Griffith Research Online
https://research-repository.griffith.edu.au
Gaming console exercise and cycle or
treadmill exercise provide similar
cardiovascular demand in adults with
cystic fibrosis: a randomised crossover trial
Author
Kuys, Suzanne, Hall, Kathleen, Peasey, Maureen, Wood, Michelle, Cobb, Robyn, Bell, Scott C.
Published
2011
Journal Title
Journal of Physiotherapy
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Official Journal of the Australian Physiotherapy Association
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Editorial
Appraisal
5
55 Critically Appraised Papers
Implications of regulatory requirements for smartphones,
gaming consoles and other devices
Research
11 Exercise and manual therapy for knee osteoarthritis
21 Increased pressure support during vibrations in intensive care
27 Mental practice in Parkinson’s disease
35 Gaming console exercise in cystic fibrosis
41 Adherence to physiotherapy guidelines for ankle injuries
47 Walking and physical activity after stroke
58Clinimetrics
62 Clinical Practice Guidelines
63Correspondence
64Media
Kuys et al: Gaming console exercise in cystic fibrosis
Gaming console exercise and cycle or treadmill exercise
provide similar cardiovascular demand in adults with
cystic fibrosis: a randomised cross-over trial
Suzanne S Kuys1,2, Kathleen Hall3, Maureen Peasey3, Michelle Wood3, Robyn Cobb3 and
Scott C Bell3,4
1
Allied Health Research Collaborative, Metro North (Northern) Health Service District, 2 School of Physiotherapy and Exercise Science, Griffith
University, 3Adult Cystic Fibrosis Centre, The Prince Charles Hospital, 4 School of Medicine, University of Queensland,
Queensland, Australia
Question: Does exercise using a gaming console result in similar cardiovascular demand and energy expenditure as
formally prescribed exercise in adults with cystic fibrosis? How do these patients perceive gaming console exercise? Design:
Randomised cross-over trial with concealed allocation and intention-to-treat analysis. Participants: 19 adults with cystic fibrosis
admitted to hospital for treatment of a pulmonary exacerbation. Intervention: Participants underwent two 15-minute exercise
interventions on separate days; one involving a gaming console and one a treadmill or cycle ergometer. Outcome measures:
Cardiovascular demand was measured using heart rate and rating of perceived exertion (RPE). Energy expenditure was
estimated using a portable activity monitor. Perception (enjoyment, fatigue, workload, effectiveness, feasibility) was rated using
a horizontal 10-cm visual analogue scale. Results: There was no significant difference in average heart rate (mean difference
3 beats/min, 95% CI –3 to 9) or energy expenditure (0.1 MET, 95% CI –0.3 to 0.5) between the two interventions. Both
interventions provided a ‘hard’ workout (RPE ~15). Gaming console exercise was rated as more enjoyable (mean difference 2.6
cm, 95% CI 1.6 to 3.6) than formal exercise but they didn’t differ significantly in fatigue (–1.0 cm, 95% CI –2.4 to 0.3), perceived
effectiveness (–0.4 cm, 95% CI –1.2 to 0.3), or perceived feasibility for inclusion in routine management (0.2 cm, 95% CI –0.7
to 1.1). Conclusion: Gaming console exercise provides a similar cardiovascular demand as traditional exercise modalities. It
is feasible that adults with cystic fibrosis could include gaming console exercise in their exercise program. Trial registration:
ACTRN12610000861055. [Kuys SS, Hall K, Peasey M, Wood M, Cobb R, Bell SC (2011) Gaming console exercise and
cycle or treadmill exercise provide similar cardiovascular demand in adults with cystic fibrosis: a randomised crossover trial. Journal of Physiotherapy 57: 35–40]
Key words: Cystic fibrosis, Respiratory disease, Energy expenditure, Exercise, Physiotherapy
Introduction
Exercise is recognised as an important component of overall
treatment for people with cystic fibrosis (Bradley and Moran
2008, Hebestreit et al 2010, Williams et al 2010). Benefits of
regular exercise in this population include enhanced mucus
clearance (Salh et al 1989, Bilton et al 1992), increased
respiratory muscle endurance, decreased breathlessness
(O’Neill et al 1987), and increased cardiorespiratory fitness
(Hebestreit et al 2010, van Doorn 2010, Shoemaker et al
2008). Other reported benefits include improved body image
through increased muscle mass and strength (Sahlberg et al
2008) and promotion of emotional well being and perceived
health (Selvadurai et al 2002, Hebestreit et al 2010). With
a lack of exercise training potentially leading to increasing
severity of lung disease and a reduced ability to perform
everyday tasks (Bradley and Moran 2008), it is imperative
that strategies to maximise adherence with treatment
regimens are investigated.
