Choosing outcome measures that reflect what is important to the patient: a case study of Clinical Pilates in a woman with multiple sclerosis.
Purpose: To illustrate the importance of selecting outcome measures
congruent with treatment goals.
Case description: A middle-aged woman with multiple sclerosis presented to the community neurorehabilitation team during an exacerbation of her symptoms. The physiotherapist assessed her walking and balance problems. Treatment goals were negotiated within the framework of the International Classification of Functioning and Disability, to include impairments, activity limitations and participation restrictions.
Physiotherapy management: The intervention was a seven month Clinical Pilates home exercise programme of 30 minutes per day, comprising mat exercises for the trunk, upper and lower limbs. The physiotherapist supervised the first four months of exercise followed by three months of unsupervised training. Outcomes were measured using: the Rhomberg test, Frailty and Injuries Cooperative Studies of Intervention Techniques, Clinical Test of Sensory Integration and Balance, Dynamic Gait Index, 10 metre walk test, and the 6 minute walk test.
Outcome: The outcome measures did not demonstrate the improvements in function and quality of life that were reported and valued by the patient. A post-hoc case and literature review revealed potential improvements in outcome measurement practice.
Discussion: The impairment focussed measures taken at baseline, and repeated at the end of treatment, were not congruent with the patient's goals about activity and participation. Post-hoc, we found other meaningful and useful outcome measures that are recommended for use in practice. Hay-Smith J, Standring D (2010): Choosing outcome measures that reflect what is important to the patient: a case study of Clinical Pilates in a woman with Multiple Sclerosis. New Zealand Journal of Physiotherapy 38(3) 91-97.
Keywords: Multiple sclerosis, Clinical Pilates, walking, balance, quality of life, outcome measurement.
|Article Type:||Case study|
Multiple sclerosis (Care and treatment)
Multiple sclerosis (Case studies)
Women (Health aspects)
|Publication:||Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193|
|Issue:||Date: Nov, 2010 Source Volume: 38 Source Issue: 3|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
Multiple sclerosis (MS) is a chronic progressive inflammatory demyelinating disease of the central nervous system with subsequent severe neurological disability. Recent preliminary (as yet unpublished) findings from a New Zealand wide study in 2008 suggested there were about 3000 people living with confirmed MS, and approximately another 1200 who potentially have the condition (New Zealand Herald 2009). The exact aetiology of MS is unknown, although a combination of genetic (including immune susceptibility) and environmental factors are probably the main contributors (Courtney et al 2009).
Physiotherapy interventions that promote walking, general mobility and physical activity may assist with maintaining quality of life for those with MS. Sutliff (2010) recently considered the link between impaired mobility and patient burden in multiple sclerosis and concluded that walking difficulties lead to a reduction in physical activity and mobility in people with MS resulting in significant disease burden and reduced quality of life (Sutliff 2010). MS has several characteristic patterns including: relapsing remitting, primary progressive, secondary progressive and progressive relapsing (White and Dressendorfer 2004). Whatever the pattern of progression, people with MS are often referred for neurorehabilitation for various combinations of physical and cognitive symptoms. Decreased muscle strength, uncoordinated movement, decreased balance, difficulties with walking and spasticity are common reasons for referral to a physiotherapist.
Exercise and MS
In the past, exercise interventions were thought to precipitate exacerbations of MS (Chard 2006). However, we now recognise that a decrease in physical activity in response to MS symptoms can lead to more muscle atrophy and the decline of muscle strength, functional capacity and overall quality of life (White and Dressendorfer 2004). Individualised and carefully controlled exercise interventions are now an accepted part of rehabilitation for people with MS. It is less clear what the optimal exercise therapy comprises.
Rietberg and colleagues (2004) published a Cochrane systematic review of randomised trials of exercise therapy for MS, and found six trials (a total of 164 participants) that compared exercise with no exercise (Rietberg et al 2004). The review authors considered the trials were at low risk of bias. Heterogeneity of interventions and outcome measures meant the trial data were not statistically pooled in the analysis. A narrative synthesis strongly suggested that exercise improved muscle power and mobility, and provided moderate evidence of improved mood. In contrast it was not clear if activities of daily living or quality of life improved.
