The effectiveness of pilates on balance and falls in community dwelling older adults

RANDOMIZED CONTROLLED TRIALThe effectiveness of Pilates on balance and falls in community dwelling older adults a School of Physical Therapy, University of the Incarnate Word, USA b Pyra

RANDOMIZED CONTROLLED TRIAL

The effectiveness of Pilates on balance and

falls in community dwelling older adults

a

School of Physical Therapy, University of the Incarnate Word, USA

b

Pyramid Plaza Physical Therapy, USA

Received 31 October 2015; received in revised form 16 January 2016; accepted 23 January 2016

KEYWORDS

Balance;

Falls;

Pilates;

Physical therapy;

Older adults;

Balance confidence

Summary Purpose: The purpose of this study was to determine whether Pilates is more effective than traditional strength and balance exercises for improving balance measures, bal-ance confidence and reducing falls in community dwelling older adults with fall risk Method: Thirty-one participants with fall risk were randomly assigned to the Pilates group (PG)

or the traditional exercise group (TG) Both groups participated in 12 weeks of exercise, 2 times/week for 1 h

Results: There was significant improvement in the Fullerton Advanced Balance Scale for both the PG (mean differenceZ 6.31, p < 05) and the TG (mean difference Z 7.45, p Z 01) The

PG also showed significant improvement in the Activities-Specific Balance Confidence Scale (mean differenceZ 10.57, p Z 008)

Conclusion: Both Pilates and traditional balance programs are effective at improving balance measures in community dwelling older adults with fall risk, with the Pilates group showing improved balance confidence

ª 2016 Elsevier Ltd All rights reserved

* Corresponding author Pilates and Physical Therapy Center of San Antonio, 211 Post Oak Way, San Antonio, TX, 78230, USA Tel.: þ1 210

410 0751.

E-mail addresses: sharonjosephsPT@gmail.com , josephs@uiwtx.edu (S Josephs).

http://dx.doi.org/10.1016/j.jbmt.2016.02.003

1360-8592/ ª 2016 Elsevier Ltd All rights reserved.

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Falls are a common problem in older adults There are

significant consequences from falling including injury,

decreased mobility and independence, increased health

care costs and psychological concerns from fear of falling

(Centers for Disease Control and Prevention, 2015a,b;

Kannus et al., 2005; Powell and Myers, 1995) TheCenters

for Disease Control and Prevention (2015a,b) reported

that in 2013 in the United States, 2.5 million nonfatal fall

injuries in older adults were treated in the emergency

department and over 734,000 of those were hospitalized

The direct medical costs of falls in older adults, adjusted

for inflation, were over $34 billion in the United

States (Centers for Disease Control and Prevention, 2015a)

Powell and Myers (1995) reported a study where 57% of

older adults living in the community reported fear of falling

and 30% reported avoidance of activities due to fear

Avoidance of activities leads to further physical frailty and

loss of independence As the population is aging, there is a

need to develop effective fall prevention programs

(Centers for Disease Control and Prevention, 2015a; Kannus

et al., 2005)

The 2012 Cochrane Review concluded that multiple

component group exercise significantly reduced rate of falls

(rate ratio 0.71, 95% CI, 0.63 to 0.82; 16 trials and 3622

par-ticipants) and risk of falling (risk ratio 0.85% 95% CI 0.76 to

0.96; 22 trials, 5333 participants) in older adults living in the

community (Gillespie et al., 2012) A meta-analysis by

Sherrington et al (2008)reported that the pooled estimate of

the effect of exercise was that it reduced the rate of falling by

17% (rate ratio 0.83, 95% CI 0.75e0.91, 44 trials, 9603

partic-ipants) A meta-regression analysis showed that the greatest

relative effects were seen when the balance portion of the

program was challenging, the dose of exercise was greater

than 50 h for the entire program, equating to twice a week for

25 weeks, and the program did not include a walking

compo-nent The inclusion of these relatively important components

improved the reduction in rate of falls to 42% (rate ratio 0.58,

95% CI 0.48e0.69) The optimal exercise prescription,

how-ever, has not yet been determined (Gillespie et al., 2012;

Sherrington et al., 2008; Arnold et al., 2008) Also, patients

need to continue exercise programs long term; otherwise the

benefits disappear (Wolf et al., 2001)