Adults with cystic fibrosis typically have low long-term
adherence to their often complex treatment regimen,
including chest physiotherapy and exercise, despite being
aware of its importance (Myers 2009). Various factors have
been shown to influence adherence to both exercise and
chest physiotherapy including the degree to which a person
is worried about their disease (Abbott et al 1996), their
gender, the perceived burden of the treatment (Myers 2009),
being too busy, and not being bothered (White et al 2007).
Strategies suggested to improve adherence to exercise
include incorporating regular supervision and providing an
individualised exercise program that is enjoyable and to the
patient’s interests and limitations (Prasad and Cerny 2002,
Pendleton and David 2000), although this has received little
investigation.
Exercise programs based on using a gaming console offer
the potential to meet some of the challenges associated
with exercise adherence in people with cystic fibrosis.
One popular commercially available gaming console is
Nintendo-WiiTM. It comprises a suite of games and activities
that involve the player in dance, martial arts, sports and
other forms of physical activity. Some programs such as
Nintendo-WiiTM Fit and EA Sports WiiTM Active specifically
target physical fitness through a range of aerobic, balance,
yoga, and strengthening activities. Nintendo-WiiTM has a
wireless controller which is purported to detect movement
in three dimensions. In addition, the WiiTM balance board,
a component of the Wii-Fit game that contains four
pressure transducers, has been shown to be a valid measure
of standing balance (Clark et al 2010). Gaming console
exercise provides instant visual and verbal feedback with
games that are goal-oriented and enjoyable and therefore
has the potential to improve motivation and adherence to an
exercise program.
Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
35
Research
An exercise program using a gaming console may improve
exercise adherence among people with cystic fibrosis because
the exercise is purported to be fun, which may increase
motivation to exercise. However, before gaming console
exercise is included in an exercise program it is important to
determine if it provides a similar cardiovascular demand as
more traditional exercise programs. Therefore, this research
sought to investigate if gaming console exercise is a feasible
mode of aerobic exercise in adults with cystic fibrosis.
Specifically, the research questions were:
1. Does participating in 15 minutes of exercise using
a gaming console produce a similar cardiovascular
demand and energy expenditure as exercise on a
treadmill or cycle ergometer in adults with cystic
fibrosis?
2. Is the gaming console exercise perceived as more
enjoyable, less fatiguing, and achieving a similar
workload as exercise on a treadmill or cycle ergometer?
3. Is the gaming console exercise perceived as equally
effective and feasible for use as a regular exercise
regimen as exercise on a treadmill or cycle ergometer?
Method
Design
A randomised cross-over trial with concealed allocation,
intention-to-treat analysis, and assessor blinding for two
outcomes was conducted at a tertiary referral public hospital
in Brisbane, Australia. Participants underwent two exercise
interventions in a randomised order within a 48-hour period.
One intervention involved exercise using a gaming console
and the other involved exercise on a treadmill or cycle
ergometer. Participants were randomly allocated to the order
of exercise interventions by an investigator independent of
the recruitment of participants using a computer-generated
random number program. Allocation was concealed with
the use of consecutively numbered envelopes.
Participants, therapists, centre
Patients with cystic fibrosis admitted to The Prince
Charles Hospital, Brisbane, for treatment of a pulmonary
exacerbation were eligible to participate in this study once
they were considered clinically stable, ie, had a temperature
within normal limits, were not excessively breathless, and
had a respiratory rate < 25 breaths/minute. Also, they were
required to be able to communicate in English and to be
receiving a daily physiotherapy exercise program as part of
routine inpatient management. Patients were excluded if they
had a cardiovascular condition prohibiting participation in
an exercise program, a systemic disease affecting muscles
or joints (eg, acute arthritis), recent surgery, or acute
musculoskeletal pain requiring physiotherapy intervention.
Demographic and clinical information collected included
age, gender, and lung function.
