able to sit for one minute on the edge of the plinth
ticipate in the intervention but performed all of the
or bed without any back or arm support with hips
clinical evaluations in a blinded manner.
and knees bent at 90 and feet flat on the support
surface, they moved on to step 2. Step 2: the exer-
Interventions cises were performed in a sitting position on a sta-
All patients followed the conventional therapy pro- ble surface (see Supplementary Figure 2). When
gramme for stroke patients provided by their the patient was able to sit on an unstable surface
respective rehabilitation centre for a 5-week period, thirty seconds, she/he moved on to step 3. Step 3:
consisting of 1 hour of treatment a day, 5 times a the exercises were performed in sitting position on
week for 5 weeks (25 sessions). The conventional a physioball (see Supplementary Figure 2).
Cabanas-Valds et al. 1027

Outcome measures homogeneous at baseline for each of the recorded


variables. A new variable called change score
The primary outcome was dynamic sitting balance was created, which is the difference between post
and trunk control measured by the Spanish Version and pre-treatment value. This new variable was
of Trunk Impairment Scale 2.0. This scale consists subsequently compared between the two groups
of two sub-scales: dynamic sitting balance (which using the Mann-Whitney U test and Students
evaluates the subjects ability to actively shorten t-test.
each side of the trunk) and coordination (which All statistical analyses were performed using
assesses the subjects ability to independently rotate the Statistical Package for the Social Sciences v.21
the shoulder girdle and pelvic girdle). These sub- with a significance level of P<0.05.
scale scores range from 0-10 and 0-6, respectively.
The Function in Sitting Test is a 14-item perfor-
mance-based clinical examination of sitting balance. Results
It is designed to evaluate sensory, motor, proactive, The patients were randomized into two groups: an
reactive, and steady-state balance factors. experimental group (n = 40) and a control group
Secondary outcome measures were standing (n = 40) (see Figure 1). Table 1 shows the charac-
balance, gait, and activities of daily living as meas- teristics of both groups at baseline. No differences
ured by the following scales: the Brunel Balance were found between the two groups for the col-
Assessment is a 12-point ordinal scale consisting lected demographic variables or stroke-related
of a hierarchical series of functional performance parameters. Comparisons between the groups at
tests that range from supported sitting and standing baseline also showed no difference for any physi-
balance to advanced stepping tasks (gait); the Berg cal outcome measures (P>0.05), except for the
Balance Scale is a 14-item objective measuring stepping section of the Brunel Balance Assessment
tool designed to assess static balance; the Spanish (gait) (P=0.020). The patients in this study were
Version of the Postural Assessment Scale for shown to have mainly mild-to-moderate disability
Stroke14 is a 12-point ordinal scale used to evaluate after stroke as assessed by the National Institutes of
postural control; the Tinetti Test consists of 2 sub- Health Stroke Scale.
scales for gait (12-point) and balance (16-point); Table 2 presents the comparison of treatment
the Barthel Index is a 10-point scale that evaluates effects between groups for all primary and second-
functional performance. All the scales have been ary outcome measures, where the P-value reflects
validated for stroke patients, and higher scores are the between-group differences of the change
indicative of better performances. scores. Patients in the experimental group signifi-
cantly improved compared to the control group in
all outcome measures except for the sitting section
Statistical methods of the Brunel Balance Assessment.
The patients were assessed before and after the The mean (SD) change total score of the
intervention. The patients characteristics were Spanish Version of Trunk Impairment Scale 2.0 for
described using frequencies for the categorical data the experimental group was 5.88 (3.48) points,
variables and for the continuous data mean and and the total score for the control group was 2.48
standard deviation for both the control and experi- (2.20) points (P<0.001). For the dynamic sitting
mental groups and the pre- and post-treatment balance sub-scale of the Spanish Version of Trunk
measurements. The Pearsons Chi-square test was Impairment Scale 2.0, the score for the experimen-
used for categorical variables, and the Mann- tal group was 4.10 (2.90) points, and for the con-
Whitney U test (no normal distribution) and trol group, the score was 1.80 (1.73) points,
Students t-test (normal distribution) were indicating a 23% improvement in dynamic sitting
employed for continuous variables. for the experimental group (P<0.001).
The Shapiro-Wilk test was used to determine For the Berg Balance Scale, the change score
whether the control and experimental groups were mean (SD) in the experimental group was 23.02
1028 Clinical Rehabilitation 30(10)

Figure 1. Flow chart of patients allocated to the core stability exercise study.

