RESEARCH REPORT

Physiotherapy after stroke: To what extent istask-oriented practice a part of conventionaltreatment after hospital discharge?

Torunn Askim, PT, PhD,1,2 Bent Indredavik, MD, PhD,1,2 Astrid Engen, PT,3

Kerstin Roos, PT,4 Tone Aas, PT,5 and Siv Mørkved, PT, PhD6,7

1Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim,Norway2Stroke Unit, Department of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway3Trondheim Rehabilitation Centre, City of Trondheim, Trondheim, Norway4Department of Physiotherapy, City of Trondheim, Trondheim, Norway5Pirbadet Physiotherapy Clinic, Trondheim, Norway6Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science andTechnology, Trondheim, Norway7Clinical Service, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway

ABSTRACT

Researchhas shown that motor training after stroke should be task-oriented. It is still unknown whether thetask-oriented approach is implemented into clinical practice. The purpose of the present study was to surveyto which extent task-specific training was a part of conventional physiotherapy practice given to stroke patientsafter discharge from hospital. This cross-sectional survey was a sub-study of a randomized controlled trial.Physiotherapists treating patients included in the trial were asked to register their choice of treatment accordingto 11 predefined activity categories during the second week after discharge from hospital. Nineteen physiothera-pists treating 46 patients suffering from mild-to-moderate stroke were included. The activities chosen in mostpatients were sit-to-stand (60.9%), balance in standing position (65.2%), walking on even ground (78.3%), andstair climbing (56.5%). Only two patients (4.3%) practiced transfers or balance related to activities of daily living(ADL), such as washing, dressing, and toileting. This study shows that conventional physiotherapy practice for aselected group of Norwegian stroke patients was mainly based on a task-oriented approach, although with verylittle emphasis on training in relation to ADL. Future research is needed to ensure that evidence-based treatmentis given to all stroke patients.

INTRODUCTION

A range of physiotherapy approaches based on differentideas about motor recovery following stroke have beenimplemented into clinical practice (Pollock, Baer, Lan-ghorne, and Pomeroy, 2007). In the 1950s and 1960s,neurofacilitation approaches based on available neuro-

physiological knowledge were developed, includingthe Bobath Concept (Davies, 1999) and the Proprio-ceptive Neuromuscular Facilitation (PNF) approach(Knott and Voss, 1968). In the 1980s, the potentialimportance of motor learning was highlighted (Lee,Swanson, and Hall, 1991; Mulder, 1991; Schmidt,1991) and the Motor Relearning Program (Carr andShepherd, 1987) was developed. The Motor Relearn-ing Program is defined as a task-oriented approachemphasizing trainingof functional tasks suchas transfers,mobility, and activities of daily living (ADL) (Carr andShepherd, 1998). The underlying assumption for the

Address correspondence to Torunn Askim, Department of Neuro-science, Faculty of Medicine, Norwegian University of Science andTechnology, Trondheim, Norway. E-mail: torunn.askim@ntnu.no

Accepted for publication 22 September 2012

Physiotherapy Theory and Practice, 29(5):343–350, 2013Copyright © Informa Healthcare, USA, Inc.ISSN: 0959-3985 print/1532-5040 onlineDOI: 10.3109/09593985.2012.734008

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task-oriented approach is the system theory assuming aninteraction between the task, the person performing thetask, and the context the task is performed within(Shumway-Cook and Woollacott, 2001). Furthermore,the task-oriented approach to intervention focuses on:1) resolve, reduce, or prevent impairments; 2) developeffective task-specific strategies; and 3) adapt functionalgoal-oriented strategies to changing task and environ-mental conditions (Shumway-Cook and Woollacott,2001). However, task-oriented practice is mainly basedon a set of implicit and explicit assumptions fromresearch on motor control and skill acquisition inhealthy people (Gordon, 1987).

In the stroke unit trial from Trondheim (Indredaviket al, 1991), it is shown that early mobilization andrehabilitation according to a task-oriented approach(Carr et al, 1987) was one of the most importantfactors for good outcome (Indredavik et al, 1999).This is in line with the evidence from the randomizedcontrolled trials and meta-analyses showing thatrepetitive task-specific training is superior to usualcare regarding functional outcome after stroke(French et al, 2007; Langhorne, Coupar, andPollock, 2009; van Peppen et al, 2004). Despite thisknowledge, the UK physiotherapists, who have astrong tradition within the Bobath Concept (Davidsonand Waters, 2000), have described their current prac-tice in the acute and post-acute phase after strokemainly as “hands-on” interventions, but also tosome degree using part of activities and some wholeactivities (Lennon, 2003; Tyson, Connell, Lennon,and Busse, 2009).

