Falls Risk Factors

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research report

]

Raimunda Beserra da Silva, PhD1 • Lúcia Costa-Paiva, MD, PhD2 • Sirlei Siani Morais, MS3
Raquel Mezzalira, MD, MS4 • Néville de Oliveira Ferreira, PT, MS5 • Aarão Mendes Pinto-Neto, MD, PhD6

Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Predictors of Falls in Women
With and Without Osteoporosis

O

steoporosis and falls are common problems in the elderly. In
developed countries, between 21% and 38% of individuals
who are 65 years or older report a history of 1 or more falls per
year,2,24 affecting mainly women over 70 years.9 Falls are a risk
factor for fractures.21 Falls are multifactorial in nature, resulting from a
combination of extrinsic factors related to the individual’s environment
and intrinsic factors related to the individual’s physical and cognitive
status.8 The consequences range from minor injuries19 to more severe conditions
such as fractures.23 Falls are responsible
for about 90% of hip fractures in the elt STUDY DESIGN: Cross-sectional study.

t OBJECTIVE: To evaluate the relationship between the occurrence of falls and muscle strength,
flexibility, and balance in postmenopausal women
with and without osteoporosis.
t BACKGROUND: Osteoporosis and falls are
common problems encountered in the elderly.

t METHODS: A total of 133 women with and
133 without osteoporosis, aged 60 years or
greater, were included in the study. Women were
interviewed about clinical and social demographic
characteristics and the occurrence of falls in the
previous 12 months. The variables evaluated were
presence of osteoporosis, muscle strength, flexibility, and balance.
t RESULTS: A significantly higher percentage

of women with osteoporosis (51%) compared to
those without osteoporosis (29%) had a history of
at least 1 fall within the previous 12 months. There

derly6 and are associated with increased
morbidity and mortality rates. Research
in some Latin American cities has shown
that mortality rates due to hip fractures
was a significant and inverse association between
trunk extension strength and trunk flexion range
of motion with falls. Logistic regression analyses
showed that the variables associated with falls
were trunk extension strength and presence of
osteoporosis. Greater trunk extension strength
was associated with a lower risk for falls (odds
ratio, 0.97), while the presence of osteoporosis
increased fall risk by a factor of 2.17.

t CONCLUSIONS: A greater percentage of
women with postmenopausal osteoporosis had a
history of 1 or more falls within the previous year
and a higher risk of recurrent falls than women
without osteoporosis. Muscle strength of the
lumbar spine and the presence of osteoporosis are
intrinsic factors associated with the risk of falls.
J Orthop Sports Phys Ther 2010;40(9):582-588.
doi:10.2519/jospt.2010.3239
t KEY WORDS: balance, bone density, flexibility,
muscle strength, postmenopausal

range from 23.2% to 30.5%.18
The following intrinsic factors are associated with increased risk of falls: being
of female sex, decreased physical mobility, depression,9 advanced age, diabetes,
hearing disorders,2 impairment in body
balance,24 impaired muscle strength22
and vision, osteoarticular disease, and
the use of medication.8 Some intrinsic factors, such as sex and age, are not
modifiable, while others, such as muscle
strength,7 flexibility,27 and body balance,34
are potentially modifiable based on adequate intervention. To be successful in
preventing fractures,10,21 in addition to
interventions related to optimize bone
mineral density,20 it is also necessary to
focus interventions on factors that predispose individuals to falls.21,30
Few studies concerning potential risk
factors for falls in women with osteoporosis have been conducted. This population
may have intrinsic factors that increase
their risk for falls compared to peers. In
theory, changes in body balance,15 posture, and muscle strength26 may be affected by the presence of osteoporosis
and therefore may increase the risk for
falls. The identification of risk factors intrinsic to falls and interventions appropriate for these factors may decrease the
incidence of fractures in postmenopausal
women with osteoporosis.