(15.95) points, and for the control group, it was Discussion


8.48 (8.74) points (P<0.001). For the Tinetti gait
sub-scale, the change score was 24% higher in the The study results showed that 6.15 hours of addi-
experimental group compared to the control group tional core stability exercises increased dynamic
(P<0.002). Furthermore, the change score for the sitting balance and trunk performance in sub-acute
Barthel Index scale for the experimental group was stroke patients. The results also suggest a carry-
36.60 (18.01) points, and for control group, the over effect of core stability exercises on standing
score was 23.33 (16.87) points (P<0.002). balance, gait and activities of daily living.
Cabanas-Valds et al. 1029

Table 1. Characteristics of the experimental and control group at baseline.

Variable Pre-treatment P-value*

Control Experimental
Group (n=40) Group (n=40)
Age, mean years (SD) 75.69 (9.40) 74.92 (10.70) 0.758a
Gender (women/men) 21/18 19/21 0.823b
Time post-stroke, days (SD) 21.37 (16.00) 25.12 (17.30) 0.225a
Paretic side (left/right) 18/21 17/23 0.653b
Type of stroke (ischemic/hemorrhagic) 31/8 33/7 0.576b
Thrombolysis (n) 6 (2.34) 7 (2.8) 0.762a
Scales Scoring
Range
NIHSS stroke severity (previous) 042 8.54 (5.06) 9.42 (5.37) 0.531b
Modified Rankin (previous disability) 06 0.5 (1.06) 0.5 (1.01) 0.861b
Primary outcome measure
S-TIS 2.0 dynamic sitting balance 010 2.70 (2.31) 2.65 (2.36) 0.889b
S-TIS 2.0 coordination 06 1.10 (0.94) 0.85 (0.70) 0.329b
S-TIS 2.0 total 016 3.8 (3.09) 3.50 (2.92) 0.732b
FIST 056 21.95 (16.50) 20.75 (16.52) 0.575b
Secondary outcome measure
BBA sitting 03 2.18 (0.91) 2.02 (1.18) 0.769b
BBA standing 03 0.61 (1.04) 0.40 (0.90) 0.280b
BBA stepping 06 0.26 (0.78) 0.00 (0.00) 0.020*
BBA total 012 3.02 (2.19) 2.30 (1.65) 0.224b
BBS 056 8.54 (11.14) 5.42 (5.60) 0.564b
Tinetti balance 016 3.36 (2.90) 2.52 (2.03) 0.524b
Tinetti gait 012 0.56 (1.77) 0.20 (0.88) 0.359b
Tinetti total 028 3.85 (4.11) 3.22 (3.90) 0.782b
S-PASS 036 15.59 (6.36) 14.72 (6.78) 0.694b
Barthel Index 0100 30.90 (15.08) 32.00 (15.27) 0.748c

Values are presented as mean (SD) or absolute frequency, aPearson Chi-square, bMann-Whitney U test, cStudents t-test, *p<0.05.
NIHSS: National Institutes of Health Stroke Scale, S-TIS (2.0): Spanish Version of Trunk Impairment Scale 2.0, FIST: Function in
Sitting Test, BBA: Brunel Balance Assessment, BBS: Berg Balance Scale, S-PASS: Spanish Version of Postural Assessment Scale for
Stroke.

A strength of this study is that it is the first trial patients had to remain sitting. Rose etal.15 advo-
of core stability exercises across two centres with cated the design of systematic and gradual training
80 stroke patients of an average age of 75 years. programmes to improve balance and walking for
Additionally, all outcomes were evaluated by the post-stroke patients.
same therapist in a blinded manner. The specific core stability exercise intervention
Another key characteristic of our study was the used in our study was designed to improve the
description and standardization of the progression endurance of the core muscles that stabilize the
of exercises at three levels of increasing difficulty. trunk and pelvis. This method is based on previous
Such methods not only allowed for reproducibility experimental treatment of randomized controlled
but also enabled the admission of patients who trials9 and takes the physiological basis of exercise
could not tolerate the sitting position in our study, into consideration. The core stability exercises ena-
unlike many previous studies in which eligible bled improvement of reaction times, which is an
1030 Clinical Rehabilitation 30(10)

Table 2. Comparison of change score of outcome measures between control and experimental group.