A literature search found more than 10 randomised trials published since the Cochrane review was completed. Nearly all of these trials addressed the effects of progressive resistance and/or aerobic exercise and none reported a Clinical Pilates intervention. One study compared yoga (the closest to Clinical Pilates of the exercise interventions trialled to date), aerobic exercise, and wait-list controls (Oken et al 2004). Unfortunately, the study by Oken et al (2004) contributed little to our understanding of the possible effects of Clinical Pilates type exercise because it was underpowered and the primary outcomes of the study (attention) were not of interest in this case study.
Clinical Pilates, an adaptation of traditional Pilates, is currently a 'fashionable' approach to core stability exercise. Kibler et al (2006) defined core stability as "the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities" (Kibler et al 2006, p189). More broadly, core stability is assumed to be pivotal in all physical activity because it provides a stable base for movement of the head and limbs.
Traditional Pilates is a conglomerate of exercises derived from gymnastics, boxing, self-defence and dance developed by Joseph Pilates in the 1920s to 1960s with the aim of improving his health/well-being and muscle strength (Levine et al 2009). Clinical Pilates adapts the traditional Pilates exercises for the conditions, impairments and symptoms presenting in a rehabilitation environment. Six core principles of Pilates exercise are to: (1) make sure the core is stable before moving the limbs; (2) be mindful throughout the movement to make sure the correct muscles are working; (3) complete the whole exercise correctly; (4) concentrate mentally throughout each exercise; (5) inhale and exhale in prescribed patterns to assist movement; (6) connect one movement with another to get movement 'flow' (Levine et al 2009). Initially Pilates exercises target the trunk and pelvic muscles, particularly the transversus abdominis muscle. Exercise progression is achieved with more complex movements, movement against gravity, exercising on an unstable surface, and movement resisted by free weights or other Pilates apparatus (Bliss and Teeple 2005, Levine et al 2009, Willardson 2007).
The literature contains a growing number of reports of Pilates type exercises for a range of musculoskeletal conditions. However, a text word search of Medline (1996 to present) combining multiple sclerosis or stroke or head injury or brain injury or Parkinsons and Pilates found just one paper. King and Horak (2009) described the development of an exercise programme that could theoretically delay mobility disability in people with Parkinson's disease, and one component of the programme was derived from Pilates exercises (King and Horak 2009). Thus, at present we do not know what the effects of Clinical Pilates for people with MS or other common neurologic conditions are.
Case studies may be considered observational research. We contacted the Lower South Regional Ethics Committee to determine if ethical approval was needed. Ethical approval was not required because the care episode was complete at the time of the case review, usual (not experimental) care was provided for the patient, and only the usual clinical data (no additional data) were collected. The patient gave written informed consent for publication of the case report.
The patient was a late middle-aged woman with an 11 year history of MS-like symptoms. Her first symptom was variable left leg weakness noticed with walking; especially "tripping" when walking and "catching" the left foot on stairs. Sensory disturbances appeared two years later with paraesthesia in both feet and hands, and trunk numbness from the waist down; these partially resolved but continued to fluctuate and were worst on the left. Around the time of her first sensory symptoms the patient also noticed blurred vision in the left eye, and bothersome urinary urgency, frequency and occasional urinary incontinence. Magnetic resonance imaging showed lesions in the periventricular white matter around the trigones of both lateral ventricles and an increased signal in the left cerebral peduncle extending into the superior pons. These changes were considered consistent with demyelination and a neurologist diagnosed probable relapsing-remitting MS.
The relapse that precipitated the treatment reported here was characterised by five weeks of increasing fatigue, deteriorating walking and balance necessitating sick leave from work. Following initial outpatient assessment by a member of the interdisciplinary rehabilitation team, the patient was referred to an occupational therapist (for fatigue management, equipment assessment and return to work planning) and a community physiotherapist (to improve balance, walking and overall fitness, and to reduce the risk of falling). After several physiotherapy treatments the patient was referred to the continence service with bothersome urinary symptoms. The continence care and outcomes are reported separately (Hay Smith et al 2010).
There was no other relevant medical history although a family history indicated that the patient's aunt had MS. Medications included oxybutynin chloride 5 mg twice daily (a bladder antispasmodic), vitamin B12 injections, iron tablets and complementary therapies (evening primrose oil and other dietary measures). The patient did not meet Ministry of Health funding criteria for prescription of Beta Interferon based on insufficient disability and too few relapses. The patient lived with her spouse in their own accessible home.