1
Professor of Physical Education, Department of Obstetrics and Gynecology, School of Medicine, Unicamp, Campinas, São Paulo, Brazil. 2 Associate Professor, Department of
Obstetrics and Gynecology, School of Medicine, Unicamp, Campinas, São Paulo, Brazil. 3 Statistics, Department of Obstetrics and Gynecology, School of Medicine, Unicamp, Campinas,
São Paulo, Brazil. 4 Assistant Professor, Department of Otolaryngology, School of Medicine, Unicamp, Campinas, São Paulo, Brazil. 5 Physiotherapist, Department of Obstetrics and
Gynecology, School of Medicine, Unicamp, Campinas, São Paulo, Brazil. 6 Associate Professor, Department of Obstetrics and Gynecology, School of Medicine, Unicamp, Campinas,
São Paulo, Brazil. Financial support for this study was provided by the Foundation for Research Support of the State of São Paulo and the Coordination for the Improvement of
Higher Level Personnel Research grant for doctorate degree. The protocol for this study was approved by The Committee of Ethics of School of Medicine, Unicamp, Campinas,
São Paulo, Brazil. Address correspondence to Dr Lúcia Costa-Paiva, Rua Alexandre Fleming, 101-Cidade Universitária Zeferino Vaz Barão Geraldo, Campinas, São Paulo, Brazil,
Maibox 6081, 13083-881. E-mail: paivaepaiva@uol.com.br

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Research examining the association
between risk factors of falls and musculoskeletal variables has used subjective evaluation methods (like functional
mobility) and has studied women aged
65 and older.15,26 Neither associations
between objective musculoskeletal variables and risk factors nor younger women
have been studied.
The aim of this study was to evaluate
the association between the occurrence of
falls and muscle strength, flexibility, and
static balance in postmenopausal women

METHODS
Subjects

A

cross-sectional study of 266
postmenopausal women was conducted, with follow-up in the
Menopause Outpatient Facility of the
Women’s Integral Healthcare Center at
the Universidade Estadual de Campinas.
The women were selected consecutively
during a routine visit for consultation
for perimenopause and postmenopause
problems and divided into 2 groups according to bone densitometry (133 women with postmenopausal osteoporosis
and 133 without osteoporosis).
Eligibility criteria included age greater than 60 years, amenorrhea for at least
12 months, and normal bone densitometry or presence of osteoporosis. Women
who reported musculoskeletal disease
with lower limb deformity, neurologic
disease with impaired balance, dizziness,
tinnitus, hypoacusis and feeling of fullness in the ear, history of malignancy, visual impairments, uncontrolled diabetes
mellitus, postural hypotension, uncontrolled thyroid disorders, and medication use that alter static balance were
excluded from the study. The study was
approved by The Research Ethics Committee of the School of Medicine/Universidade Estadual de Campinas and all
participants provided written informed
consent.
Sample size calculations were based
on correlations between the number of

FIGURE 1. (A) Lumbar spine extension strength assessment. (B) Lower extremity strength assessment.

falls and balance measure. Arnold et al1
correlated the number of falls with intrinsic risk factors in postmenopausal
women with osteoporosis. Based on a
correlation value of 0.27, considering a
significance level of 5% and type II error of 20% (power of 80%), the necessary sample size was calculated at n = 40.
Given a 30% rate of 1 or more falls per
year, the estimated required sample size
was 133 women with osteoporosis and
133 without osteoporosis.

Procedures
All women were interviewed by the researcher, who collected demographic and
clinical information such as age (provided
by the patient), body mass index (BMI),
time since menopause, ethnicity (Caucasian and non-Caucasian), marital status
(with or without partner), occupation,
smoking cigarettes (number of years),
physical exercise (at least 30 minutes for
3 or more times per week), and use of
medication and hormone therapy. Falls
were determined during the interview
when the subject reported the occurrence, number, and location of falls in the
previous 12 months. A fall was defined as
an unexpected and unintentional change
in position causing an individual to land

at a lower level and not resulting from
sudden onset of paralysis, epileptic seizures, or overwhelming external force.32
Height and weight were taken during
the data collection using anthropometric
and stadiometer scale with the patient
in standing, wearing light clothes, and
barefoot.33
Evaluation of bone mass was performed at the Division of Nuclear
Medicine at the Clinical Hospital of the
Universidade Estadual de Campinas, by
bone densitometry with a Lunar DPX
densitometer (GE Medical Systems Lunar, Madison, WI). The women were
placed in a supine position, with hips
and knees flexed 60° to 90°. The bone
density of the lumbar spine (L1-L4) was
measured in the anteroposterior plane.
The diagnosis of osteoporosis was based
on the World Health Organization densitometry criteria,34 which classifies
normal bone mass as a t score higher or
equivalent to –1.0 SD (young adult) in the
lumbar spine (L1-L4) and osteoporosis as
a value lower than or equal to –2.5 SD
(young adult), as measured by dual energy X-ray absorptiometry (DXA).
Muscle strength of the trunk and
lower limbs was evaluated by using a
Crown dynamometer (range, 1-200 kg).