Outcome Control group (n=39) Experimental group (n=40) D=Mean D/total p-value
measures difference of subscale
the change score (%)
score

Post- Change Post- Change


treatment scorec treatment scorec
S-TIS 2.0 4.51 (2.95) 1.82 (1.73) 6.75 (3.00) 4.10 (2.80) 2.28 (3.29) 22.80 0.001a
dynamic
sitting balance
S-TIS 2.0 1.77 (1.01) 0.66 (0.86) 2.63 (1.31) 1.77 (1.20) 1.11 (1.48) 18.50 0.001b
coordination
S-TIS 2.0 total 6.30 (3.70) 2.48 (2.20) 9.38 (3.90) 5.88 (3.48) 3.40 (4.12) 21.25 0.001a
FIST 35.23 (16.71) 13.28 (11.80) 43.70 (13.75) 22.92 (14.31) 9.64 (18.55) 17.21 0.002a
BBA sitting 2.70 (0.73) 0.51 (0.75) 2.90 (0.49) 0.87 (1.15) 0.36 (1,37) 12.00 0.251b
BBA standing 1.64 (1.32) 1.02 (1.08) 2.17 (1.21) 1.77 (1.44) 0.75 (1.80) 25.00 0.004b
BBA stepping 1.33 (1.70) 1.07 (1.42) 2.37 (2.30) 2.37 (2.30) 1.30 (2.70) 21.67 0.017b
BBA total 5.41 (3.20) 2.38 (2.04) 7.55 (3.55) 5.25 (3.11) 2.87 (3.72) 23.92 0.001b
BBS 17.03 (15.11) 8.48 (8.74) 28.45 (17.75) 23.02 (15.95) 14.54 (18.19) 25.96 0.001a
Tinetti 5.92 (3.81) 2.56 (2.51) 9.75 (4.15) 7.22 (3.73) 4.66 (4.50) 29.13 0.001b
balance
Tinetti gait 3.18 (3.71) 2.62 (3.52) 5.77 (4.54) 5.57 (4.43) 2.95 (5.66) 24.58 0.002b
Tinetti total 9.00 (7.23) 5.15 (5.48) 15.52 (8.33) 12.30 (8.65) 7.15 (10.24) 25.54 0.001b
S-PASS 21.43 (7.53) 5.84 (5.00) 25.82 (6.70) 11.10 (6.35) 5.26 (8.08) 14.61 0.001b
Barthel Index 54.23 (23.32) 23.33 (16.87) 68.50 (22.37) 36.50 (18.81) 13.17 (25.27) 13.17 0.002a

Values are presented as mean (standard deviation).


aAnalysed by Students t-test, bAnalysed by Mann Whitney Test U, cChange score: Difference post-pre of outcome (p-value<0.05).

S-TIS 2.0: Spanish version of Trunk Impairment Scales 2.0, FIST: Function in Sitting Test, BBA: Brunel Balance Assessment,
BBS: Berg Balance Scale, S-PASS: Spanish version of Postural Assessment Scale for Stroke Patients.

important factor in optimal balance. This result is somewhat higher than that observed in previous
consistent with recent work showing that core mus- studies.18,23 This difference could be because our
cle endurance is associated with balance perfor- study added some exercises performed on an unsta-
mance in elderly subjects.16 ble surface (i.e., the physioball). This observation
Additionally, the average age of the study popu- is corroborated by other studies20,21,24 that also
lation was 75.3 (10.03) years, which is close to included a similar series of exercises.
the average age of stroke patients in high-income Training the core musculature on an unstable
countries.17 This age group is in inconsistent with surface improves balance, stability, and proprio-
several studies that included younger patients.18-21 ceptive capabilities.25 Additionally, spine stability
Another factor to be taken into account is that depends not only on muscular strength but also
improvement occurred within days of the stroke,22 proper sensory input that alerts the central nervous
and the mean number days post-stroke to perform system about interactions between the body and the
core stability exercises in this study was earlier environment, providing constant feedback and
than in previous investigations.18-20 allowing refinement of movement.26
Furthermore, the magnitude of improvements The improvement in standing balance in the
observed in our study, as measured by the Span- experimental group as assessed by the Berg
ish Version of Trunk Impairment Scale 2.0, was Balance Scale was almost three times more than
Cabanas-Valds et al. 1031