Changing clinical practice is a demanding andtime-consuming process, and clinical experience inworking with patients has been shown to be the mostimportant factor, before education and professionalliterature, influencing current choice of treatment(Carr et al, 1994). Still, it is unknown to whichextent task-specific training is a part of conventionaltreatment given to patients discharged to home or tocommunity-based inpatient rehabilitation after initialtreatment in a stroke unit.

The task-oriented approach forces motor trainingto be goal-oriented, as well as to be tailored to thepatients’ individual needs. In clinical practice, it isexpected that training given to patients who differ infunction should differ. It is, therefore, relevant toinvestigate if patients are given training related totheir ability or inability to walk independently.

The primary aim of the present study was to surveyto which extent task-specific training was a part of con-ventional treatment, given to a selected group of strokepatients discharged to home or to community-basedinpatient rehabilitation, after initial treatment in a hos-pital stroke unit. The secondary aim was to investigate

whether stroke patients with initial dependent walkingability were given different training tasks compared topatients with initially independent walking ability.

METHODS

Study design and setting

This cross-sectional survey was a pre-defined substudyof a randomized controlled trial including 62 patients(Askim et al, 2010). Forty-six patients receiving con-ventional treatment were included in the presentstudy. The second week after discharge from thestroke unit at St. Olavs Hospital, Trondheim Univer-sity Hospital was chosen for the survey.

The setting for the conventional treatment could beeither physiotherapy at home, at a private physiother-apy clinic, at an outpatient clinic, or as inpatient reha-bilitation. However, all settings were organized by theprimary healthcare system, in the city of Trondheim,hence it was community based. The overall goal ofthe treatment was to improve the functional level asmuch as possible. Figure 1 shows the study designand flow of patients through the study.

Patients with initial unassisted walking ability (i.e.,ability to walk without support from another person)were classified as independent (mRS = 0–3), while

FIGURE 1 Flow of patients included into the survey.

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patients with initial assisted walking ability were classi-fied as dependent (mRS = 4–5).

The questionnaire

Seven experienced physiotherapists were invited toparticipate in a workshop to develop a questionnairefor the survey, containing items that represented thewide range of tasks and techniques usually applied inphysiotherapy after stroke. The International Classifi-cation of Functioning, Disability and Health (WorldHealth Organization, 2001) was used as a frameworkfor the questionnaire, and the items were classifiedas either “body function” or “activities and partici-pation” (World Health Organization, 2011).

The main categories within the domain of bodyfunction were: 1) mobility of joint function in lyingor standing position; 2) muscle power function,including muscle training of the muscles surroundingthe affected hip, knee, and ankle in sitting position andtraining by the use of training equipment; and 3)movement function that included training com-ponents of transfer in sitting position, training com-ponents of walking in standing position, and thetasks for the affected arm.

The main categories within the domain of activitiesand participation were: 1) changing and maintainingbody position, including reaching in sitting and stand-ing position, balance in sitting position, sit-to-stand,balance standing with both feet on the floor or on abalance board or pad, standing on one leg, squatand heel raise; 2) walking and moving, which includedwalking on even and uneven ground, walking sidewayand backward, walking across obstacles, turningaround, outdoor walking, step tasks, stair climbing,

and practicing fall routines; and 3) self-care, which in-cluded training of balance and transfers related toADL such as washing oneself, dressing, and toileting.

Each task within the questionnaire was labeled witha number. A manual giving a detailed description ofthe different categories was also developed.

Physiotherapists

Nineteen physiotherapists (5 men and 14 women)working in the primary healthcare system agreed toparticipate in the survey. Their median (IQR) timefrom end of education to inclusion into the surveywas 5 (2–15) years. Only two physiotherapists wereeducated as specialists at the time of the survey; onewith speciality in geriatrics and one with speciality inneurology. Five out of the 19 included physiothera-pists also participated in developing the questionnaire.