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FIGURE 2. Range-of-motion assessment for lumbar flexion (A) and extension (B).

To assess trunk extension strength, the
standing position with lower extremities
extended was used (FIGURE 1A). To evaluate lower-limb strength, the standing position with lower extremities flexed was
used (FIGURE 1B). After positioning, the
subject was asked to exert a maximum
lifting force. Subjects were encouraged
to produce the maximum force possible
within their physical limits. The test was
performed once, similar to the protocol
used for the validation study.12 Measurements were taken after orientation and
practice trials (variable to each subject) to
ensure that the patients understood the
test procedures.
To evaluate lumbar spine flexibility,
flexion and extension of the trunk were
measured by a Sanny Fleximeter device
graded in degrees. The standing position was adopted by the participant with
lower limbs together and extended. The
measuring device was placed along the
lateral trunk. Spinal flexion was evaluated by asking the subject to maximally flex
the trunk bringing arms toward the feet
until the lower limbs tended to flex (FIGURE 2A). Spinal extension was measured
by requesting maximal trunk backward
bending, with arms along the body, un-

til the hips projected forward (FIGURE 2B).
The test was performed once, similar to
the validation study.5 Measurements were
taken after orientation and practice trials to ensure that the subjects understood
the test procedures.
Static balance was assessed by stabilometry, which quantifies body sway. The
AccuSway Plus force platform system recorded center-of-pressure movements in
the anterior-posterior (y) and lateral (x)
directions, based on the forces exerted
on the platform by the soles of the feet
(FIGURE 3A). Assessment was performed
with the subject standing barefoot on the
platform with heels 2 cm apart, forming
a 30° angle (FIGURE 3B). Arms were held at
the sides. The subject stood still and focused on a target located directly ahead,
with eyes open for 30 seconds, followed
by 30 seconds of testing with eyes closed.
The stabilometer parameters analyzed
were the mean amplitude of center-ofpressure movements in the anteriorposterior (y) and lateral (x) directions,
ellipse area of center-of-pressure movement (anterior-posterior, lateral), and
the mean velocity, with eyes opened and
closed. The test was performed once,
similar to the validation study.29

]

FIGURE 3. (A) AccuSway Plus force platform and
computer. (B) Subject standing on the platform with
heels 2 cm apart and feet forming a 30° angle.

Statistical Analysis
For statistical analysis, the Mann-Whitney
test was used to compare control variables
among the groups. Because there were
significant differences in these variables,
strength, flexibility, and balance (dependent variables) were compared by using
general linear model methodology, controlled by age, BMI, school education, time
since amenorrhea, and physical exercise
(considered as independent variables).
However, because the dependent variables
did not have a normal distribution, BOXCOX4 (a statistical test) was used to transform data into normal distribution and
apply a general linear model. The control
variables were not transformed. The general linear model procedure is used to test
the difference in means, controlling for the
variables that differed between the groups
To correlate strength measures, flexibility, and balance with the number of falls,
Spearman’s correlation coefficient and
Spearman’s partial correlation coefficient
(adjusted) were adjusted for age, BMI,
educational level, time since menopause,
physical exercise, and osteoporosis. We
evaluated the variables associated with falls



8/18/10 10:07 AM

TABLE 1

Characteristics of Postmenopausal Women With
(n = 133) and Without Osteoporosis (n = 133)
With Osteoporosis*

Without Osteoporosis*

P Value†

Age (y)

66.0  4.5

64.9  4.4

.03

Age at menopause (y)

46.4  6.2

49.2  4.8

.01

Body mass index (kg/m2) 27.5  4.8

29.8  5.1

.01

Bone mass density (g/cm2) 0.8  0.1

1.2  0.1

T-score (young adult)

0.0  0.9

–2.9  0.4


* Data presented as mean  SD.
†
Mann-Whitney test.

