Narrator

Hello and welcome to the Talking Physio podcast. In this episode, Dr Christina Ekegren from the School of Public Health and Preventive Medicine, Monash University, chats with Dr Claire Baldwin, lecturer in physiotherapy, Flinders University, and Dawn Simpson from the Menzies Institute of Medical Research, University of Tasmania, about deconditioning in the acute hospital system and the positive impacts of the End PJ Paralysis campaign. Before we dive in, this episode has been brought to you by the Physiotherapy Research Foundation - supporting the promotion and translation of research - and sponsored by FlexEze, the exclusive partner of the Physiotherapy Research Foundation. Let's get started. 

Christina
So, Claire, we're hearing more and more about the problem of sedentariness in hospitals. I thought we might kick off by just maybe defining what sedentary behaviour is for our listeners. 

Claire
Absolutely. In the literature, we see two components to the definition of sedentary behaviour. One part is the postural component. So it's the time that you're awake, that you spend either in a sitting or a lying down position. But it's also a lack of activity, I guess a low energy expenditure of less than 1.5 mets. So we have this combination of low energy activities that are conducted in a sitting and lying position and, of course, this is what patients spend most of their time in hospital doing and we can explore the sorts of problems that that might bring. But we know a lot about the impacts with the general community and the health impacts of sedentary behaviour can have on our health. So, Dawn tell us a bit more about that perhaps. 

Dawn
I mean, that's one of the things the health implications of a prolonged, sedentary time are becoming more understood, and certainly have emerged more over the last few years. So we know that prolonged sedentary behaviour is associated with greater all cause, greater cardiovascular disease mortality, which isn't good. We know that kind of breaking up sitting with light intensity activity actually has health benefits in terms of reducing postprandial glucose, lowering insulin levels, and can actually help waist circumference, BMI, reduce triglycerides and kind of the general population or kind of metabolic populations such as people with diabetes. We also know, my particular interest is in recovery after stroke, and we know that kind of breaking up sitting time after stroke has benefits for stroke survivors, in terms of reducing overall systolic blood pressure and obviously, that's an important modifiable risk factor after stroke, but also an important risk factor for other cardiovascular diseases. So the health implications are distinct from just not doing physical activity, and I think we're starting to understand that a bit more and understand why it's a problem that we need to tackle when people are in hospital. 

Christina
So your researchers looked at the stroke population specifically, so I guess we should set the scene by talking about how sedentary stroke patients are in hospital. 

Dawn
Sure. Very, is the short answer, which is unfortunate. In the acute setting, people are spending around 80% to 90% of their waking day in sitting and lying postures, and that's not a new problem that's emerged recently. Julie Bernhardt's seminal work from the early 2000s, of patients being inactive and alone really started highlighting the problem. And I think still today, studies such as our own are showing in the rehabilitation setting about 79% of the day is spent sedentary, so we haven't shifted behaviour much over the last 15 years, and I think that's why there's a big push now to try and actually start changing behaviour because we need to. It's been too long. 

Christina
Did you see that exchange on Twitter yesterday about this issue? 

Dawn
No, I didn't catch that one. What was that? 

Christina
So it was exactly what you were just talking about. We tweeted about your presentation and someone said, 'Hang on. We've known about this for 15 years. Why haven't these statistics changed?' And so people started replying and it was really interesting thread about some of the reasons for why this hasn't shifted. And a lot of the responses had to do with policies in hospital around falls. And I think maybe we can get into that a little bit more later on. 

Claire
Certainly we see those issues in the acute setting as you've already identified, and from some of the review work we've done, you know, we've had people have studied this in different surgical populations. Whether it be cardiac, thoracic, upper abdominal, they looked at it in older medical patients coming to medical wards, stroke, respiratory populations as well, and that this is a common thread across conditions. So in the acute setting sometimes we face with these patients are sick and how do acute illness factors come in? But because of what inactivity, sedentary behaviour does to your cardio metabolic health, means that it contributes so much to chronic disease and what we're seeing in the hospital sense is how we weigh up these acute on chronic issues that many of our patients have part of their disability burden is attributed to their inactivity. So they're coming with diabetes, heart disease, stroke, either as a comorbidity or the primary reason why they're presenting to hospital. So we are starting to understand more about the patient as a whole in a trajectory, and I think it's how we sort of select and perhaps look at their activity history to try and understand where they're at in hospital with this acute illness and then try and change it from there. Maybe the reason it hasn't changed and you know, we talk about as being a complex and a wicked problem. And even when patients are in the inpatients setting, you don't necessarily see a huge change in their sedentary behaviour or their activity over their hospitalisation, even though their physical capability or their mobility may improve. You can get this disconnect between, for some patients, around what they're physically capable of doing and the opportunity for what they do, and it would be interesting to see how all this research progresses and how patients then discharge home and whether they actually are able to respond to increasing their activity and reducing their sedentary behaviour or whether they stay on this low level trajectory and become a risk of representation. So it sits in this wider, you know, context of disease burden, chronic disease, acute and how they're moving between our acute and chronic hospital settings. 

