R&I - (PO1) Commercial Research Policy

R&I - (PO2) Sponsorship & Central Trial Management Fees Policy

R&I – (P03) Excess Treatment Costs In Research at NBT has been suspended. All new research projects with excess treatment costs require approval from the General Manager/Clinical Director.

R&I - (PO4) NIHR Research Funding Recovery Policy

R&I - (PO5) - PPI in Research Payment Policy

R&D - (P06) Research Misconduct Policy

R&D P07 Safeguarding in Research Policy

NBT (CG-134) Adult Safeguarding Policy

NBT (CG-197) Safeguarding Children Policy

NBT (PEO-33) Fairness at Work Policy

RD/QMS/SOP/001 : Preparation of Research Standard Operation Procedures
RD/QMS/SOP/002 : Obtaining R&D Confirmation for Research to Start
RD/QMS/SOP/003 : Research Study Amendments
RI/QMS/SOP/004 : Maintenance of Research Equipment SOP
RD/QMS/SOP/005 : Research Staff Training
RI/QMS/SOP/006 : Honorary Research Contract Letters of Access SOP
RI/QMS/SOP/006a External Researcher Information Form
RI/QMS/SOP/007 : Applying for NBT Sponsorship
RI/QMS/SOP/007b NBT Terms & Conditions of Sponsorship
RI/QMS/SOP/007c Delegation of Responsibilities
RI/QMS/SOP/008 : Writing a Protocol for CTIMPS
RD/QMS/SOP/009 Periodic Reporting to Regulatory Authorities
RI/QMS/SOP/010 : Archiving
RI/QMS/SOP/011: R&I Closing Suspending and Terminating Research
RI/QMS/SOP/012 : R&I Managing Breaches of GCP or the Protocol
RI/QMS/SOP/012a : ICH GCP NonCompliance Report Form
RI/QMS/SOP/012b Identifying & preventing noncompliance with Good Clinical Practice or the protocol
RI/QMS/SOP/012c : Protocol Deviation Review & Analysis Form
RI/QMS/SOP/013 : R&I Safety Reporting
RI/QMS/SOP/014 : R&I Monitoring
RI/QMS/SOP/015 : R&I Computer System Validation & Backup
RI/QMS/SOP/016 : R&I Research Contracts & Vendor Selection
RI/QMS/SOP/017 : R&I Data Management
RI/QMS/SOP/018: R&I Management of Fridges & Freezers
RI/QMS/SOP/020 : Management of healthy volunteers in research
RI/QMS/SOP/021 : R&I Informed Consent in Adult Research Setting

QMS/TMPL/001/File Note

RD/QMS/TMPL/SOP 007a Sponsorship Request Form

RD/QMS/TMPL/SOP 007d Delegation of Responsibilities Log

RD/QMS/TMPL/SOP 007e CI Declaration Form

RD/QMS/TMPL/009 DSUR Template

RD/QMS/TMPL/012a ICH GCP + Protocol Non-compliance Report Form

RD/QMS/TMPL/012c Protocol Deviation Review + Analysis Form

RD/QMS/TMPL/013a Initial Safety Report Form- CTIMP

RD/QMS/TMPL/013b Follow Up Report Form - CTIMP

At North Bristol NHS Trust, we are committed to ensuring that all research conducted within our organisation upholds the highest standards of ethical integrity, safeguarding the rights, dignity, safety and wellbeing of everyone involved.

We support high-quality, ethical research that contributes to improving patient care, public health, and service delivery.

Ethical Review Process

All research involving our patients, staff, data or facilities must receive appropriate ethical review and approval before it begins. This may include:

• Review by a Health Research Authority (HRA) Research Ethics Committee (REC) – required for most research involving patients or identifiable NHS data.
• Local review through the Trust’s Research & Development (R&D) Department, which ensures projects meet NHS and Trust-specific governance requirements.

We work closely with the HRA to ensure compliance with the UK Policy Framework for Health and Social Care Research and all relevant legal and ethical standards, including GDPR and the Declaration of Helsinki. 

The HRA provides comprehensive guidance on the ethical review process, including the roles and responsibilities of RECs to ensure that we protect the rights, safety, dignity and wellbeing of participants.

This centralised approach ensures consistency and rigour in the ethical review of health and social care across the UK.