TABLE 2

Muscle Strength and Flexibility in
Postmenopausal Women With (n = 133) and
Without Osteoporosis (n = 133)
With Osteoporosis*

Without Osteoporosis*

P Value†

Muscle strength
Lumbar spine (kg)

33.4  11.8

40.0  14.5

.06

Lower limbs (kg)

33.6  11.8

40.8  14.7

.02

Flexibility
Trunk flexion (°)

81.2  16.7

82.6  16.0

.62

Trunk extension (°)

20.3  8.3

18.7  7.3

.01

* Data presented as mean  SD.
†
Generalized linear model procedure to control for variables: age, body mass index, school education,
time since amenorrhea, and physical exercise.

by dichotomizing subjects into groups who
had at least 1 fall and those with no falls.
The estimated risks for falls were calculated
by odds ratio (OR) (95% confidence interval [CI]) through binary logistic regression.
The variables with significant differences
among the groups were studied through
bivariate analysis. Age, BMI, time since
menopause, physical exercise, ethnicity,
marital status, occupation, smoking, use of
medication, hormone therapy, osteoporosis, muscle strength, flexibility and balance
were examined and selected according to
significance through binary logistic regression with stepwise selection. For these procedures, SAS Version 9.1.3 was used.

RESULTS

T

ABLE 1 shows the clinical character-

istics of the women in each of the
2 groups. Women with osteoporosis had a lower BMI and younger age
at menopause. The mean  SD t Score

(young adult) of the lumbar spine (L1-L4)
was –2.9  0.4 in the group with osteoporosis and 0.0  0.9 in the group without osteoporosis.
The majority of women in the study
were white (80.5% with osteoporosis and 84.2% without osteoporosis),
had a sedentary lifestyle (76.7% with
osteoporosis and 72.9% without osteoporosis), received hormone therapy
(approximately 75% with osteoporosis),
and used some type of medication for
chronic diseases (approximately 90%
with osteoporosis). The mean number
of drugs used by women in both groups
was 3 (90.2% and 85.7% in the groups
with and without osteoporosis, respectively). The most widely used drugs
were captopril, hydrochlorothiazide,
and calcium. Fifty-one percent of the
women with osteoporosis had a history
of 1 or more falls within the previous
year, compared to 29% of the women
without osteoporosis (P.01). Among

those who fell during the previous year,
57% of the women with osteoporosis
had recurrent falls (2 or more falls),
compared to 26% for the women without osteoporosis (P.01).
Lumbar spine extension and lowerlimb strength were lower in the group
with osteoporosis. However, there was
a significant difference only for muscle
strength of the lower limbs (P.02).
Flexibility measures found trunk extension to be significantly higher (P.01) in
the osteoporotic group (TABLE 2).
The comparison between balance
parameters using stabilometry among
the groups of women with and without
osteoporosis in the test performed with
the eyes open showed that women with
osteoporosis had increased sway (greater
amplitude) in the anterior-posterior axis
compared to women in the control group.
No statistically significant difference was
observed in lateral sway, mean velocity of
movement, and ellipse area in the tests
with eyes open and closed, and in sway
amplitude in the anterior-posterior direction with eyes closed.
Adjusted correlation analysis between
intrinsic factors and falls showed very
weak and inverse correlation between
strength of the lumbar spine (P.03) and
flexion of the spine (P.04). There were
no significant correlations with any of the
sway parameters evaluated (TABLE 3).
The OR for falls was calculated after adjusting through multiple logistic
regression for the variables found to be
significant in the bivariate analysis. The
independent variables entered into the
stepwise model and adjusted were age,
BMI, time since menopause, physical
exercise, ethnicity, marital status, occupation, smoking, use of medication,
hormone therapy, osteoporosis, muscle
strength, flexibility, and balance. Binary
logistic regression showed that the variables associated with falls were muscle
strength of the lumbar spine and the
presence of osteoporosis. Greater lumbar spine strength was associated with a
decreased risk for falls (OR, 0.97; 95%
CI: 0.95, 0.99), while the presence of os-