Christina
And I thought we had an interesting question yesterday from the floor, which I think we could talk about a little bit more in the light of your research, Claire, what about when patients are sick? Should we be getting them up if they actually need to be sick and lying in bed? 

Claire
Yeah, so my background is actually through intensive care and critical illness, so a huge body of our work and the field is really around early rehabilitation and moving in the intensive care units. So whether that's because you've got skilled teams and high level monitoring, we kind of go, 'Oh sickness okay'. There's still lots of things that we can do that there's actually, very few complete red stop signs that say no, don't go, that it's not appropriate to mobilise these patients. And so the safety data that's been generated over years, the expert consensus recommendations that I had the pleasure of being involved with colleagues and putting together, really sort of set out these parameters to say that perhaps we're being too conservative and we can actually move these patients forward a lot earlier. So, yes, there are circumstances where patients are sick and they can get fluctuations in their symptoms and how they feel. But there is still this underlying sense in which early rehabilitation, early mobilisation and the illness factors can potentially be addressed. And when people have looked into the barriers and facilitators, an element of it is perhaps healthcare providers, patients and families, attitudes and beliefs. An element is the physiology, but there's also things around team and culture. There's also things around equipment availability and the environment as well. So some of these barriers and enablers may be slightly different because of acute illness in hospital to rehab, but there are elements of the environment and other things that are the same. So maybe this is why it has been so hard to shift, and we're seeing the same problems from the work in stroke. But it's actually the same problems that get published in a topical issue 70 years ago in a British journal of medicine where Dr Richard Ashes said, 'Look at the patient lying in bed, the flesh rotting from his seat'. Talking about glute muscles, wasting away from being in bed. 'With the spirit, evaporating from their soul', the mental health things and says, 'Teach us to live that we may dread unnecessary time in bed'. Get people up. We may save patients from an early grave. This is 70 years ago. We don't prescribe bed rest anymore, but maybe we don't prescribe activity. So maybe we're still in this movement and still having this problem recognised for our patients. 

Christina
Yeah, so let's get into the barriers. 

Dawn
I guess I can kick off in that aspect then. So some of my PhD work has been quantitative, looking at activity at different time points after stroke, and we looked at what factors might influence physical activity and sitting time during the transition from hospital to home, and found that people were more active in the first week at home than they had been in hospital. And that's not a surprise, but it is a little bit unfortunate and confronting for us as health professionals. 

Christina
That's fantastic data that you've got. Very original. 

Dawn
And the thing that we found kind of modified that was the presence of depression. So people who had depression spent more time sitting in the first week at home than they had done in hospital. And I think quantitative data takes us so far. So what I was talking about in our seminar yesterday was the qualitative work. I don't think we know enough from the perspective of the actual patients. So in my case, stroke survivors and their carers, what their experience of sedentary time has been and what they feel about that and need to know more about. So one of the key things that we found was that people didn't have any recollection of having any discussions with health professionals about the problem of sedentary time and very limited understanding of physical activity, thinking about physical activity as the opposite end of the continuum from sedentary time. So I think understanding what the issues are and what the implications for their health and recovery is a significant component, and I've certainly heard that discussed in other fields throughout the conference that we've been at currently as well. So I think, you know, patient understanding and their carer understanding's a big component. Certainly one of the other things that came through quite strongly is, unsurprisingly, if somebody doesn't have the functional ability to get out of a chair, it's very hard for them to reduce their sedentary time and people with more significant mobility limitations certainly reported less opportunities to get up and be physically active. And I think that feeds into some of the service level barriers and problems that also came through from our thematic analysis. In that, staff availability is obviously a problem. We all know that we're doing the best we can with pretty limited resources, but I think perhaps we can think of it more cleverly about empowering the patients who have the ability to move to do that independently so that we can target our limited resources towards people who actually need greater support to do that. But picking up on one of your comments from before Christina, certainly hospital processes around safety and risk very strongly came through as potentially promoting sedentary time. So patients did report that they felt that walking activity was discouraged because of fear of falls and the risk associated with that, and not to take away the fact that that is a risk and it can be catastrophic. Certainly some patients felt that the risk that they had been labelled with didn't meet their perception of their level of risk and, interestingly, their carers’ perception of risk as well. 