The included therapists were given oral instructionon how to complete the questionnaire. Treatment cat-egories applied and time spent on training wasrecorded at the end of every treatment session. Inaddition, the intensity of the training, according toBorg Rating Scale of Perceived Exertion (Chen, Fan,and Moe, 2002), was recorded.

Stroke patients and setting

Table 1 shows the baseline characteristics for the 46included patients. They were on average 76 years oldand suffered from a moderate stroke. Sixteen patientswere classified as dependent, whereas 30 patients wereclassified as independent. Dependent patients spenton average 1 week more in the stroke unit compared

TABLE 1 Baseline characteristics.

All patients(n = 46)

Independentpatients(n = 30)

Dependentpatients(n = 16)

Between groupdifferences, p-value

Age, mean SD 75.6 9.0 74.8 10.0 77.1 6.6 0.363Number of days in stroke unit, mean SD 15.8 7.1 13.2 5.9 20.6 6.7 0.001Living alone, number % 17 37.0 12 40.0 5 31.2 0.558Gender; women, number % 21 45.7 14 46.7 7 43.8 0.850Hemorrhages, number % 2 4.3 1 3.3 1 6.2 0.644Inpatient rehabilitation during 2nd

week after discharge from hospital, number %18 39.1 5 16.7 13 81.3 0.000

Functional state 11 days after onset of stroke, mean SDSSS 47.3 6.8 50.4 4.1 41.3 6.9 0.000Barthel Index 69.0 18.4 78.8 12.6 50.6 12.2 0.000Rankin Scale 3.5 0.7 3.2 0.7 4.1 0.3 0.000

Note: SD, standard deviation; SSS, Scandinavian Stroke Scale.

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with the independent patients (20.6 days vs. 13.2 days,p = 0.001). The dependent patients also showedgreater neurological impairments with a significantlylower Barthel Index (50.6 points vs. 78.8 points, p= 0.000) and Scandinavian Stroke Scale score (41.3points vs. 50.4 points, p = 0.001) compared to theindependent patients. A total of 18 out of the 46patients were treated in an inpatient rehabilitationsetting during the second week after discharge fromthe hospital. Also a significant greater proportion ofthe dependent patients were treated in the inpatientsetting (81.3% vs. 16.7%, p = 0.000) compared toindependent patients. The home-dwelling patientswere treated either at home, at a private physiotherapyclinic, or at an outpatient rehabilitation clinic.

Ethical approval

Informed consent was obtained from all participants,both the stroke patients and the physiotherapists.The study was approved by the Regional Committeeof Medical and Health Research Ethics.

Data analysis

All data (data from the baseline assessment of the strokepatients, data from the completed questionnaires, anddata from the training diaries) were plotted andanalyzed in SPSS version 16.0. Missing values onthe Borg Rating Scale or time spent with thephysiotherapists were imputed with the average forthe group. The descriptive statistics are presented asmean and standard deviation or number and percen-tage of patients receiving each activity category for allpatients and dependent and independent patients,respectively. An independent sample t-test wasapplied to analyze the difference between independentand dependent patients on the continuous variables,whereas chi-square test was used for dichotomousvariables. A p-value <0.05 was applied for rejectingthe null hypothesis.

RESULTS

If all training was defined as100%; 13% was at thelevel of body function and 87% at the level of activityand participation.

Body function

One out of the 46 patients (2.7%) was treated with apassive technique in lying position (mobility of joint

function in lying position). This patient was initiallyclassified as independent. Compared to dependentpatients more independent patients practiced byusing training equipment (26.7% vs. 0.0%,p = 0.023), like treadmill, bicycle, and progressiveresistance apparatus compared to the dependentpatients.

Activities and participation

Table 2 shows that 2 out of 46 patients (4.3%) weretraining balance and transfers in relation to ADL(such as washing oneself, dressing, and toileting), 1out of 46 patients (2.7%) was practicing fall routines,and 7 out of 46 patients (15.2%) were practicingoutdoor walking. More than 50% of the includedpatients practiced sit-to-stand, balance in standingon both feet, walking on even ground, and climbingstairs.

Furthermore, the results show that a significantgreater proportion of the independent patients prac-ticed balance standing on one leg (36.7% vs. 6.3%,p = 0.025) and heel raise (46.7% vs. 0.0%,p = 0.001).

