Group-based, individualized exercises can provide perceived bodily changes and strengthen aspects of self in individuals with MS: a qualitative interview study

Figures & data

Table 1. Description of the GroupCoreDIST intervention

GroupCoreDIST Dose and equipment	GroupCoreDIST Content and examples
Individual clinical examination 60-minute session before the start of the group sessions	History: Medical, social and patient history; symptoms; main issues from the patient’s perspective Analysis: Observation and hands-on interaction. Consider the patient’s resources and constraints for movements. Posture analysis: Various postural sets; for example, standing, sitting and lying down. Consider the alignment throughout the body and for each body area, adaptation to the base of support and interaction with the environment. Activities/movement analysis: For instance; walking, standing on the toes or heels, squats, one-leg standing and other balance challenges. Consider the body’s relation to the base of support, movement patterns of the body as a whole, and specific body parts and their relation to each other, the task and the environment. Consider the ability to perform selective movements (to move one part of the body while stabilizing other parts) to provide coordination. Specific tests: Muscle length, muscle activation and strength, tonus, somatosensory function, pain, reflexes. Introduction to GroupCoreDIST exercises: Choose and try out a few exercises in relation to the individual’s movement problems. Hands-on adjustments to improve alignment, adaptation to the base of support and movement quality. Explore the participant’s ability for improved performance in the exercises. Conclusion: Consider the patient’s resources and issues, hypothesis of causation and the main problem related to movement and balance and potential for improved movement control.
Group sessions Duration: 60 minutes, 3 times per week for 6 weeks Equipment: Large therapy balls, small mobilization balls as well as rolled towels, bolsters, plinths and rubber bands for optimal alignment.	Planning the group sessions: Consider each participant’s main problem and which underlying impairments are related to it. Choose exercises that suit the three participants and choose the appropriate postural set and variation of exercises (5 variations for each of the 33 exercises, 6 different exercise categories) for each participant to be able to perform the exercise with optimal movement quality. Goal: Teaching the participants specific exercises that can be performed both together with a physical therapist and at home. It is a goal that participants should perceive improvements in balance and movement control.
Beginning and end of all group sessions	The physiotherapist asks how everyone is doing that day and for experiences regarding the performance of home exercises. Individual balance challenges are performed simultaneously for all participants at the beginning and end of each session, to perceive and reflect on their own balance that day, compare their own balance before and after each session, and provide an opportunity for the physical therapist to interlink the individual’s balance challenges with the choice of exercises.
Exercises Perform up to 3 × 10 repetitions according to the individual’s capacity and quality of performance. As the quality of movement in the exercise improves, the physiotherapist may adjust the dose by increasing the number of repetitions, using a more difficult variation of the exercise or adding dual task challenges.	Group members concurrently conduct the same exercise but with different variations according to symptoms and quality of performance. All six exercise categories should be used at every group session. All exercises target optimal adjustment to the base of support and activation of the core while performing the exercise. The 6 exercise categories are: 1) Somatosensory stimulation/activation of the hands or feet: exercises 1–2, somatosensory activation of the feet or hands to enhance adaptation to the base of support, for instance, by rolling a mobilization ball with the hands or feet. 2) Muscle length: exercises 3–9, addressing concentric and eccentric activity in muscles of the neck, upper and lower limbs. 3) Selective movement and coordination: exercises 10–21, selectively moving the arms and legs or particular parts of the core. Focus on dynamic stability, keeping one part of the body stable while moving another. 4) Training larger muscle groups: exercises 22–27, recruiting larger muscle groups in various standing positions for instance rolling the ball up and down toward the wall with your back. 5) Advanced challenges for balance and postural control: exercises 28–32, giving advanced challenges for postural control and balance for instance jumping while bouncing the therapy ball. 6) Relaxation: exercise 33, systematically performing contraction/relaxation of other parts of the body.
Additional challenges and adaptations	Motor-motor dual tasks are performed in all exercises while performing more than one motor task at once for instance as keeping the back in contact with the therapy ball while rolling it from side to side. Advanced motor-motor dual tasks such as throwing a towel or a ball to the other group members could be added. Motor-cognitive dual tasks may be added, for instance, singing, rhyming or calculating while performing exercises. All dual task activities may also enhance group dynamics, engagement and having fun. Both instructions and hands-on facilitation are allowed to improve movement quality, make movement possible or easier, decrease inexpedient compensatory movement patterns and optimize the movement experience (Vaughan-Graham and Cott, 2016).
Home training Unsupervised GroupCoreDIST exercises for 30 minutes, 2 times per week during the six weeks of the intervention	The physical therapist cooperates with each participant to identify exercises for home training. The exercises are individualized and mirror what is highlighted during group trainings. Home training contains all six exercise categories. The training progresses in line with the exercises performed in the group sessions. Equipment: The same as for the group sessions

Table 2. Participants’ demographic background data. The mean or % and (min-max) are presented

Variable	Total (n = 13)
Age	Mean 46 (25–78)
Gender	9 women/4 men, 69%/31%
Type of MS	Relapsing remitting 9/69% Primary progressive 2/15.5% Secondary progressive 2/15.5%
EDSS	Mean, 3.5 (1–6.5) years
Time since diagnosis	Mean, 10.8 (0.5–23) years