A problem discussed in the literature is the difficulty

recruiting and retaining older patients in a moderate

in-tensity exercise program (Means et al., 2005) Pilates is an

exercise method that is well suited for the older adult The

equipment is adaptable and the intensity can be modified

to assist or resist depending on the level of the patient

(Anderson and Spector, 2000) The potential benefits of

Pilates include: improved posture, core and extremity

strength, flexibility, motor control, balance and body

awareness (Endelman, 2009)

Research using Pilates’ equipment to improve balance in

older adults, however, is still in its infancy stage, with only

4 studies reported and none specifically on patients with

fall risk (Kaesler et al., 2007; Siqueira Rodrigues et al.,

2010; Bird et al., 2012; Bird and Fell, 2014).Kaesler et al

(2007)reported a study with a small sample size of 8 high

functioning subjects, aged 66e71 and no control group and

showed an improvement in the Timed Up and Go (TUG) and balance sway measures following a Pilates-inspired exercise program, 2 times per week for 8 weeks.Siqueira Rodrigues

et al (2010) reported a randomized controlled trial of 52 women, aged 60e72, where the Pilates group (n Z 25) showed improvement in the Tinetti test for balance and the Latin America Development Group for Elderly score of personal autonomy compared to a no treatment group of age-matched controls (n Z 27) Their intervention was 2 times per week for 8 weeks Bird et al (2012)reported a randomized crossover design trial of 32 subjects over the age of 60 The Pilates exercises were performed for 5 weeks They found an improvement in TUG, Four Square Standing test and balance sway measures pre to post Pilates for each group, but no difference between the groups They suggested that the lack of between group differences might

be due to the small sample size and/or the crossover design Bird and Fell (2014)then did a follow-up study 12 months after the initial intervention Postural sway, dy-namic balance and functional improvements seen after the initial Pilates training were maintained 12 months later in all participants, with increased benefits in participants that continued Pilates exercise

Balance confidence refers to a person’s perception of their balance ability and is important to study as low bal-ance confidence leads to avoidbal-ance of activities and phys-ical frailty.Kendrick et al (2014)in a Cochrane review of 24 studies and 1692 participants found a small to moderate reduction in fear of falling following an exercise interven-tion (standardized mean differences 0.37, 95% confidence interval 0.18 to 0.56) without increasing the frequency of falls Six of the 24 studies used the Activities-Specific Bal-ance Confidence Scale (ABC), a questionnaire that mea-sures balance confidence

There are many limitations in the current balance liter-ature Many traditional balance studies fail to describe their exercise protocols in enough detail to allow them to be reproduced (Arnold et al., 2008) Pilates studies have yet to investigate the effectiveness of Pilates exercise using Pilates equipment to reduce rates of falls, improve balance confi-dence, study patients with documented fall risk or compare Pilates to a traditional strength and balance program The literature indicates that this older population needs to continue the program long term (Wolf et al., 2001) How-ever, balance exercise programs provided by physical ther-apists have difficulty meeting the current recommended exercise dosage under the current funding model (Shubert,

2011) Group based therapy is billed at a fraction of the rate of individual therapy, and Pilates is a form of exercise that patients can continue following discharge

The purpose of this study was to investigate the effec-tiveness of Pilates group exercise versus traditional strength and balance group exercise for improving balance, reducing falls and improving balance confidence in com-munity dwelling older adults with fall risk

Methods and procedures

This study was a single blind randomized controlled trial The study was granted approval by the University of the Incarnate Word Institutional Review Board

Subjects and screening procedure

Thirty-nine subjects, 65 years of age and older living in the

community, were recruited through local physicians in the

area, seniors groups at churches and community centers,

word of mouth and notices posted in the local libraries

Potential subjects signed an informed consent form and

underwent a screening evaluation by a blind student or

volunteer assessor The assessors were trained in the

assessment procedure and the order of testing was

stan-dardized The screening included a demographic

question-naire, fall history and medical history form, blood pressure

(BP) and heart rate (HR), Timed up and Go (TUG), Fullerton

Advanced Balance Scale (FAB) and Activities-Specific

Bal-ance Confidence Scale (ABC) A fall was defined as an

un-expected event in which the participant came to rest on

the ground, floor or lower level (Lamb et al., 2005)