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without osteoporosis. Few studies have
assessed the intrinsic risk factors for falls
TABLE 3
specifically in women with osteoporosis.
Sinaki et al26 studied women with
osteoporosis and found that they had
Correlation With Falls
a greater propensity for falling, lower
grip strength, lower trunk extension
Variables
r†
P Value
muscle strength, and lower-limb muscle
Muscle strength
strength compared to women without
Lumbar spine (kg)
–0.13
.03
osteoporosis. These data on muscle
Lower limbs (kg)
–0.10
.11
strength of the lower limbs are consistent
Flexibility
with the results of the present study.
Trunk flexion (°)
–0.13
.04
Regarding muscle strength, studies
Trunk extension (°)
–0.09
.15
conducted in postmenopausal women28
Balance
and in the elderly in general22 indicate
Amplitude of movement lateral, eyes open (cm)
–0.00
.97
that lower-limb strength that falls below
Amplitude of movement lateral, eyes closed (cm)
–0.03
.61
a certain threshold may predispose an
Amplitude of movement anterior-posterior, eyes open (cm)
–0.05
.44
individual to falls. In contrast, Keskin et
Amplitude of movement anterior-posterior, eyes closed (cm)
0.02
.73
al14 analyzed muscle strength of the lower
Ellipse area (cm2), eyes open
0.03
.62
2
limbs in older women and observed no
Ellipse area (cm ), eyes closed
0.05
.43
difference in this variable among indi Velocity (cm/s), eyes open
0.09
.16
viduals with a history of falls. Although
Velocity (cm/s), eyes closed
0.04
.47
lower-limb muscle strength has been
* Adjusted by group with (n = 133) and without (n = 133) osteoporosis.
†
Spearman's correlation coefficient adjusted for age, body mass index, school education, time since
implicated as a risk factor for falls in the
menopause, physical exercise, and osteoporosis.
elderly, some studies have found no association between falls and this variable,14,17

similar to the results of this study.
Binary Logistic Regression Analysis for
Differences on the impact of lowerVariables Associated With Falls in
TABLE 4
muscle strength on falls found in previous
Postmenopausal Women (n = 266)*
studies may be the result of the populations studied. For example, Sinaki et al26
Variables
P Value OR (95% CI)
included only women with osteoporosis
Muscle strength for lumbar spine extension
.01
0.97 (0.95, 0.99)
who had spinal kyphosis. It is well known
Osteoporosis
.01
2.17 (1.29, 3.65)
that spinal deformities, such as kyphosis,
Abbreviation: CI, confidence interval; OR, odds ratio.
are associated with structural changes of
* Binary logistic regression with stepwise variable selection criteria. Dependent variable: fall (binary).
the spinal column, vertebral compression
Independent variables: age, body mass index, time since menopause, physical exercise, ethnicity, marital status, occupation, smoking, use of medication, hormone therapy, osteoporosis, muscle strength,
fractures, and decreased strength of the
flexibility, and balance.
trunk extensor muscles.26 The present
study did not include women with excesteoporosis increased fall risk by a factor within the previous year compared to the sive kyphosis, which may explain the little
group without osteoporosis (29%). These difference in the strength of the lumbar
of 2.17 (95% CI: 1.29, 3.65) (TABLE 4).
data were similar to those of other stud- spine between the groups. Nevertheies showing that the history of 1 or more less, the correlation analysis showed falls
DISCUSSION
falls occurring in 1 year in all elderly is to be negatively correlated with muscle
he aim of this study was to de- approximately 38% compared with 30% strength of the lumbar spine.
Correlation analysis also showed that
termine the association between in women with osteoporosis.1,2
the occurrence of falls and a group
Fall risk depends on both intrinsic and falls correlated with trunk flexion range
of specific intrinsic risk factors for falls extrinsic factors. In the present study, of motion. It is known that muscles and
in postmenopausal women with and the intrinsic factors evaluated showed tendons tend to become more rigid with
without osteoporosis. Significantly more decreased lower-limb strength and aging, resulting in decreased flexibilwomen (51%) in the group with osteo- greater flexibility of trunk extension in ity.13 Intervertebral disc degeneration is
porosis had a history of 1 or more falls women with osteoporosis than in women also a factor limiting range of motion.31