Intervention
The gaming console used for the experimental intervention
was the Nintendo-WiiTMa. The intervention incorporated
interval training using the EA Sports WiiActiveTMb
program and involved an individualised program
comprising games and activities such as boxing, running/
track exercises, and dancing tailored to each participant’s
preferences, impairments, and activity limitations. The
control intervention consisted of moderate intensity interval
training using a treadmill or cycle ergometer, depending
on the participant’s preference, and again tailored to each
36
participant’s impairments and activity limitations. For both
interventions, instructions were provided to participants to
exercise at an intensity that resulted in some breathlessness
but still allowed speech, aiming for a Borg scale score
between 3 and 5. Each intervention was supervised by the
same physiotherapist. Prior to each exercise intervention,
participants sat quietly in a chair for 10 minutes before
recording resting measures. Each exercise intervention
comprised 15 minutes of exercise, including warm up and
excluding rest periods and cool down. The warm up and
cool down consisted of lower intensity exercise relevant
to each intervention, eg, walking or slow pedaling and
stretching.
Outcome measures
Cardiovascular demand of the two exercise interventions
was measured using heart rate and oxygen saturation
recorded continuously via a forehead probe with a pulse
oximeterc. Participant perception of the cardiovascular
demand of each exercise intervention was measured using
the modified Borg dyspnoea scale (Mahler et al 2001) and
Rating of Perceived Exertion scale (6 to 20) (Borg 1982) to
indicate breathlessness and exercise intensity respectively.
Energy expenditure during the exercise was measured
using a SenseWear Pro activity monitord. The SenseWear
Pro activity monitor, worn on the right upper arm, measures
skin temperature, galvanic skin response, heat flux, and
motion via a 2-axis accelerometer, calculating energy
expenditure in metabolic equivalents (MET) during the
recorded movement (Jakicic et al 2004). The SenseWear Pro
activity monitor has been shown to be reasonably accurate
for measuring energy expenditure during short bursts of
different intensity activities in healthy adults (Berntsen et al
2010) and in adults with cystic fibrosis (Dwyer et al 2009)
with the activity monitor slightly overestimating energy
expenditure during low to moderate intensity activities
and underestimating energy expenditure at high exercise
intensities compared to indirect calorimetry (Dwyer et al
2009). Data from the activity monitor were deidentified at
downloading to allow assessor blinding for average and
total energy expenditure.
The participants’ perception of using a gaming console
as an exercise modality was measured using a 10-cm
horizontal visual analogue scale. Participants were asked
to rate their level of enjoyment, fatigue experienced, and
workload achieved during the exercise intervention. In
addition, participants were asked to rate their confidence
that the exercise intervention met their perception of an
effective exercise for them and that the exercise intervention
was feasible to be included as a component of their routine
exercise regimen. All visual analogue scales were anchored,
with the left hand anchor indicating no agreement with the
statement (no enjoyment, not fatiguing, no workload, not
effective, not feasible) and the right hand anchor indicating
strong agreement (very enjoyable, very fatiguing, etc).
Cardiovascular demand and energy expenditure measures
were recorded continuously during 5 minutes of rest at
the start of the exercise interventions and during the 15
minutes of exercise. The participants’ perceptions of the
exercise intervention were measured at the completion of
the exercise.
Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Kuys et al: Gaming console exercise in cystic fibrosis
Inpatients with CF screened (n = 21)
Excluded (n = 2)
• early discharge planned
Measured heart rate, oxygenation energy expenditure
Randomised (n = 19)
(n = 9)
(n = 10)
Experimental Intervention
• Gaming console x 15 min
• Usual care
Control Intervention
• Cycle ergometry or treadmill
walking and running x 15 min
• Usual care
Measured heart rate, oxygenation, energy expenditure, enjoyment, fatigue, perceived workload,
perceived effectiveness and perceived feasibility
(n = 9)
(n = 10)
Washout period of 24 hr of usual activity and usual care
Measured heart rate, oxygenation and energy expenditure
(n = 9)
(n = 10)
Control Intervention
Experimental Intervention
Measured heart rate, oxygenation, energy expenditure, enjoyment, fatigue, perceived workload,
perceived effectiveness and perceived feasibility
(n = 9)
(n = 10)
Figure 1. Design and flow of participants through the trial.