You can find out more information here: 

• HRA guidance – Applying to a Research Ethics Committee

Supporting Researchers

Our R&D team offers support and guidance throughout the ethical approval process. We help researchers:

• Identify the appropriate level of ethical review
• Prepare and submit applications via the Integrated Research Application System (IRAS), including development of the required submission documents such as research protocol, participant information sheets and consent forms.
• Understand key ethical considerations such as consent, confidentiality, risk, and public involvement.

If you are planning a research project, please contact our R&D team early in your planning process to ensure ethical requirements are met, as part of our sponsorship review process.

Contact Us

For further information or support with research ethics, please contact:

Research and Development

Research Sponsor
North Bristol NHS Trust
Email: researchsponsor@nbt.nhs.uk
Phone: 0117 414 9330

The risk of serious complications like these is small:

• Bleeding.
• Infection.
• Tears in the stomach.
• Abscess (a pocket of infection).
• Leaking of stomach contents into the chest or abdominal cavity.
• Pulmonary Embolism (a blood clot in the lung).
• Pneumothorax (collapsed lung).

Protein: try to include a protein food at every meal. Aim for 60-80g protein each day. Focus on low-fat protein sources such as chicken, fish, turkey, beans, lentils, tofu, or low-fat dairy.

Fats: limit the amount of oil, butter or margarine you use. Cooking sprays are a good alternative. Try to avoid high-fat foods such as cakes, biscuits, or crisps.

Carbohydrate: Limit carbohydrates with lots of starch. Try to have 1-2 meals per day which do not include starchy carbohydrates. Choose wholegrain options if you do eat them. Aim for less than 120g per day.

Sugars: Avoid adding any type of sugar, honey, or syrup to foods. Artificial sweeteners are ok to use. Aim to avoid eating any foods high in sugar e.g. cake, chocolate, sweets, fruit juice.

You will need to start taking a multivitamin and mineral supplementation as this diet is won’t give you all the nutrients you need. This can be either tablet or chewable/gummy. There is more information about vitamins later in this booklet.

Meal ideas

Nutrient tracking options

• Calorie Tracker & BMR Calculator to Reach Your Goals | MyFitnessPal
• Carbs & Cals | Dieting & Calorie Counting Books & App
• Top rated calorie counter website and app | Nutracheck

Where to find recipes

• Low-carb diet and meal plan | Eating with diabetes | Diabetes UK
• Low-carb meals - BBC Food
• Low calorie recipes and diet information - BBC Food
• Easy Low Calorie Meals | olivemagazine
• Books:
  • Pinch of Nom
  • Carbs and Cal: Very Low Calorie Recipes and Meal Plan
  • The Fast 800 Recipe Book

You can have low-sugar, high-protein, meal-replacement shakes to provide 800-1000 calories in total each day. Many of these shakes are low in fibre so it can be helpful to include 1-2 portions of vegetable or salad each day (fibre in these helps prevent constipation).

Look for shakes with 200-300 kcals and 20-30g protein per serving. Aim for a low sugar option - about 5g of sugar per 100g/100ml.

Some suitable options

* vegan options

If you have diabetes treated with tablet medication and/or insulin you will probably need to change these medications. Your diet before and after surgery will have very little carbohydrate and can increase your risk of hypoglycaemia.

We will help you make a plan in your pre-operative assessment appointment. You will need to monitor your diabetes control more closely during this time.

Following surgery, you will need to drink thin liquids (drinks) only for 2 days such water, squash, protein water, tea and coffee, and semi-skimmed milk.

• Have small amounts of fluid (no more than 50mls) every 10-15 minutes.
• Aim for least 2 litres of fluids each day.
• Even if you feel thirsty it is important you drink small quantities at a time
• Avoid fizzy or high sugar drinks such as juices.
• If you have stomach pain or nausea whilst drinking stop until the feeling has passed.

Aim to have high protein drinks, shakes, or soups which are smooth (with no lumps) regularly through the day. The liquids should be able to run off the back of a spoon like thin yoghurts, tinned soups, or runny custard.

• Portion sizes are approximately 100-300ml.
• Take small mouthfuls one at a time and give yourself a break in between mouthfuls so you can recognise the early signs of fullness and stop.
• If you feel pain, stop immediately.
• You will need to drink other fluids (water, tea, squash) to get your 2 litres fluids per day.
• It can be difficult to get enough nutrients while you are following a liquid diet.
• Aim to include as many liquids with lots of protein as possible. Protein is important for your general health including maintaining your muscle mass while you are losing weight. This will help your overall weight loss.
• Aim for 60g protein.