Christina
Absolutely. And we found the same thing in our interviews we did with older adults on GEM wards. So we interviewed patients and their carers, and it was often surprising to hear that it wasn't that patients were unmotivated to walk, which is what the nurses, some of the nurses said, but it was they didn't feel that they were allowed to walk. And when we talked to the carers and said, well, do you think that you would feel competent and capable of walking with your wife or your husband, they pretty much all said yes, and they said, 'Well, I'm going to have to do it when we go home anyway, which is only a week away, so why aren't they letting me do it?' 

Claire
We've been looking at some work, we're still going through the results, looking at a Delphi study and seeing what health professionals, we have got a small patient involvement - this is doctors, nurses and a large representation of physios. And these are really common threads around some of things around permissions to be able to get up and moving. And the group want to have a bit of a layered and targeted approach for people who need assistance, those who can mobilise independently. But then also some generally embedded principles. Whether that's around policy, staff roles, availability, but also staff competence and how we come into training. And I see the word encourage come up and encourage patients to be mobile. And an interesting comment we've had from one of our participants in the data, we're still processing is, encouragement not seen as bullying. And so I think there's something to be said for how that interpersonal approach comes from all health professionals and also looking at roles of families and carers and volunteers because there are different models of health services and culture perspectives that are really valuable and important to work through and how you actually engage somebody in being mobile. But I'm also interested, is that becomes very individual dependent and it's good to be focused on the patient, but this sense of which how much responsibility is really on individuals and health professionals, but also recognising that we operate in this complex bigger system where we do have policies where we've got physical environments where hospital bays are set up in particular ways, there's lack of meaningful places to walk. There's a cognitive engagement to think about in stimulation as well as all those other factors that, actually why it's so hard for us to tackle. 

Christina
One of the issues we haven't talked about yet is clothing. So some of you might have heard of the End PJ Paralysis Global Campaign that started in the UK and has spread all over the world. And one of their main targets is to get patients out of bed and dressed out of their pyjamas because everyone knows that walking around with your bum flapping out in your hospital gown is never a good look. Some patients do it. They don't seem to mind, but I don't think I would. So the idea with this was getting patients to think about the fact that they don't have to wear pyjamas when they're in bed, whether it be hospital gowns or their own pyjamas that they bring in and that this then not only empowers them to walk, but also gets them out of the sick role. So if I'm in my PJs all day at home, I know I'm going to feel pretty crusty by the end of the day. I think it's a really interesting strategy because it enlists nurses in the remit of hospital mobility, which I think they're less and less seeing as part of their role and more and more giving the responsibility to physios for that. And I think it's a clever strategy because it really sort of gets nurses involved by stealth because clothing is part of their remit. 

Claire
We're all physios here but from the nursing perspective, there are groups of nurses that are very interested in function focused care, and some of the studies and approaches we've identified from our literature review work have been around function focused activities and dressing is one of those. But we also see opportunities for activity around meal time, showering, dressing. And I think in the hospital setting the ability to break up your sedentary time and have opportunities for activity related to self-care are an important strategy because we may sort of have patients walking and be able to potentially move to increase their activity in hospital, but it does tend to be in concentrated pockets of times, such as during a rehabilitation session. So it's almost like we need multi-pronged approaches in which we yes, we think about exercise and rehabilitation time, but that really builds into the self-care and how it's more embedded and threaded throughout the day, gives the permissions to the patients, and that's what they do when they go home. They increase their activity because they do need to get up and make meals, brush their teeth, shower and those sorts of things so the clothing is a really important part in messaging about enabling that I think. 