Data analysis
The primary outcome was the average heart rate during
exercise. We planned and undertook an analysis of the first
14 participants to determine the standard deviation of the
difference between two recordings of the average heart rate
during exercise in the same patient, which was 12 beats/
min. In the absence of an established value, we nominated
10 beats/min as a clinically worthwhile difference in heart
rate during exercise based on our clinical experience and
because it exceeds day-to-day variability in heart rate
(Achten and Jeukendrup 2003). Therefore, a sample size of
18 participants was required to achieve 90% power to detect
a difference of 10 beats/min between the two exercise
interventions at a significance level of 0.05.
All measures were analysed using an intention-to-treat
analysis. Means and standard deviations were calculated
for all variables. Average, minimum and maximum values
were recorded for heart rate and oxygen saturation during
the 5-minute rest period and the 15-minute exercise period
for each exercise intervention. Average energy expenditure
during the 15 minutes of exercise was estimated by the
activity monitor software in metabolic equivalents (MET).
Total energy expenditure for the entire exercise intervention
was estimated in kilocalories by the same software.
Differences in all variables between the two exercise
interventions were analysed using paired t–tests. Results
were reported as mean differences and 95% CI. Statistical
significance was set at 0.05.
Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
37
Research
Table 1. Baseline characteristics of participants.
Characteristic
Age (yr), mean (SD)
Gender, n male (%)
FEV1 (% pred), mean (SD)
FVC (% pred), mean (SD)
Table 3. Mean (SD) of all outcomes collected after exercise,
and mean (95% CI) difference between interventions.
n = 19
28 (7)
10 (53)
51 (21)
71 (16)
Outcome
FEV1 = forced expiratory volume in 1 sec, FVC = forced vital
capacity, % pred = percentage of the predicted value
Energy expenditure total
(kcal)
Table 2. Mean (SD) of heart rate, oxygenation and energy
expenditure at rest before each exercise intervention, and
during each exercise intervention, and the mean (95% CI)
difference between intervention groups during exercise.
Outcome
Heart rate
(bpm)
Maximum
Average
Minimum
Oxygenation
(SpO2%)
Maximum
Average
Minimum
At rest
During exercise
Exp
Con
Exp
Con
Exp
(n = 19) (n = 19) (n = 19) (n = 19) minus
Con
102
(14)
91
(16)
81
(16)
101
(16)
90
(15)
80
(15)
174
(20)
144
(13)
108
(17)
165
(16)
141
(15)
95
(17)
9
(3 to 15)
3
(–3 to 9)
13
(2 to 24)
99
(2)
98
(2)
95
(4)
99
(2)
98
(2)
96
(2)
99
(2)
97
(3)
94
(4)
98
(3)
96
(3)
92
(8)
1
(0 to 3)
1
(0 to 2)
2
(–2 to 6)
Energy
1.6
1.5
6.5
6.4
0.1
expenditure
(0.8)
(0.5)
(1.0)
(1.1)
(–0.3 to
(MET)
(n = 17) (n = 17) (n = 17) (n = 17)
0.5)
bpm = beats per minute, SpO2 % = percentage saturation of
oxyhaemoglobin measured by pulse oximetry, MET = metabolic
equivalents, shaded rows = primary outcomes
Results
Flow of participants through the study
Interventions
Difference
between
interventions
Exp
Con
(n = 19) (n = 19)
Exp minus
Con
127
101
(55)
(55)
(n = 17) (n = 17)
26
(17 to 35)
Visual analogue scale
(cm)
Enjoyment
7.3
(1.6)
4.7
(2.0)
2.6
(1.6 to 3.6)
Fatigue
4.9
(2.3)
5.9
(2.0)
–1.0
(–2.4 to 0.3)
Perceived workload
6.3
(1.4)
6.1
(2.4)
0.2
(–0.9 to 1.3)
Perceived
effectiveness
7.9
(1.5)
8.3
(1.2)
–0.4
(–1.2 to 0.3)
Perceived feasibility
8.0
(1.5)
7.8
(1.6)
0.2
(–0.7 to 1.1)
Borg dyspnoea scale
(0 to 10 scale)
5.1
(2.1)
5.1
(2.2)
0
(–0.6 to 0.6)
RPE
(6 to 20 scale)
15.0
(2.6)
15.5
(2.6)
–0.5
(–1.4 to 0.4)
kcal = kilocalories, RPE = Rating of Perceived Exertion scale
During the 15-minute exercise, there was no significant
difference in the average heart rate between the gaming
console exercise of 144 beats/min (SD 13) and control
exercise of 141 beats/min (SD 15), mean difference 3 beats/
min (95% CI –3 to 9). However, gaming console exercise
induced a significantly higher maximum heart rate, by
9 beats/min (95% CI 3 to 15) and a significantly higher
minimum heart rate, by 13 beats/min (95% CI 2 to 24).