At the time of assessment the patient was on sick leave from her full-time work. Nevertheless, the patient could complete all other activities of daily living and she was independent with all transfers (including on and off the floor). A perching stool was used for some activities (such as meal preparation) due to a combination of decreased balance and increased fatigue with standing. The physiotherapist observed a heel to toe walking pattern with small steps, the right foot inverted more than the left, and a bilateral decrease in hip and knee flexion during swing phase of gait. The patient had a left foot drop when fatigued, and although she had a walking stick she preferred not to use it because she did not like "how it looked".
As the patient was referred with balance and walking deficits the physiotherapist chose a number of familiar balance and walking measures used in her current practice. It was only later during the case review that the physiotherapist realised her choice of measures was more influenced by investigating the extent of impairment during assessment than evaluating treatment outcome. The consequences of the physiotherapist's choice are considered in the discussion.
Baseline measures of static balance were the Romberg Test (Romberg 1853) and the Frailty and Injuries Cooperative Studies of Intervention Techniques (FICSIT) (Rossiter-Fornoff et al 1995). Postural sway was measured by using the modified Clinical Test of Sensory Integration and Balance (CTSIB) (Shumway-Cook and Horak 1986). The Romberg Test is a series of self localisation tests that examines vestibulospinal function. The patient stands with the eyes alternately open and closed, with the feet apart and together, for a timed period (in this case 30 seconds). In an extension of the Romberg test, the FICSIT evaluates the ability to maintain balance for at least 10 seconds with feet in parallel, semi-tandem, tandem and one-legged stances. The CTSIB is a series of tests repeated while standing on a firm then a compliant surface (i.e. the floor and foam mat respectively) with the eyes open and closed for 30 seconds at a time to investigate the influence of vestibular, somatosensory and visual inputs on postural control.
All three measures were scored as achieved or not achieved. The baseline (T0) data showed no balance deficits in normal standing, but when the base of support was reduced with tandem or one leg stances the patient was unstable (Table 1). The inability to balance with eyes shut when standing on foam (CTSIB test) suggested a vestibular disturbance; standing on the foam with closed eyes alters somatosensory and eliminates visual input.
A single measure of dynamic balance, the Dynamic Gait Index (DGI) was used (Shumway-Cook and Wollacott 1995). The DGI assesses functional balance during eight increasingly complex gait tasks and is scored from zero (none) to three (severe) for each task. A score of 19 or less indicates an increased risk of falling in older adults (Shumway-Cook et al 1997). However, later work by Cattaneo and colleagues (2006) in people with MS reported a cut off score of 12 for increased risk of falls although this test had only moderate ability to discriminate fallers and non-fallers (sensitivity 45% and specificity 80%) (Cattaneo et al 2006). The patient's baseline DGI score (Table 1, [T.sub.0]) did not suggest an increased falls risk using either cut-off.
Two walking measures were used. First, the Ten Metre Walk Test is a timed 10 metre walk (with an extra two metres at each end to eliminate acceleration and deceleration) at the patient's preferred speed; walking aids are permitted if usually required (Wolfson et al 1990). Gait velocity (in metres per minute), cadence (steps per minute) and stride length (metres) are calculated (Table 1, [T.sub.0]). At assessment all three scores were outside the 95% confidence intervals for these variables in healthy women of a similar age (Oberg et al 1993). However, the scores were within one and a half standard deviations of the mean scores for these variables in a random sample of community dwelling ambulatory MS patients in Sweden (Einarsson et al 2006).
The Six Minute Walk Test (6MWT) measured exercise capacity. This test was originally developed in people with respiratory and cardiac conditions (Butland et al 1982). It is sensitive to reduced walking capacity in people with MS compared to normal controls (Savci et al 2005). In the 6MWT the patient walks as quickly as possible for six minutes between two fixed points 20 metres apart; total distance (metres), and the number and duration of any rests (to allow for fatigue), is recorded. No baseline score was obtained as the patient "tripped" and fell during the test and was unable to continue.