Dawn
One of the other strategies I was really interested that you talked about yesterday, Christina, with the implementation work that you were doing at Caulfield, was shifting the focus of the mandatory reporting boards. So you talked about how on entry to the ward that there were big signs up talking about falls rates and pressure area rates and one of the strategies you adopted was to actually report back on how many people were dressed by a certain time, how many people had actually been up and walked and mobilised by a certain time. And I think one of the key strategies in changing any kind of practise is understanding what's going on in your own individual unit, which takes measuring audit processes, all of those kind of things. Can you talk a little bit more about that strategy because that was a very interesting way of not taking away what was already done on the ward, but to add to it to shift the focus and the perception of reporting. 

Christina
Yeah, so I think that the reporting is important, but it definitely creates a culture of fear, particularly amongst nursing staff. I think nurses get particularly frightened about falls because maybe they feel that it's not really their area of expertise, hospital mobility, and maybe they feel like if someone falls when they're with them, it's because they did something wrong. So I think in a lot of cases, if nurses see that sort of assist by one status, they sort of tend to stay away from that patient and 'Oh, no, wait. Wait till the physio gets here and then and then we'll get you up'. So yes, putting up the data was a way of shifting the focus from the fear of mobility, to the goal of mobility. And every day, someone on the ward counted the number of patients out of the total that were, as you said, dressed, out of bed for lunch and mobilised before two o'clock. And every month the statistics would shift and they could see whether they were making progress. This was in a background of a series of strategies that were implemented on these wards so they were able to see what worked and what didn't. And we had some successes, and we had some failures, as I spoke about yesterday, with those pedometers. And I think it did two things. First of all, it allowed people to see what the successes and failures were, but it also shifted the focus towards mobility as a positive thing. And it's something to aspire to and really getting the nurses on board. And in addition to that, the activePAL data that we collected was hugely influential. The numbers were pretty shocking. The average number of steps amongst the patients across the four awards was 388 a day. 97% of the day was spent sitting or lying so pretty shocking and actually pretty consistent with the published literature. So when everyone heard about that, I think there was a little bit of shock and maybe shame. Not that you want to be shaming people, but it really did motivate people to act. 

Claire
I think that's really consistent with work that's done out of bigger groups like the Johns Hopkins in America. They've got the activity mobility promotion. And there is, Michael Friedman was the physiotherapist from there that sat on the panel at the World Physiotherapy conference this year. And they had a panel on these sorts of issues, and the messaging that came through very much strongly was around measuring how data is really important part of that process. Whether that's with accelerometers, whether it's just doing the behavioural mapping or having a look and just simple numbers that can have a look at how many patients are up, dressed and moving. It's a conversation starter. You can have those conversations on the ward with people, and you can do it in a way that it is respectful of everyone's role in the team. And it's not about shaming. It's about sort of understanding a problem, the magnitude of the problem, and then having those small wins where you can see changes and what's working and seeing it as a process and valuing their staff time and valuing patients' time as well. 

Christina
I think if anyone is wanting to start their own kind of End PJ Paralysis strategy or a mobility strategy on their wards, I think the data collection is the first place to start and then get your team together because the, the other issue that I want to pick up on what you said Dawn is about teams, and hospitals are multi-disciplinary environments and therefore the solutions need to be multi-disciplinary. So the team I worked with at Caulfield consisted of nurses, nurse unit managers, physios, OT, social workers, gerontologists and also people from management. So we had that sort of policy input as well. We also got input from patients and that was really, really interesting and important and the solutions came from the staff themselves. They knew what wouldn't work. And so you know, you save yourself so much time by going straight to the source rather than just overlaying some newfangled idea on these people who are against it from the outset, potentially. 

Dawn
And I think the whole overarching behaviour change principles are part of that in the data collection and the kind of naming up the problems, the first component. There is intervention to reduce sedentary behaviour underway being trialled in the United Kingdom at the moment, being led by a team at Leeds. Coralie English, from Newcastle University, is involved in that programme of work as well. And Dave Clark was out here presenting at the Smart Strokes Conference earlier this year and it really is the leg work about naming up the problem and using data to do that. But then really working through a co-design process, which is what you've just alluded to, Christina, in terms of you have to talk to everybody. You have to get everybody on board and actually having a framework that underpins that, which I know you did in your programme. But potentially, you know, that could be using the behaviour change will principles or the COMBI framework to actually attach your ideas and solutions to. And actually make sure that we're working through these potential solutions in a really systematic and methodical way that may lead to better sustainability of the behaviour change and hopefully, better outcomes for our patients. 