Average, maximum and minimum oxygen saturation during
exercise did not differ significantly between the groups,
with between-group differences of only 1–2% (absolute).
Participants thought both exercise modes provided a ‘hard’
workout, rating each on average a score of about 15 on the
RPE scale (Table 3).
Nineteen participants with cystic fibrosis admitted to
inpatient care following an acute episode were recruited
to this study (Figure 1). Their baseline characteristics are
presented in Table 1. Ten (53%) participants undertook the
control intervention (exercise using either a treadmill or
cycle ergometer as prescribed by the treating physiotherapist)
first. The two exercise interventions were conducted for
all participants within a 48 hour period, within 72 hours
of discharge. Both exercise modes were delivered by the
same physiotherapist in the Physiotherapy Gym of the
Adult Cystic Fibrosis Unit at The Prince Charles Hospital
in Brisbane, Australia.
Energy expenditure
Cardiovascular demand
The participants’ perception of the exercise is presented
in Table 3. Participants rated the gaming console exercise
as significantly more enjoyable on the 10-cm visual
analogue scale, mean difference 2.6 cm (95% CI 1.6 to
Exercise heart rate and oxygen saturation data during rest
and each exercise intervention are presented in Table 2.
38
Energy expenditure at rest and during the 15 minutes of
exercise is presented in Table 2. No data were recorded for
two participants, one each in both exercise interventions.
There were no significant differences between the two
exercise modes during the 15 minutes of exercise (1.0
MET, 95% CI –0.3 to 0.5). However, there was a significant
difference between the two exercise interventions for the
total energy expended in the whole exercise session (26
kcal, 95% CI 17 to 35), as presented in Table 3.
Perception of exercise
Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
Kuys et al: Gaming console exercise in cystic fibrosis
3.6). Participants did not perceive significantly different
fatigue or workload between the two types of exercise.
Participants thought both exercise modes were an effective
form of exercise, rating each on average a score of about 8
on the visual analogue scale. Similarly, participants thought
both exercise modes would be feasible to include as part
of their regular exercise regimen, rating each on average a
score of about 8 on the visual analogue scale. The amount
of dyspnoea also did not differ between the two types of
exercise.
Discussion
Exercise involving a gaming console appears to be a feasible
mode of aerobic exercise for adults with cystic fibrosis. The
cardiovascular demand, energy expenditure, perceived
workload, and amount of fatigue appear to be similar
between the two types of exercise. Participants reported
greater enjoyment at the completion of the exercise session
using the gaming console.
Aerobic exercise appears to be beneficial for people with
cystic fibrosis (Shoemaker et al 2008) with some slowing
of the decline in lung function (Schneiderman-Walker et
al 2000). Therefore, it is worthwhile investigating exercise
options – especially those that appeal to patients – to
determine if they are appropriate for people with cystic
fibrosis. There are three requirements for exercise to be
classified as aerobic: appropriate activity, intensity, and
duration (ACSM 2010). Recommended activities are those
that: involve large muscle groups, are rhythmical in nature
such as walking or running, and last a minimum of 20
minutes in total. The gaming console used in the current
study incorporates some whole body, some predominantly
upper limb, and some predominantly lower limb activities.
The modalities of exercise typically investigated for cystic
fibrosis, on the other hand, tend to involve predominantly
lower limb activities such as walking, running, and cycling
(Bradley and Moran 2008). Adults with cystic fibrosis work
less during arm compared to leg exercise (Alison et al 1997).