Inclusion criteria were: 65 years of age or older living in

the community; impaired balance as defined by at least one

of the following: a fall in the past year, TUG>13.5 s or FAB

25; and ability to follow instructions as assessed by the

ability to complete the questionnaires without assistance

Subjects were not screened for ability, such as use of an

assistive device for walking, but only that they met the

inclusion criteria of history of fall or meeting the cutoff for

balance compromise with the TUG or FAB Exclusion criteria

included: participation in a Pilates program within the last

year; significant health problem that would keep the

sub-ject from participating; vestibular conditions and

progres-sive neurological conditions Subjects were excluded if they

were not community dwelling, e.g if they lived in an

institution such as an assisted living facility

Outcome measures

The TUG is a widely used test of balance and has been

found to be reliable and valid and normative values have

been reported for community dwelling older adults (Steffen

et al., 2002; Lin et al., 2004) A TUG>13.5 s is associated

with fall risk (Shumway-Cook et al., 2000) The TUG is

considered to be appropriate for older people who are

frailer or who use walking aids (Lin et al., 2004) The test

was performed by measuring the time it took the subject to

stand up from an armchair, walk a distance of 3 m at their

usual pace with their usual assistive device, turn, walk back

to the chair and sit down (Podsiadlo and Richardson, 1991)

The FAB is a newer test and a more comprehensive

assessment of the multiple dimensions of balance as

iden-tified in the systems theory of postural control (Rose et al.,

2006; Sibley et al., 2015) The Berg balance scale is a more

widely used balance test, but it has been criticized for its

ceiling effect in community dwelling older adults

(Pardasaney et al., 2012) The FAB includes more difficult

static and dynamic balance tasks to make it less prone to

ceiling effects and more sensitive to evaluate the

effec-tiveness of an intervention conducted in a higher

func-tioning group of patients (Rose et al., 2006) It has been

shown to be reliable and valid, but normative values have

not been reported (Rose et al., 2006) A score of less than

or equal to 25 has been associated with fall risk (Hernandez

and Rose, 2008) The FAB was performed as per the

documented instructions (Rose, 2008), with one exception

In the reactive postural control test where the assessor removes their hand support from the patient to test their postural reaction, the documented test does not inform the patient that the assessor will be removing their hand We chose to inform our patients that we would be removing our hand, but not when in order to maintain the patients’ trust and for patient safety

The patient also completed the ABC, a 16-item ques-tionnaire that is a psychological measure of balance confi-dence in performing specific activities (Powell and Myers,

1995) Each item is scored from 0% (no confidence) to 100% (full confidence in the ability to perform the activity without losing balance) The ABC has been shown to be reliable and valid (Powell and Myers, 1995) Scores on the ABC showed an association with tandem stance time (Cyarto et al., 2008), one-leg stance time (Cyarto et al.,

2008), TUG (Cyarto et al., 2008; Hatch et al., 2003) and Berg Balance Scale (Hatch et al., 2003)

Procedures

Patients that met the inclusion and exclusion criteria were randomly assigned to either the Pilates exercise group or the traditional exercise group using a randomization table Groups were separated based on the participant group allocation Both groups exercised 60 min, 2 times per week for 12 weeks Participants that missed a session due to illness or scheduling conflict made up the missed session, such that each subject completed 24 sessions of exercise The groups were a maximum of 4 participants The exercise classes were taught by 1 of 2 physical therapists, both Board Certified Clinical Specialists in Orthopaedics and comprehensively certified Pilates instructors The therapist supervising a group continued with that group for the entire

12 weeks as much as possible, with the other physical therapist substituting on occasion Both therapists taught both Pilates’ groups and traditional groups over the course

of the study Additional student volunteers assisted with spotting for safety purposes

The Pilates group performed exercises as perAppendix 1 The Pilates program utilized the Reformer, Cadillac and Chair apparatus Exercises were individually made more chal-lenging by altering spring tension, reducing base of support, adding complexity to the exercise and altering surface sta-bility Each exercise was performed for 10 repetitions The traditional group performed exercises as per Appendix 2 Elastic resistance bands, ankle weights, foam balance pads, boxes of varying heights and half foam rollers were props that were used with the traditional group Repetitions of the resistance exercises were progressed individually When the patient could perform 20 repetitions, the resistance was increased: elastic resistance bands were progressed to the next color; ankle weights were progressed by 0.5 pounds; box heights were progressed by 2 inches All exercises for both groups were performed in a challenging but pain-free way Modifications were made to exercises in consideration of a patient with spine or peripheral joint pain by reducing the range of motion performed during an exercise, reducing the resistance or changing position Occasionally, an exercise was discontinued if a pain-free modification could not be

found All patients were asked to work at level 12e14 on the

Borg Perceived Exertion Scale, which rates exertion

subjec-tively from 6 to 20 (Borg, 1970) It has been shown to be a valid

measure of exertion (Day et al., 2004; Eston and Evans, 2009)