control group. This result may be because the stability exercises. Previous studies18,33 have added
patients in the experimental group achieved good 10 hours of core stability exercises in their inter-
sitting balance earlier than the control group due to vention group, and the results were of a similar
the core stability exercise regimen, thus allowing magnitude to ours, leading us to conclude that
them to begin the more difficult standing tasks ear- these exercises alone are a relevant factor to explain
lier. Kaji etal.27 showed that the use of core stabil- the benefits observed in our study. A second limita-
ity exercises in healthy subjects transiently tion was that there was a lack of long-term follow-
decreased the area of the centre-of-pressure trajec- up of the patients to determine whether the
tory and its mediolateral and total excursions dur- improvement observed in the short term was main-
ing quiet standing with the eyes closed. tained over time.
The results of this study also highlight the exist- Future research needs to examine core stability
ence of a positive relationship between core stabil- exercises to learn how to teach patients how to per-
ity exercises and gait. Additionally, these findings form these exercises without a therapist being
are corroborated by Gjelsvik etal.,28 Saeys etal.,20 present.
and Chung etal.,29 all illustrating a relationship In conclusion, core stability exercise training
between improved trunk control and walking. We along with conventional therapy improves trunk
speculate that this positive association is due to the control, dynamic sitting balance, standing balance,
central nervous system stabilizing the spine through gait, and activities of daily living in sub-acute post-
the contraction of the trunk and pelvic musculature stroke patients.
in response to the reactive forces of the lower
limbs30 and the greater stability of the pelvis during
the walking support phase. Clinical messages
During the performance of motor skills, antici- An additional 6.15 hours of exercise
patory postural adjustments play an important role therapy focused on increasing core sta-
in maintaining balance during task performance bility led to a significant improvement in
and in the central control of posture.6 These adjust- mobility and activities of daily living.
ments in the trunk are executed before or along Core stability exercises are suitable for
with a focal movement of the limbs.31 post-stroke patients unable to maintain a
To the best of our knowledge, this is the first sitting position.
study to demonstrate the beneficial effect of addi-
tional core stability exercises on activities of daily
living as measured by the Barthel Index. In the Acknowledgements
experimental group, the score was 68 (22.37) The authors would like to thank: Professor Doctor Xavi
after treatment compared to control group was 54 Girons, Mrs. Ana Germn, Mr. JC Oliva Morera, Mr.
(23.32). A Barthel Index score 60 points means Xavi Bel, Mrs. Silvia Covarrubias, Mrs. Anabel Gelices,
that the patient has made a transition from com- Mrs. Marta Puiggene, Mrs. Laura de Juana, Mrs.
plete dependence to assisted independence, accord- Esperanza Almansa, Mr. Gary Siuming Lau, and Mrs.
ing to Granacher etal.32 Core stability is important Elena de Pontcharra.
for the successful performance of activities of daily
life in elderly, healthy subjects. Declaration of Conflicting Interests
There are some limitations to our study. First, The author(s) declared no potential conflicts of interest
the control group did not receive additional ther- with respect to the research, authorship, and/or publication
apy. The experimental group performed 6.15 hours of this article.
more therapy than the control group. It is plausible
that the improvements could be due to longer exer- Funding
cise, but we do not believe that this is the only The author(s) received no financial support for the
reason for the improvement observed with core research, authorship, and/or publication of this article.
1032 Clinical Rehabilitation 30(10)

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Next event

Annual Meeting 2016 21-23 November 2016


at The Midland Hotel, Manchester

Theme: Rehabilitation following major trauma


plus SIG sessions

Closing date for receipt of abstracts 30 September 2016

Regular updates including abstract submission and registration at


www.bsrm.org.uk

The British Society of Rehabilitation Medicine is the Society which represents the specialty of
Rehabilitation Medicine. It promotes an understanding of the specialty through the education and
development of clinical guidelines and standards

BSRM, c/o Royal College of Physicians, 11 St Andrews Place,


London NW1 4LE (tel: 01992 638865) www.bsrm.org.uk

Registered Charity Number 293196