However, any reduction in workload during upper limb
activities in the current study appears to have been minimal
or compensated for by other activities because participants
rated both exercise interventions as a ‘hard’ workout with
similar heart rate and energy expenditure recorded. This
suggests that participants were able to achieve a comparable
workload during the gaming console exercise compared
to exercise using a treadmill or cycle ergometer. In fact,
calculating the workload using average heart rate during
each exercise intervention as a percentage of age predicted
maximal heart rate, an average intensity of 73% was
reached. This is a sufficient intensity for those with low to
average levels of fitness (ACMS 2010) to improve aerobic
fitness. This is therefore a reasonable intensity level for use
with these adults with cystic fibrosis who had just recovered
from a pulmonary exacerbation. However, this may not be
applicable for other populations because people with cystic
fibrosis have been shown to have a higher energy cost for
physical activity, in particular, for walking compared to
healthy controls (Richards et al 2001).
We included maximum and minimum measures in the
current study to gauge the range of cardiovascular demand
in both exercise interventions. In particular, maximum heart
rates were monitored as is typically done during a treatment
session, to ensure that excessive cardiovascular demand
was not being placed on the participant. Although the
average heart rate during the exercise did not significantly
differ between the two types of exercise, higher minimum
and maximum heart rates were recorded during the gaming
console exercise. This might require monitoring if gaming
console exercise is included as a treatment option for
inpatients or as a component of a regular exercise program.
The greater total energy expenditure observed during the
gaming console exercise might be due to the method of
delivery. Gaming console exercise uses a number of different
games or activities, each lasting up to several minutes. At
the completion of each game, feedback is provided including
a ‘score’ and verbal encouragement about the performance.
During this time, no exercise is undertaken but the person
remains standing. This intermittent form of exercise may
account for the longer time – at least 20 minutes – required to
complete the 15 minutes of exercise when using the gaming
console. This had the added benefit of increasing the total
time spent active and may have contributed to the greater
overall energy expenditure observed during the gaming
console exercise intervention. The duration of exercise used
in the current study of 15 minutes was not sufficient to meet
the requirements for aerobic training. However, as fatigue
levels were recorded at only about 5 cm on the 10-cm visual
analogue scale, we are confident that patients could achieve
longer periods with both types of exercise, although this
requires confirmation.
The reasons for adherence to exercise programs are
complex. Enjoyment and perceived competence in an
activity or exercise have been suggested to be among the
most important (Prasad and Cerny 2002). Participants in
the current study enjoyed the gaming console exercise more
than the standard care exercise. However, novelty may have
contributed to this. Despite the widespread availability of
gaming consoles, few participants reported using the type
in the current study prior to participation in this study,
though this was not formally recorded. Anecdotally, some
of the study participants have purchased a gaming console
subsequent to participating in this study and continue
to use them in their exercise program. A longer exercise
program using gaming consoles needs to be investigated to
determine if these factors affect adherence and outcomes.
A limitation of this study is that it examined only one
short session of each exercise. Longer periods of exercise
and longer duration programs should also be investigated,
ideally using a randomised study design. The SenseWear
Pro armband may have introduced another limitation in
the measurement of energy expenditure. Gaming console
exercise may involve more vigorous upper limb activity
compared to exercise on a treadmill or cycle ergometer. In
addition, the device has not been specifically validated for
upper limb exercise and for some people, walking or running
on a treadmill may involve holding onto the handrail (Wass
et al 2005), thus limiting upper limb movement. This might
limit the accuracy of the energy expenditure measurement.
In conclusion, in this group of adults with cystic fibrosis being
discharged from hospital after recovering from a pulmonary
exacerbation, participation in an exercise program using a
gaming console appears feasible. Cardiovascular demand
and energy consumption were comparable between the two
types of exercise and greater enjoyment was reported when
using the gaming console than when using the treadmill or
cycle ergometer. n
Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011
39
Research
Footnotes: aNintendo Model No. RVL-001(AUS), bWiiTM
EA Sports ActiveTM Model No. RVL P R43P-AUS,
c
Nellcor N-20PA Handheld Pulse oximeter, dBody Media,
Pittsburg, PA
Ethics: The Prince Charles Hospital Human Research
Ethics Committee approved this study. All participants
gave written informed consent to participate in the study
before data collection began.
Competing interests: None declared.
Correspondence: Dr Suzanne Kuys, Allied Health
Research Collaborative, Metro North (Northern Cluster)
Health Service District, The Prince Charles Hospital, Rode
Road, Chermside, Queensland 4032, Australia. Email:
[email protected]
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Journal of Physiotherapy 2011 Vol. 57 – © Australian Physiotherapy Association 2011