On non-program days and daily following discharge

from the program, patients were asked to perform home

exercises The same 15e20 min home exercise program

was given to both groups in order to minimize

confound-ing effects of the home exercise program The home

lower extremity strength exercises were drawn from both

Pilates mat exercises and traditional physical therapy

exercises The home program also included standing

bal-ance exercises See Appendix 3 Patients were given a

home exercise handout and a monthly calendar to record

their home exercise participation This was done in

anticipation of the patients performing their home

exer-cises on non-program days, and continuing for 8 weeks

following discharge from the program; their exercise dose

would then exceed the recommended 50 h The calendar

was also used to record falls during the 1-year follow-up

after discharge

The follow-up assessment occurred following

comple-tion of the 12 weeks of exercise BP, HR, the TUG, FAB and

ABC were re-tested by an assessor who was blinded to

group assignment, using the standardized testing

procedure

Following completion of the program, the patients were

telephoned once per month to obtain information on any

falls that occurred during the previous month The patients

were also asked about their current participation in all types of exercise (home program and other exercise such as walking and group fitness classes) This data is currently being collected and will be reported in a follow-up study

Data analysis

All data was analyzed at the 0.05 alpha level using Microsoft Excel and SPSS version 19 software The pre-test to post-test within group, between group, and interactions data were analyzed with paired t-test, independent t-test and

2 2 factorial ANOVA respectively

Results

Thirty-one patients met the inclusion criteria and 8 sub-jects were excluded due to lack of fall risk as defined above Seven patients dropped out of the study and the remaining 24 patients completed all 24 sessions of exercise and the follow-up evaluation SeeFig 1

Of the 24 participants, 18 were female and 6 were male The age range was 65e85, with an average of 75.6 in the Pilates group and 74.5 in the traditional group Ten out of

13 patients in the Pilates group and 8 out of 11 in the traditional group had fallen in the past year Three patients

in each group met the inclusion criteria only because of the fall they had in the past year, while not meeting the fall risk criteria on the TUG and FAB All subjects were similar at Figure 1 Summary of participants

baseline for age (p Z 693), sex for males and females

(p Z 094), education (p Z 812), number of falls

(pZ 703) and co-morbidities (p Z 274) However, there

were differences in number of males (38.46% of PG, 9.1% of

TG) and amount of activity (77% physically active in PG, 45%

physically active in TG) between groups at baseline.Table 1

presents the demographic data In the traditional group,

there was a significant difference (mean differenceZ 7.45,

pZ 01) between the pre-test and post-test scores of the

FAB In the Pilates group there was a significant difference

in the pre-test and post-test scores of the FAB (mean

difference Z 6.31, p < 05) and the ABC (mean

difference Z 10.57, p Z 008) respectively.Table 2

pre-sents the outcome data There were no significant between

group differences on any of the selected tests A 2  2

factorial ANOVA showed no interaction between groups for

pre and post intervention scores, and type of intervention

Follow-up data on number of falls is still being collected for

future analysis

Discussion

Both the Pilates and the traditional group improved in their FAB scores, with neither group showing significant improvement over the other The traditional balance ex-ercise literature indicates that effective fall prevention exercise programs include multiple components and chal-lenging balance exercises, so both of the exercise programs

in this study were designed to include core and lower ex-tremity strength, flexibility and challenging balance exer-cises Both exercise groups were taught with an emphasis

on whole body alignment and core stabilization, similar to Pilates’ principles of exercise Therefore, it is not surprising that the study found no between group differences The Pilates group showed improvement in balance con-fidence, as measured by the ABC, while the traditional group did not This is an interesting finding considering that the balance measure, FAB, improved in both groups, with neither group showing significantly more improvement than the other One possible explanation for this is that the patients in the Pilates group had to learn new skills on foreign equipment, and the learning of this novel skill lead