Table 3. Interview guide: 7-week interviews

Theme	Possible questions
Background information	Could you tell me a little bit about yourself, please? Time of diagnosis, type of MS, EDSS status, where you live, are you employed, your social status, physical activity, and have you been seeing a physiotherapist before the study?
Opening question	Is there anything you would like to point out and tell me about your participation in the GroupCoreDIST training?
Experiences from the first meeting with the physical therapist and the individual clinical examination	How did you experience the first meeting with the physiotherapist and the individual clinical examination? What did the individual clinical examination before the group training started mean to you?
Experiences from the 6 weeks of group-based training	How did you experience the GroupCoreDIST training? How did you perceive and respond to the training? How did you perceive the group?; the content of the training?; individualization?; hands on interactions and and instructions? How did you experience the physiotherapist`s role and competence? How did you perceive the dose and intensity of the training? What did the training mean to you? Did you learn anything from the training period? Were there any challenges during the training? Could you tell me what happened in these challenging situations? Did you experience some things that went really well? Some things than did not work out so well?; Or some things that you would like to change? Could you tell me if there were any episodes in particular that made a special impression on you? Was there anything you did not like, something that made you feel uncomfortable or was not as expected? Have you reflected on the group-based training compared to previous experiences with physical therapy?
Experiences from home training	How did you experience the obligation for home training? Can you describe one of your regular home-training sessions, how you experienced this and what it meant to you? Were there any challenges? Things that went well or not so well? Are there things you would like to change? How did you experience performing the exercise on your own?
Experiences of impairments, daily function, activities and participation	Can you describe how you experience your function, impairments and disability? Can you describe daily activities you normally participate in? Did you experience any changes? How was family life and life in general during the period?
Experience of quality of life	Is there anything you would like to pinpoint concerning your daily life? Did you experience the training as having a negative or positive influence in your daily life?
Closing question	Are there any experiences from the group-based training that you would like to share that other individuals with MS or physiotherapists could learn from? How did you experience being interviewed?

Table 4. Interview guide: 30-week interviews

Theme	Possible questions
Opening question	Is there anything you would like to point out and tell me about your participation in the GroupCoreDIST? Do you have any reflections of the period after the training was completed?
Experiences of impairments, daily function, activities and participation	Can you describe how you experience your function, impairments and disability? What daily activities do you normally participate in? Did you experience any changes in daily activities during or after the training period? Were there any challenges? How did you experience family life and life in general after the training period was completed?
Experiences from home training	Did you perform home training after the intervention was completed? How did you experience this? Were there any challenges? Things that went well or not so well? Or things you would like to be different?
Retrospective reflections from the 6 weeks of group-based training	How did you experience the training? How did you respond to the training? How did you experience the group? The content of the training? Individualization? Hands on adaptations and instructions? How did you experience the physiotherapist`s role and competence? How did you perceive the dose and intensity of the training? What did the training mean to you? Did you learn anything from the training period? Were there any challenges during the training? Could you tell me what happened in these situations? Did you experience some things that went really well? Or not work out so well? Would you like to change something? Could you tell me if there were any episodes in particular that made a special impression on you (positive or negative)? Have you reflected on the group-based training versus previous experiences with physical therapy?
Experience of quality of life	Is there anything you would like to pinpoint concerning your daily life/life quality in the period after the training finished? Did you experience the training to have any influence in your daily life long term (positive or negative)?
Thoughts about the future	Do you have any thoughts concerning future physical therapy, group-based training, or activity in the future? Any challenges?
Closing question	Are there any experiences from the group-based training or the period after the intervention was completed that you would like to share that other individuals with MS or physiotherapists could learn from? Do you have anything else you would like to share? How did you experience being interviewed?

Table 5. Description and examples of the analytical process

Preliminary themes	Feeling a change Changes in everyday life and activity Confirmation of change The examination The physiotherapist’s one-to-one interactions, adaptations and engagement
Theory: Dynamic systems theory	Manipulation of constraints in the individual, the task and the environment. Changes in the individual´s subsystems make the whole movement pattern change which leads to improved movement control.
Theory: Phenomenology of the body	Changes influence the self-pattern: both pre-reflective and reflective aspects, how each individual looks at themselves and becomes attached to own movement possibilities: body schema, sense of ownership and agency. Body image and narrative self. “I can” or, in some cases, “I can’t.”
Meaningful units	“The changes feel fantastic; it makes me feel like there is hope, that it is actually possible to improve something that has been totally pacified and to move easier.”	“Suddenly, I experienced myself walking up the stairs without holding the handrail.”
Code group	Changes in bodily impairments and activities are meaningful for the participant
Sub-groups	Bodily changes and engagement	Reaccessing opportunities
Condensates (short summaries)	The participants reported the intervention to have a major impact, both immediately and in the long term, involving the absence of headaches, improved sensation in the hands and feet, improved activation of core muscles and better balance, as well as a faster gait with longer steps, more power and propulsion, and more endurance. They highlighted the importance of specific and engaged verbal instructions for exercises combined with hands-on facilitations by the physiotherapist during the group sessions.	The participants highlighted that living with a progressive disease such as MS meant gradually giving up activities. They were therefore astonished by the way the improvements in impairments and movement control had enhanced daily life activities and the performance of domestic obligations such as doing laundry without taking breaks and being able to stand on one’s toes to reach the upper kitchen cabinets and to carry two cups of coffee while walking. The participants expressed emotionally that increased energy allowed them to spend more time with their children and other family members.
Category	Movement control, orientation and insights

Table 6. Overview of the categories and subgroups

Category	Movement control, orientation and insights		The individual within the group
Subgroup	Bodily changes, and engagement	Re-access to opportunities	Acceptance and interactions	Adjustments and attentiveness to the individual

Vaughan-Graham J, Cott C 2016 Defining a Bobath clinical framework – A modified e-Delphi study. Physiotherapy Theory and Practice 32: 612–627.

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