Claire
Christina, I'm interested in what the environment was like when you came to set this up in the first place. We took yesterday about local barriers need local solutions, and you've talked about solutions that worked in your setting. When we look at the literature, there's a range of other solutions and there may be ones that we haven't thought about. But there is this need to operate interpersonally with teams and within the environment. And from what I can understand, there are some settings and wards that are perhaps ready to change, and perhaps others aren't. So what did you see in terms of that groundwork that was already in place that was really positive that made you think, yes, we can move to actually start off the process, if you like? 

Christina
I think actually, the environment was pretty negative when we started, and it got turned around through the process. So we conducted a survey of all of the nurses at the start of the 12 month intervention, and the attitudes to mobility were mostly pretty negative. We don't have time. This isn't our job. And through a series of, I guess team building activities, I've seen that completely change. One of the most powerful things that they did at Caulfield was a video. They filmed patients, staff, all with these sort of corny signs saying 'Move It' and set it to a backtrack of the song Move it. And it was just the most joyful, infectious thing you've ever seen. And it went viral. And it made the staff really proud of the work that they were doing. And so now when I go back to the site, it feels different, and it feels like people are on board with it. They still have all the same issues with time and so forth, but it's put the issue sort of front and centre in their minds. So I think that for these interventions to work, they need to be fun, and they need to bring people joy. It can't be a punitive thing like we're telling you what you're doing wrong, but here's some fun things that we could try. I did also want to pick up on your topic of the environment because I think as hard as you try, if you have a poor environment that doesn't enable physical activity, a deconditioning environment, we might call it, there's a lot of challenges to making change. And I think one of the key things that patients told us is that they just had nowhere to go on the wards. They also felt that the corridors of the hospital weren't their domain. They didn't belong there. That was where the nurses worked and they lived in their rooms. One of the classic comments from a patient was, 'I feel like a prisoner in a prison cell', because he felt like he couldn't leave, and he wasn't encouraged to leave. There was no outdoor spaces, no communal spaces. Some of the gyms were pretty depressing places that you might not want to go to and weren't allowed to go to on your own. So I think this is a big issue to tackle hospital ward design and you don't do it easily or cheaply. But I think that there are some small changes that you can make to hospital wards. And one of those things is just making staff mindful of clutter in the rooms and in the corridors so that patients aren't at risk of falling, and I think also creating some communal spaces. So maybe there's some dusty store room that could be converted to a sitting room, a TV room or a library. Something like that. And I think these things can really make a big difference to patients feeling that they are allowed and encouraged to leave their rooms. 

Claire
Some of those threads again have come through our Delphi, if we've got some more objective sort of numerical data, but we've also got this rich bank of comments. And some of that has come up with a therapist in hospitals around the world saying, 'Bring back the communal dining room'. So there's obviously lots of different hospital designs around the place and lots of different ways that it needs to be tackled. Maybe some patients do want to eat together with other patients, and maybe some patients don't like to eat with other people, so I think their voice is still going to be really important in strategies moving forward. You do hear, in terms of the research space, people are looking at things like more objectively saying what impact a walking track might have. But again, these are still often local solutions to local problems. People have talked about getting theatre companies in to do theatre shows, but they could potentially be quite resource intensive. So you may have this, end up having a combination of kind of these more motivational, one off activities that help to sort of encourage people and change the culture, but you also have this underlying approach. If you're in one part of the world or in one city, the landmarks and the approach you have to making more enjoyable spaces to be and walk in are related to your city or related to the profile of your, of your patient mix. I believe there's a study in process, because I haven't heard much about it, there's only this sneaky line in the bottom of the paper, that said that they were developing an art tour around their hospital and scanning QR codes and so you can actually walk around the hospital and get information on local art. What a wonderful way that would be to bring in local perspective, different sort of cultural aspects to a hospital, and give some stimulation, something for people to do when they're in hospital. 

Dawn
On the large research scale at the moment, there's some really exciting work going on at the Florey in this space, where they're looking at how we can optimise healthcare environments, and apologies to the researchers if I slightly misquote what they're doing because I'm talking off the top of my head now. But they're using really exciting partnerships with health architects and architecture companies, but also using things like virtual reality to mock up environments that consumers can then spend time in and provide feedback on. So you know about the amount of natural light, the position of windows, the colours involved in hospitals, the spaces that they have to move in. So that they're going to have this really rich bank of data to then kind of work out what works best for certain circumstances in encouraging activity, but also supporting rest and sleep, which is important, and we don't want to take away too much from that as well. So yeah, there's some very cool big blue sky thinking, going on as well, and I think it will be very exciting to see the research based principles that emerge from that. And yes, it's hard to then implement that into environments that are already built and not very good. But we will be able to learn and translate principles and certainly more hospitals, new hospitals are getting built these days, and surely that gives us better ammunition to get these places designed better in the first place? 