Joint range of motion, muscle strength and coordination were assessed using goniometry, the Oxford Scale, and finger-nose-finger test (upper limb) and heel-shin test (lower limb), respectively.
The observed impairments were grade four muscle strength of the left foot and ankle, decreased coordination on heel to shin testing on the left, and reduced co-ordination of the left arm with finger to nose to finger testing (data not tabled).
Physiotherapy treatment goals
The patient and physiotherapist negotiated the treatment goals (Table 2) within the framework of the International Classification of Functioning and Disability (World Health Organization 2002). Impairments, activity limitations and participation restrictions were identified.
The patient was visited at home. Treatment began with a muscle strengthening programme using Rep Band [R] and balance exercises adapted from the tests described in Table 1. After two weeks the patient reported that she was not motivated by the prescribed exercises and requested an alternative programme. The physiotherapist suggested Clinical Pilates as another form of exercise for balance and strengthening. This alternative appealed to the patient; she had previously enjoyed yoga and she thought Clinical Pilates was similar.
The Clinical Pilates home programme comprised 30 minutes of mat exercises each morning targeting the upper, middle and lower trunk (principally abdominal and pelvic floor muscles), the upper limb (particularly biceps and triceps), and lower limbs (mainly the hip abductors, hip extensors, and knee extensors) (Table 3). The 30 minute programme fitted the patient's daily routine, and did not lead to fatigue. All exercises incorporated a contraction of the transversus abdominis muscle. Movements were performed slowly, concentrating on quality of movement, with six repetitions of each exercise. At each home visit the physiotherapist gave feedback, verbally and by tactile cues, to correct movements. The exercise programme was progressed as appropriate.
The physiotherapist visited for an hour once a week for one month, then fortnightly for three months. After this the balance and walking measures were repeated (Table 1, [T.sub.1]), and again after a further three months of unsupervised home exercise (Table 1, [T.sub.2]). Table 1 shows that there was no change in static or dynamic balance measures, although walking speed and distance had improved somewhat. The most important self-reported changes that the patient attributed to an improved sense of movement control were an overall sense of well-being (e.g. less anxiety about the future and feeling more able to cope with her mood and current situation), increased social confidence (e.g. improved walking and balance enabled her to "go out" without fear of tripping and falling) and a feeling of "more control over my life" (e.g. managing her own activities and coping with others' expectations).
At the seven month physiotherapy review the patient reported a number of falls that she attributed to a progressive left foot drop. The patient had lost confidence in her ability to walk safely and used her walking stick a lot more. The local orthotics department fitted a custom-made ankle foot orthosis (AFO) which resulted in improved walking and confidence as well as no subsequent falls. As she was happy with her exercise programme, and requested no further physiotherapy management, the patient was discharged from physiotherapy.
This case highlighted four issues with outcome measurement that changed the physiotherapist's practice. First, walking function and well-being/quality of life (or conversely symptom impact) are common community physiotherapy treatment goals yet none of the instruments used at the time measured these. Second, the purpose of assessment and outcome measurement is different, and instruments used to investigate impairments during assessment might not be useful as measures of outcome. Third, if treatment goals and outcome measures are not congruent the opportunity to demonstrate change important to the patient is limited. Fourth, measures based solely on therapist observation do not allow the patient to report the value of any changes.
Therefore, post-hoc, we searched MEDLINE for patient reported psychometrically measures of walking function and well-being/quality of life that were developed for or tested in people with MS. We also looked for measures that were appropriate to the range of MS patients typically seen by the community physiotherapy service, and would be acceptable to patients and physiotherapists (e.g. not burdensome or expensive). Below we describe and discuss two measures that met these requirements.
The Multiple Sclerosis Impact Scale (MSIS-29) (Hobart et al 2001) and the Multiple Sclerosis Walking Scale (MSWS-12) (Hobart et al 2003) were developed in the United Kingdom from the same research programme, with the aim to extend patient-based outcome measures for use in MS research. An immediate attraction of these measures was that they were developed specifically for people with MS, and people with MS were involved with their development.