We also found that a significantly greater pro-portion of the dependent patients practiced sit-to-stand (87.5% vs. 46.7%, p = 0.007) and balance insitting (50.0% vs. 13.3%, p = 0.007) and standing(87.5% vs. 53.3%, p = 0.020) position. There wasalso a trend toward a greater amount of dependentpatients practicing walking on even ground (93.8%vs. 73.3%, p = 0.096) and ascending or descendingstairs (75.0% vs. 46.7%, p = 0.101).

Amount and intensity of training

The dependent patients received significantly moreminutes of physiotherapy compared to the indepen-dent patients (140.3 minutes vs. 103.3 minutes,p = 0.001) during the second week after dischargefrom the stroke unit, but there was no difference inthe intensity of training rated by Borg Rating Scalebetween the two groups (Table 3).

DISCUSSION

The main finding from the present study was thatstroke patients primarily practiced tasks within thedomain of activities and participation after dischargefrom the hospital. Furthermore, a significantlygreater proportion of patients, not able to walkwithout assistance from another person, practiced

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sit-to-stand and balance in sitting and standing pos-ition, and also to some extent walking on evenground and stair climbing when compared to patientswho were initially able to walk independently. On theother hand, a significantly greater proportion ofpatients, independent in walking, trained musclepower function at the level of body function.

However, very few patients practiced balance or trans-fers related to ADL, such as washing, dressing, andtoileting, as part of the conventional treatment.

The underlying assumption for the task-orientedapproach is the System Theory assuming an inter-action between the task, the person performing thetask, and the context the task is performed within

TABLE 2 Number and percentage of patients practicing the different activity categories.

Category

All patients(n = 46)

Independent patients(n = 30)

Dependent patients(n = 16)

Between groupdifferences∗

Number Percentage Number Percentage Number Percentage p-value†

Body function1. Mobility of joint function, affected lega. Lying position 1 2.7 1 3.3 0 0 0.460b. Standing position 2 4.3 2 6.7 0 0 0.2912. Muscle power functiona. Muscles surrounding the affected hip,

in sitting position1 2.7 0 0 1 6.3 0.166

b. Muscles surrounding the affected knee,in sitting position

8 17.4 3 10.0 5 31.3 0.177

c. Muscles surrounding the affected ankle,in sitting position

7 15.2 3 10.0 4 25.0 0.667

d. Training muscle power and movementfunction by the use of training equipment

8 17.4 8 26.7 0 0 0.023

3. Movement functionsa. Components of transfer in sitting position 4 8.7 2 6.7 2 12.5 0.504b. Components of walking in standing

position8 17.4 7 23.3 2 12.5 0.378

c. Affected arm 5 10.9 2 6.7 3 18.8 0.210Activities and participation1. Changing and maintaining body positiona. Reaching in sitting position 10 21.7 5 16.7 5 31.3 0.253b. Reaching in standing position 13 28.3 8 26.7 5 31.3 0.742c. Sit-to-stand 28 60.9 14 46.7 14 87.5 0.007d. Balance in sitting position 12 26.1 4 13.3 8 50.0 0.007e. Balance, standing on both feet 30 65.2 16 53.3 14 87.5 0.020f. Balance, standing on one leg 12 26.1 11 36.7 1 6.3 0.025g. Balance, standing on a balance board

or pad14 30.4 11 36.7 3 18.8 0.208

h. Squat 18 39.1 14 46.7 4 25.0 0.152i. Heel raise 14 30.4 14 46.7 0 0 0.0012. Walking and movinga. Walking on even ground 36 78.3 22 73.3 15 93.8 0.096b. Walking on uneven ground 3 6.5 2 6.7 1 6.3 0.957c. Walking sideway 13 28.3 6 20.0 5 31.3 0.394d. Walking backwards 7 15.2 5 16.7 2 12.5 0.708e. Walking across obstacles 9 19.6 4 13.3 5 31.3 0.145f. Turning around 12 26.1 6 20.0 6 37.5 0.198g. Outdoor walking 7 15.2 6 20.0 1 6.3 0.216h. Step on a step 22 47.8 16 53.3 6 37.5 0.306i. Stair climbing 26 56.5 14 46.7 12 75.0 0.101j. Practicing fall routines 1 2.7 0 0 1 6.3 0.1663. Self-Carea. Activities of daily living 2 4.3 2 6.7 0 0 0.291

∗Difference between independent and dependent patients.†Chi-square test.