to improved balance confidence

Means et al (2005)discussed the problem of attrition in balance studies Their study reported a 17% attrition rate during the intervention and discussed the difficulty in recruiting and retaining older patients in a moderate in-tensity exercise program This study had a 19% attrition rate in the Pilates group: 2 patients dropped out prior to starting any exercise and 1 dropped out due to a family crisis There was a 27% attrition rate in the traditional group: 2 of the patients dropped out following 2 weeks or less of exercise, 1 dropped out as he did not feel he was improving and 1 dropped out due to a knee injury that happened while on vacation Studies have shown that the benefits of exercise quickly diminish once the program is completed (Wolf et al., 2001) Therefore, there is a need to develop programs that the patients can continue long-term

as a wellness program Long-term commitment to exercise also means that patients need to enjoy the program It is the experience of the investigators that Pilates is an exer-cise method that older adults enjoy and may offer an option for patients to participate in a program that can be initi-ated as a physical therapy intervention and continued long term as a wellness program

Shubert (2011)discussed the difficulty of providing the recommended 50-h dose of strength and balance exercises in physical therapy due to the current funding models Group based exercise is more cost-effective than one-on-one therapy as it is billed at a fraction of the rate However, group exercise presented a problem as challenging balance exercises also meant that there was a risk of falling during the exercise Additional student volunteer spotters were used to ensure the safety of the patients Group based programs are also social and this motivating factor may improve adherence compared to home programs (Phillips et al., 2004)

The addition of home exercises has also been suggested

as a method to try to reach the recommended dose (Martin

et al., 2013) and home exercises were included for both groups on non-program days as well as following discharge from the program

Table 1 Demographic characteristics of participants at

baseline for both groups

Pilates group

Traditional group Mean SD age, years (range) 75.6 6.2

(66e85)

74.5 6.9 (65e83)

Mean height, inches (range) 65.2

(58e72)

63.8 (58e70) Mean weight, pounds (range) 158

(107e230)

169 (101e235) Education (# of patients)

Less than high school 1 0

High school graduate 0 2

Some college/technical

school

Living situation (# of patients)

Employment

# of participants working 4 2

Walks with an assistive device

Exercise regularly

Mean SD number of falls

(range)

1.5 1.3 (0e4)

1.8 2.2 (0e7)

# that fell in the past year 10 8

Mean SD # of comorbidities

(range)

2.7 1.5 (0e5)

3.8 3.0 (1e10) Mean SD # of medications

(range)

5.8 (0e13) 3.8 (1e9)

Many previous studies failed to describe their exercise

program in enough detail to allow it to be reproduced

(Arnold et al., 2008) This creates problems for clinicians

trying to compare programs and for clinicians attempting to

incorporate evidence-based practice The programs in this

study are described in detail, although repetitions,

resis-tance and balance challenge were individually determined

depending on the patient’s level such that the patient

would work at a moderate intensity

Study limitations

The exclusion criteria were limited to make the study

generalizable However, this did end up including some

subjects with limited ability to improve due to their

comor-bidities: one patient had a quadriceps rupture with a failed

repair and one had weakness from post-polio syndrome, both

unrelated to the study There were also 6 patients that

qualified for the study only because of a fall in the past year

Their TUG scores were initially low and their FAB scores were

initially high, with potentially limited ability to improve

A limitation of the study is the small sample size,

potentially under powering the study and the lack of a third

control group that received no intervention Another

limi-tation was that, although the subjects were followed by

phone calls for 1 year, the patients were not re-tested at

1-year follow up Despite randomization of subjects to

groups, two variables showed differences at baseline that

may have affected the results Although not statistically

significant (pZ 094), there were more males in the PG

(nZ 5) than the TG (n Z 1) There were also more regular

exercisers (p Z 113) in the PG (n Z 10) than the TG

(n Z 5) Repeating the study with a larger sample size

might minimize this effect

The FAB was chosen because it is a higher level balance test

and not subject to the ceiling effect that the TUG and BERG

are criticized for However, it is a newer test, and there is less

research available on it compared to the other tests used

A final limitation is cost effectiveness of Pilates-based

vs traditional rehabilitation Although Pilates equipment is

potentially costlier at the outset compared to free weights

and bands, the improvement in the ABC scale could

potentially justify the cost of Pilates apparatus The ABC

scale is proven to be a valid predictor of balance

impair-ment and falls in older adults (Powell & Myers, 1995; Lajoie

and Gallagher, 2004) In addition, the initial Pilates

research literature indicated benefit in less than 50 h of

total exercise dose, thus improving the cost effectiveness

by requiring fewer hours of intervention to improve balance

in older adults (Bird et al., 2012)