The 29 item Multiple Sclerosis Impact Scale (MSIS-29) began as a 129 item questionnaire, developed from patient interviews and literature review and multidisciplinary health professional opinion (Hobart et al 2001). Factor analysis of responses from nearly 800 people with MS resulted in a 29 item questionnaire with two subscales covering physical (20 items) and psychological (nine items) impact (Hobart et al 2001). The two stem questions are: "in the past two weeks how much has your MS limited your ability to" and "in the past two weeks how much have you been bothered by". The response options for each item are: not at all, a little, moderately, quite a bit, and extremely. Among the physical items are balance, gripping things, difficulties moving indoors, stiffness and spasms. Psychological impact includes limited social and leisure activities, cutting down on work, mental fatigue, anxiety and lack of confidence. High total or subscale scores, indicate greater MS impact.
The MSIS-29 is psychometrically robust. Initial testing demonstrated test-retest reliability, and high internal consistency of items in the scale (Hobart et al 2001). The way the measure was developed indicated good face and content validity. Early investigation of construct validity substantiated the predicted correlations (convergent and divergent validity) with other measures such as generic quality of life, function and demographic characteristics (Hobart et al 2001). The developers of the measure reported few difficulties with floor or ceiling effects, and effect sizes of 0.82 for the physical and 0.66 for the psychological subscales (Hobart et al 2001). The measure was also psychometrically robust in other MS populations and locations (Gray et al 2009, Hoogervorst et al 2004, McGuigan and Hutchinson 2004). The instrument is easy to use, takes five to ten minutes to complete, and there are few missing data (Gray et al 2009, Hobart et al 2001, McGuigan and Hutchinson 2004). For the physical subscale it appears that a minimal clinically important difference (MCID) is eight points or more (Costelloe et al 2007). The MCID for the psychological subscale or total score are not yet established.
The Multiple Sclerosis Walking Scale (MSWS-12) is a 12 item patient-rated measure of walking quality with higher scores indicating greater impact of MS on walking (Hobart et al 2003). The development of the instrument is as described above. The single 'stem' question ("in the last two weeks how much has your MS") is followed by 12 items covering impact on balance, speed, distance, quality and effort of walking, indoor and outdoor walking and so on. Similar to the previous measure, responses for each item include: not at all, a little, moderately, quite a bit, and extremely. Psychometric testing in three studies (including hospital and community based samples of people with MS, and people with primary progressive and relapsing remitting MS) suggested the measure has test-retest reliability (Hobart et al 2003, McGuigan and Hutchinson 2004), internal consistency (Hobart et al 2003, Motl and Snook 2008), is responsive (Hobart et al 2003, McGuigan and Hutchinson 2004) and has no noticeable floor or ceiling effects (Hobart et al 2003, McGuigan and Hutchinson 2004). There is growing evidence of construct validity with strong correlations with related measures, and only weak to moderate correlations with less related measures (Hobart et al 2003, McGuigan and Hutchinson 2004, Motl and Snook 2008). Like the MSIS-29, patients find the instrument easy to use with very few missing data (Hobart et al 2003, McGuigan and Hutchinson 2004).
We are satisfied both these measures would be useful and meaningful in practice because they have been developed and tested in population samples representative of various types and severity of MS, and they are psychometrically robust. A difference of eight points on the MSIS-29 physical subscale is clinically important (Costelloe et al 2007), but it is still not clear how much change in the total MSWS-12 or MSIS-29 scores, or psychological subscale of the MSIS-29, is needed before this becomes important to the patient.
The physiotherapist knew neither of these measures before the case review. Both are now used in her practice, and have been adopted by other members of the community neurorehabilitation team. More broadly, this case review has prompted the physiotherapist to remain critically aware of her choice of outcome measures in all aspects of her practice. As the purpose of community physiotherapy is to help maintain or improve functional status and wellbeing for people with chronic (and sometimes progressive) neurological conditions living in their home community (Chard 2006) the physiotherapist continues to develop her portfolio of measures for activity, participation, wellbeing and quality of life outcomes.
The measurement of outcome for a woman with relapsing-remitting MS who presented to a community physiotherapist with walking and balance deficits did not demonstrate the changes in function and well-being reported by the patient after treatment. Retrospective case review found that the choice of measures lacked congruence with the treatment goals and did not allow for patient-reported outcome. A search for more useful and meaningful measures located the Multiple Sclerosis Impact Scale (MSIS-29) and Multiple Sclerosis Walking Scale (MSWS-12). These are psychometrically robust measures that may have utility for MS patients presenting for community physiotherapy.