Correlation Between Muscle Strength,
Flexibility, and Balance With Falls in
Postmenopausal Women*

T



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Furthermore, the literature shows that
weakness of trunk extensor muscles in
individuals with osteoporosis leads to
a decrease in trunk extension range of
motion.7
In the present study, the differences
between absolute values for flexibility
angles were very small and had no clinical significance. We believe that the small
numerical difference (1.6°) in trunk extension angles between the groups
(mean  SD, 20.3  8.3 versus 18.7 
7.3) is within the range of error for that
measure.
Advancing age and the presence of
certain degenerative diseases of the locomotor system, such as osteoporosis,
may decrease flexibility and independence of movements. The greatest resulting concerns are related to gait, and
the contribution to a higher risk of falls
and fractures.30 The logistic regression
analysis showed that increasing strength
of the lumbar spine by 1 unit would decrease the risk of falls (OR, 0.97), while
the presence of osteoporosis increases
the risk (OR, 2.17). Although multiple
factors contribute to falls, a decrease in
balance has been cited as an important
element.17 Lynn et al16 observed differences in strategies for balance control among
individuals with and without osteoporosis. In particular, those with osteoporosis
are better at using strategies involving
the hip to maintain balance compared to
normal individuals.
The erect posture is not a static event
and is characterized by sway, which
maintains the body in continuous movement. Postural sway is involuntary and
depends on action of the sensory system
(visual, vestibular, and proprioceptive),
processing in the central nervous system,
and neuromuscular system.11 Sway may
be quantified on a force platform used to
record center-of-pressure movements on
surface planes in both the anterior-posterior and lateral directions. In the present
study, the only difference observed in balance measurements between groups was
in the amplitude of sway in the anteriorposterior direction when measured with

eyes open. However, there was no association between measures of balance and
the occurrence of falls, and there were no
studies in the literature that evaluated
stabilometric data in individuals with
osteoporosis for comparison purposes.
Melzer et al17 tested elderly individuals
(mean age, 78 years) on a force platform
using a wide base of support. The authors
found no association between the stabilometric parameters and the occurrence
of falls. Findings of the current study are
in agreement with those of other authors
who also failed to observe differences in
balance parameters and the occurrence
of falls.14,17
The diversity of study results may be
explained by other variables such as differences in mean age, dwelling location
(in a community or nursing home), lifestyle of the participants, and the techniques employed to assess the variables
analyzed. This suggests that there may be
many interactive causal factors for falls
that need further investigation, and it
emphasizes the complex interaction between intrinsic and extrinsic factors associated with falls.
The main limitation of this study was
the assessment of falls based upon selfreport. This might have influenced the
estimation of fall occurrence data. Moreover, it is important to note that the study
was performed with community-dwelling
women, using objective tests to evaluate
all the variables studied.

CONCLUSIONS

A

greater percentage of women
with postmenopausal osteoporosis had a history of 1 or more falls
within the previous year and a higher risk
of recurrent falls than women without osteoporosis. Moreover, muscle strength of
the lumbar spine and the presence of osteoporosis are intrinsic factors associated
with the risk of falls. The results of this
study may guide future studies investigating a cause-and-effect relationship
among factors related to falls in individuals with osteoporosis. This will help

guide intervention strategies to prevent
falls and their consequences. t

KEY POINTS
FINDINGS: A greater percentage of women

with postmenopausal osteoporosis
had a history of 1 or more falls within
the previous year compared to women
without osteoporosis. Among those who
fell, the incidence of recurrent falls was
also greater for the women with osteoporosis. Muscle weakness of the lumbar
spine and the presence of osteoporosis
are intrinsic factors associated with the
risk of falls.
IMPLICATION: These results may serve to
guide intervention strategies to prevent
falls and their consequences in women
with osteoporosis who are at greater
risks of fall-related fractures.
CAUTION: Long-term studies with more
subjects are needed to determine if
these results could be applied to a larger
population.

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588 | september 2010 | volume 40 | number 9 | journal of orthopaedic sports physical therapy


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