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(Shumway-Cook and Woollacott, 2001). In the clini-cal setting, this approach is often defined as “func-tional training in a functional setting.” However, theresults from the present study show that only 2 outof 46 patients practiced ADL as a part of the conven-tional physiotherapy treatment, even though ADLtraining gives the opportunity to practice balanceand transfers in relation to real-life situations, whilemost patients practiced tasks such as sit-to-stand,balance in standing position, walking on evenground, and climbing stairs. The latter tasks are alsofunctional tasks although most of them are practicedas isolated tasks and not implemented in the contextthey are meant to be performed within. These resultsmight suggest that physiotherapists may regard thepreparation for independency in self-care, like reachingin sitting or standing position, as their main domain.While training balance and transfers in relation todifferent self-care situations might be regarded as thenurses and occupational therapists’ domain withinrehabilitation after stroke, it is also important tonotice that 30 of the included patients were classifiedas initially independent in walking, which indicatesthat some of them are independent in self-care,hence a strong focus on dressing, washing oneself,and toileting was most likely not appropriate for thesepatients. Nevertheless, 16 patients were classified asinitially dependent in walking and enhancement ofself-care is probably a considerable need for these par-ticipants. Our study also shows that 80% of the depen-dent patients were treated in an inpatient setting, whichindicates that it should also be possible for the phy-siotherapists to focus on training in real-life situationsby joining the nurses and nurse assistants when thepatients got out of bed and transferred to the bathroomfor grooming in the morning or transferred to the toiletduring the day.

As seen from the present results, the workshoprevealed a list of activities that were both task-specifictraining and not. The list of categories delineated inTable 2, range from training mobility of joint functionin lying position (body function) to outdoor walking(activities and participation), shows that experienced

physiotherapists are picking from a large repertoire oftreatment techniques when they are treating strokepatients. However, they are much more restrictedwhen it comes to which treatment they actually areusing for the main proportion of their stroke patients.The activities most often chosen were basic tasks suchas sit-to-stand, balance in sitting and standing pos-ition, walking on even ground, and stair climbingwhich are all important tasks for becoming indepen-dent. Hence, conventional treatment after dischargefrom the hospital seems to be task-specific, which isin line with the outcomes from the randomized con-trolled trials and meta-analysis investigating the effec-tiveness of motor training after stroke (French et al,2007; Langhorne, Coupar, and Pollock, 2009; vanPeppen et al, 2004). It is also important to noticethat the median time from end of education to entryinto the survey was only 5 years, indicating that 50%of the included physiotherapists were relatively newlyqualified. One may speculate that task-specific train-ing has been strongly advocated during their edu-cation, thus influenced their choice of treatment. Onthe other hand, it looks like these tasks are universaltasks; as sit-to-stand, balance, and walking were themost frequently used activities also by the UK phy-siotherapists over the last 5 years (Tyson, Connell,Lennon, and Busse, 2009; Tyson and Selley, 2006).Based on these findings, future studies investigatingthe rationale for physiotherapists’ choice of treatmentin a broader scale should be warranted.

According to our study, relatively few patients weretreated with the tasks at the level of body function,while most patients were practicing tasks at the levelof activities and participation. This is in contrast tothe UK physiotherapists who were mainly using inter-ventions involving facilitation of whole and part ofactivities (Tyson, Connell, Lennon, and Busse,2009). It appears that the physiotherapists involvedin the present study were more likely to let the patientspractice activities at a higher level, allowing thepatients to experience by themselves how to performthe movement. Such a problem-solving approach isshown to improve motor skill acquisition (Lee,

TABLE 3 Intensity and amount of physiotherapy during the second week after discharge from the stroke unit.

All patients(n = 46)

Independentpatients(n = 30)

Dependentpatients(n = 16) Between group differences

Mean SD Mean SD Mean SD p-value

Borg Rating Scale 13.9 1.2 13.8 1.0 14.3 1.6 0.219Total minutes of physiotherapy 103.3 57.9 82.1 48.4 140.3 55.5 0.001

Note: SD, standard deviation.

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Swanson, and Hall, 1991) and is also an importantelement of the Motor Relearning Program, whichlately has shown to be preferable regarding quality ofmovement compared to the Bobath concept (Lan-ghammer and Stanghelle, 2011).