Future research

Future research ideas include having 3 groups, Pilates, traditional and a control group and following the results longer term The initial Pilates research in healthy older adults indicates that balance can be improved in less than the 50 h of recommended exercise dosage This study in-dicates that balance and balance confidence can be improved in less than 50 h in patients with fall risk A future research study should investigate this further in adults with fall risk The effectiveness of these programs to reduce rates of falls will be reported at a later date

Conclusions

The results of this study suggest that both a short-term Pilates program and a traditional exercise program with components of strength, flexibility and balance exercises, supplemented with home exercises, can improve balance in patients with fall risk The Pilates program improved bal-ance confidence compared to the traditional program

Conflicts of interest

The authors have no conflicts of interest

Funding sources

None

Acknowledgments

Thank you to the students and volunteers that performed assessments and assisted with spotting during class Thank you to the Physical Therapy Department at University of the Incarnate Word for their encouragement and support

Appendix 1

Pilates Group 60 min;

Beginner exercises are written in regular font; Pro-gressions are written in italics

Table 2 Outcome variables at baseline and post intervention for both groups

Test Pilates group

pre-test average SD

Pilates group post-test average SD

Mean difference

p-value

Traditional pre-test average SD

Traditional group post-test average SD

Mean difference

p-value

TUG (seconds) 14.38 6.54 13.07 4.59 1.31 NS 13.16 6.39 11.26 2.89 1.9 NS FAB (0e40 points) 18.54 10.08 24.85  12.54 6.31 <.05 19.82  8.86 27.27 6.41 7.45 01 ABC (0e100 points) 63.08  24.08 73.65  22.47 10.57 008 70.18 16.02 74.91  18.87 4.73 NS

Abbreviations: TUG, Timed up and Go test; FAB, Fullerton Advanced Balance Scale; ABC, Activities-Specific Balance Confidence Scale;

SD, Standard deviation; NS, not significant.

Footwork double leg and single leg (3 springs) (Fig 2)

Bridge (generally 3 springs, progress to lighter/less

springs)

Bridge with press away

Feet in straps (2 springs)

Scooter (2 springs)

Scooter without arms (1 spring)

Seated leg press (1e2 springs)

Figure 2 Footwork on the Pilates reformer

Chair:

Standing leg press forward and lateral (reduce arm

support; add standing on unstable surface) (Fig 3)

Supine hip extension

Prone scapular series

Figure 3 Standing leg press forward on the Pilates Chair

Cadillac:

Feet in straps supine, single leg; progress to double leg;

progress to side lying (Fig 4)

Breathing; progress to single leg

Assisted squat standing Curl up

Upper extremity shoulder pull down, retraction, push up in standing using roll down bar; and punch using handles; vary base of support to narrow, tandem, add stepping to punch

Figure 4 Side lying feet in straps on the Pilates Cadillac

Appendix 2

Traditional Group 60 min Beginner exercises are written in regular font; pro-gressions are written in italics

Supine:

Ball squeeze adduction with bridge Resistance band abduction with bridge Single leg bridge with increasing hold times Straight leg raise (progress weights) Short arc quads (progress weights) Side lying:

Clam (external rotation) Clam with band at knees Clam with band, propped on elbows Side lying abduction with weights (progress weights) Side lying adduction with weights (progress weights) (Fig 5)

Figure 5 Side lying hip adduction with ankle weights

Wall slides (progress depth)

Step up laterally (reduce hand support, increase height

of step)

Step up forward (reduce hand support, increase height

of step)

Forward reach and side reach (increase excursion)

Leg kicks front, side and back with resistance band

(reduce hand support) (Fig 6)

Sit to stand

Standing with increasingly narrow base of support: feet

together

Tandem stand, single leg stand (Fig 7)

Obstacle course with steps, foam pads and reaching

Stretches

Hip flexor

Piriformis

Gluteal

Hamstring

Gastrocnemius

Figure 6 Standing leg kicks, hip flexion using resistance

band

Figure 7 One leg standing balance exercise

Appendix 3

Home exercises Beginner exercises are written in regular font; Pro-gressions are written in italics

Ball squeeze adduction with bridge Resistance band abduction with bridge Single leg bridge

Clam (external rotation), adding band at knees when able, propping on elbow (Fig 8)

Wall slides Standing narrow base of support, progressing to tandem and single leg when able

Figure 8 Side lying clam exercise using resistance band

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