Christina
Absolutely. And I think that bringing together lots of different disciplines is the only way we're going to tackle this problem. It is really complex. And I think that Twitter exchange about why hasn't this changed in 15 years is a lot to do with maybe the approach that we've taken. I don't think a single researcher can go out and fix these problems on wards. The ideas, you know, as we said, have to come from the staff. But you have to include those architects and building designers and all of those different people, and we need different research approaches as well. So just embedding a single intervention on a ward, which is what we normally do when we do research so that we can evaluate it properly, is not going to work. And the model that we used was the IHI model for healthcare improvement. And I'd encourage anyone to have a look at that because I think it works really well in that you get to try things and if they don't work, you get to try something else. And you just have to make sure that you're collecting data consistently through that time. 

Claire
Other than thinking of a more traditional research paradigm, hospitals would be familiar with safety and quality processes. We've talked about the risk aversion from having falls as an issue. But another way to look at the situation and communicate it, is the risk of deconditioning and the negative side effects and the statistics around how bad that is for you, is up there with how bad the other complications that they would be monitoring for hospital accreditation. So if you took the flipside of not falls is a safety and quality problem, but actually the other end is the deconditioning that happens in hospital as being a safety and quality problem because of the complications that brings. Maybe that's a way to sort of message and communicate and bring that onto your hospital radar. And if that becomes a target, just like you might look at pressure areas or central line, hospital acquired infections, because the stats around patient problems and impacts from that are probably quite similar, if not worse, because the deconditioning actually feeds into risks factors for all of those things. That may be a way not necessarily within a research paradigm, but within a safety and quality paradigm, to sort of build in the importance of that and monitoring. And if it's important at that level, and it's got the bottom up approach in terms of engaging people, teams finding out their problems on the ward. But you've also got that top down support from a safety and quality framework at that, how you can meet in the middle. 

Christina
Yeah, and I think it's about getting people to see falls as a deconditioning problem. In the past, I think people have seen the solution to falls as stop them moving, but maybe we need to see the solution for falls as get them moving and interestingly, at our site, there was no increase in falls despite an increase in mobility. And that's consistent with the worldwide data from End PJ Paralysis. And in fact, some sites are showing a reduction in falls. So we need to communicate this message about falls risk being pinned to deconditioning. And I think Amelia Crabtree, who is the lead geriatrician at Caulfield, has a great thing that she says, is that you might have a 20% risk of falls, but you've got a 100% risk of deconditioning. 

Dawn
I think that's a really important statistical kind of key message about that. Picking up Claire on your point about policy, I think that's a really pivotal part of the jigsaw and I think we've talked a lot this morning about being such a multifaceted approach, but I think that is a key issue in terms of changing messages and having policy and structures and processes in place. And we've also heard quite a lot about advocacy, I guess across the conference these last few days as well, and I think as physiotherapists, that's possibly where we need to step up more in that space as well. We're doing the research. We're doing the clinical side of things, but we need to communicate the problems really quite clearly and actually get that as a policy agenda and I'm not sure how we do that exactly, but I think it's one of the most important things that we need to do. 

Christina
Yeah, I think we need to talk to our individual hospital falls risk groups because often they're really setting the agenda. And we've certainly found that at Caulfield. They don't want to see an increase in falls. That's their main priority. So you've got to work with them to reframe the conversation. 

Dawn
I think that about wraps it up. We've probably got sessions that we need to move on to now. So thank you so much for chatting this morning, ladies. It's been fantastic to find out more about our research ideas for the future. 

Christina
Thanks, Dawn. Thanks Claire. 

Claire
Thank you both. 

Narrator
That was Dr Christina Ekegren from Monash University, Dr Claire Baldwin, from Flinders University, and Dawn Simpson, from the University of Tasmania. And you've been listening to another episode of Talking Physio brought to you by the Physiotherapy Research Foundation and FlexEze. Thanks for listening and make sure you catch the next episode of the Talking Physio podcast.