Regarding our secondary hypothesis, we founddifferences in the activities practiced by the dependentand independent patients. More dependent patientspracticed sit-to-stand and balance in sitting and stand-ing position. We also found that more dependentpatients practiced walking on even ground and climb-ing stairs. Even though these tasks seem to be ratherdemanding for the dependent patients, they must beregarded as highly relevant for patients aiming for inde-pendent walking. On the other hand, the independentpatients practiced more balance on one leg, performedheel raise, and were exercised by the use of trainingequipment. One may speculate whether the indepen-dent patients could have benefited even more fromadditional training in real-life situations like challen-ging their balance during outdoor walking. It is alsoimportant to note that a majority of the independentpatients were home dwelling at the time of the surveyand received their treatment either at home, at aprivate physiotherapy clinic or at the outpatient rehabi-litation clinic while amajority of the dependent patientswere treated in an inpatient setting. These differencesin the environmental context may also explain someof the reason for the different choices of treatment.Furthermore, the significantly more minutes of phy-siotherapy given to the dependent patients comparedto the independent patients can also be explained bythe greater proportion of dependent patients beingtreated in an inpatient setting.Despite these differencesin tasks being trained, amount of physiotherapy and theenvironmental context, the dependent and indepen-dent patients did experience the training equally inten-sive, as both groups rated their perceived exertion as“somewhat hard” on Borg Rating Scale (Chen, Fan,and Moe, 2002).

The main weakness of this study is the lack of a vali-dated tool for collecting data on the conventionaltreatment. Tyson and Selley (2004) have developedthe Stroke Physiotherapy Intervention RecordingTool (SPIRIT) that describes physiotherapy interven-tions for the rehabilitation of postural control post-stroke. We considered using SPIRIT, but we foundthe tool inappropriate because it did not cover allareas of physiotherapy that we wanted to describe,like practicing fall routines and training of ADL.Analysis of video recordings (van Vliet, Lincoln, andRobinson, 2001) was another possibility, but thismethod was considered to be too time consuming.Instead, we developed a simple tool based on theresults from the workshop that covered all aspects of

physiotherapy that were possibly given as a part ofconventional treatment. However, this approachmight have led to the fact that certain areas of phy-siotherapy have been omitted from the questionnaire,which again could have given possible biased resultsfor the survey. The questionnaire also needs to betested for reliability before it is applied in futurestudies. Another limitation is the fact that data wereonly collected from physiotherapists working in theprimary health- care system in the city of Trondheim,which makes generalization to other Norwegian citiesand municipalities difficult. However, we regard thenumber of participating patients and physiotherapistsappropriate for giving a valid description of the con-ventional treatment for this selected group of patients,but a larger survey particularly designed to surveyclinical practice should be carried out to describe con-ventional treatment in different settings and withinpatients at different age groups, gender, and livingcondition. It would also improve the understandingof the results if some more details about the back-ground of the physiotherapist had been registered. Inspite of these limitations, we believe that this surveyhas provided an important contribution to thedebate regarding the level of implementation of thetask-oriented approach in physiotherapy practice forstroke patients after discharge from the hospital.

CONCLUSION

In conclusion, this study shows that conventionalphysiotherapy practice applied to a selected group ofNorwegian stroke patients after discharge fromthe hospital was mainly based on a task-orientedapproach. However, intervention was mainly focusedon isolated training of balance and transfer activitiesand less focused on training of balance or transfersin relation to ADL, such as washing, dressing, and toi-leting. We also found that more dependent than inde-pendent patients, practiced tasks, like balance instanding position and walking on even ground. Still,further clinical research, in particular implementationresearch, is needed to ensure that all stroke patients aregiven evidence-based practice independent of theircounty or country of living. This study providessome insight into the research within this field.

Acknowledgments

The authors thank AnneHansen, Head ofDepartmentof Physiotherapy in the City of Trondheim and all phy-siotherapists who participated in this study for theirenthusiasm and support through the collection of data.

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Declaration of interest: The authors report nodeclarations of interest. The authors alone are respon-sible for the content and writing of the article.Torunn Askim was supported through The NorwegianFund for Postgraduate Training in Physiotherapy andfrom Clinical Service, St. Olavs Hospital, TrondheimUniversity Hospital.

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