* Measures of outcome must be congruent with the aims of treatment, and what is expected to change.
* Outcome measures should be selected for their ability to measure outcome, not because they collect useful information about impairments at baseline assessment.
* It more important to measure activity limitations, participation restrictions, and well-being/ quality of life than impairments as outcomes of treatment in chronic neurological conditions.
* The Multiple Sclerosis Impact Scale (MSIS-29) and Multiple Sclerosis Walking Scale (MSWS12) are psychometrically robust measures with utility for MS patients presenting for community physiotherapy.
We would like to thank the patient who kindly consented to have her case reported and commented on the manuscript.
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Jean Hay-Smith PhD MSc MPNZ
Senior Lecturer in Rehabilitation (1), and Senior Lecturer in Women's Healt h (2)
(1) Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago, Wellington, New Zealand
(2) Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
Debbie Standring BScPhysiotherapy, PGDipPhty(Neurorehabilitation), MPNZ
Southern District Health Board, Dunedin, New Zealand
ADDRESS FOR CORRESPONDENCE
Jean Hay-Smith, Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin, New Zealand. Email: firstname.lastname@example.org. Telephone: +64 3 474 7007 extension 8568; Fax: +64 3 474 7620
Table 1: Outcome measurement Measure Baseline ([T.sub.0]) Eyes open Eyes closed Rhomberg Feet apart [check] [check] Feet together [check] [check] FICSIT Semitandem Left [check] [check] Right [check] [check] Tandem Left [check] X Right [check] X Single leg stand Left X X Right X X CTSIB Feet apart [check] [check] Feet together [check] X DGI (out of 24) 20 10 MWT Velocity (m/min) 42.9 Stride length (m) 0.8 Cadence (steps/min) 51.6 6 MWT not completed (fell) Measure 4 months ([T.sub.1]) Eyes open Eyes closed Rhomberg Feet apart [check] [check] Feet together [check] [check] FICSIT Semitandem Left [check] [check] Right [check] [check] Tandem Left [check] X Right [check] X Single leg stand Left X X Right [check] X CTSIB Feet apart [check] [check] Feet together [check] X DGI (out of 24) 20 10 MWT Velocity (m/min) 60 Stride length (m) 1.05 Cadence (steps/min) 57.1 6 MWT not completed (fatigue) Measure 7 months ([T.sub.2]) Eyes open Eyes closed Rhomberg Feet apart [check] [check] Feet together [check] [check] FICSIT Semitandem Left [check] [check] Right [check] [check] Tandem Left [check] [check] Right [check] X Single leg stand Left X X Right X X CTSIB Feet apart [check] [check] Feet together [check] X DGI (out of 24) 20 10 MWT Velocity (m/min) 54.5 Stride length (m) 1 Cadence (steps/min) 54.5 6 MWT 280 metres Key: FICSIT=Frailty and Injuries Cooperative Studies of Intervention Techniques, CTSIB=Clinical Test of Sensory Integration and Balance, DGI=Dynamic Gait Index, 10 MWT=10 metre walk test, 6 MWT=6 minute walk test Table 2: Treatment goals Impairment Activity Participation Increase left leg Be able to carry out Be able to strength activities of daily living return to work full time Improve balance Be able to garden Decrease falls Be able to go for walks Table 3: Clinical Pilates exercise programme Weeks Exercises 1 Overhead arms (supine lying), single leg lifts (supine lying) 2 As week 1 and added: single leg lifts with a straight leg (modified version) (supine lying) double leg lifts (modified version) (supine lying) single leg lifts with arms in air (modified version (supine lying) 3 As week 2 and added: overhead arms with curl forwards (modified version) (supine lying) 4 As week 3 and added: preparation (modified hundred version) (supine lying) 5 As week 4 and added: swimming (modified version) (prone lying) cat stretch (4 point kneeling) partial roll down (long sitting) partial roll down oblique (long sitting) standing roll down (standing) 6 to 10 As week 5 11 to 16 As week 5 and added: stretches (modified version) (long sitting) up/down and front/back side leg lifts (side lying) 17 to 28 As week 11 to 16, as unsupervised home programme
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