High protein liquids

• ‘Fortified milk’ - 1 pint semi-skimmed or skimmed milk with 4 tbsps of dried skimmed milk powder.
• Smoothies – fruit or vegetables blended with fortified milk, natural yoghurt or protein powder. (Avoid shop bought smoothies as these are low in protein and high in sugar).
• Smooth Soup (homemade or tinned). Add 1-2 tbsp of skimmed milk powder, protein powder or quark.
• Meritene or Complan shakes or soups – available in Supermarkets or pharmacies.
• Meal replacement shakes e.g. Slimfast, Tesco Slim, Asda Great Shape, Exante or Lighter Life.
• High protein milkshakes e.g. UFit, Arla, For Goodness Shakes, Urban Active
• Protein Water e.g. Vieve, Upbeat or +PW
• Whey, soya, or pea protein powders

Recipes

After 10 days of a liquid diet, you can progress to foods with a thicker, puree consistency. You will need to use a food blender, processor or liquidiser.

Start with 1 tsp of food at a time and check how you feel after. Each meal should have around 2- 4 tbsp. Aim to eat the protein part of the food first. It may be helpful at this stage to cook and freeze foods, as portions will be small.

See the example menu plan on the next page.

Tips:

• Eat protein food first, then vegetables and finally carbohydrates. P.V.C (Protein, Vegetable, Carbohydrate). In the early days, you may only manage the protein.
• Use high-protein milk in/with foods such as cereal, scrambled eggs etc.
• Try one new food at a time. If you feel sick, gas, or bloated, it may be the case you are not ready for this type of food, try again in a few days.
• Food can be liquidised in bulk and frozen. You can use an ice cube tray and take a few ice cubes out per meal.
• Slow cook or casserole meat in plenty of liquid to make it easier to blend.
• Adjust your portion sizes as you feel necessary. Listen to your body and stop before you feel full.

Sample meal plan

You no longer need to blend food. Gradually introduce foods which are soft in consistency, that is they fall apart easily with a fork. Foods which are naturally moist are good at this stage or add sauce/gravy to dishes.

You can also include crunchy foods in this stage such as cereal, crackers or toast. Make sure you chew these foods thoroughly. Start with a small portion e.g. 3 tablespoons as a meal and increase gradually depending on how you feel.

Tips:

• Aim to grill or air fry and use herbs/spices to flavour foods.
• If using oil, measure out a small amount (1-2 tsp).
• Try 1 tbsp (tablespoon) of a new food every 1-2 days. If you feel nauseated or bloated after eating, then you may not be ready for this food. Wait a few days before trying this food again.

Sample meal plan

You are now ready to progress onto your long-term healthy diet.

This can be challenging as you learn how much you can eat of certain foods and the importance of paying attention to your body as you eat. Continue to add new foods in slowly. Aim to eat 3 small meals per day with 1-2 snacks as necessary. Focus each meal and snack on protein-rich foods. Keep portions small by using a side plate. Aim to eat 60-80g protein per day.

Cooking tips:

• Remove fat and skin from meat before cooking.
• Use low fat cooking methods such as grilling, baking (wrap in foil to keep things moist), steaming or boiling.
• Limit oil or butter added to vegetables or salads. If you need extra flavour, add seasoning, low-calorie dressing or vinegar.
• If you need to use oil to stop food from sticking, use a spray oil.
• Add flavour using herbs, spices, seasonings, lemon juice, ginger, onions, and garlic.
• Aim to avoid adding oil or butter to carbohydrates.
• Choose high fibre (wholegrain) carbohydrate foods where possible like wholegrain bread, brown pasta, brown rice, wholegrain / seeded crackers or oatcakes and keep skins on potato.

Sample meal plan

Snack ideas - 100 calories with high protein

• Small handful nuts
• Slice of smoked salmon or ham with cucumber sticks
• Trail mix of nuts/seeds with dark choc chips
• 1 pot of high protein natural yoghurt (Icelandic or low fat Greek style)
• 1 pot Greek style Soya yoghurt
• 1 boiled or Devilled egg
• 1 oatcake or rye crispbread with 1 tbsp cottage cheese or low fat cream cheese
• 1 egg muffin
• Veg sticks with 1 tbsp of hummus or bean dip
• 2 tbsp roasted pumpkin/ sunflower seeds
• Slice smoked salmon with 1 teaspoon cream cheese
• Nice cream – frozen banana whizzed with peanut butter
• 1 pot of fruit flavoured high protein yoghurt
• 2 tbsp low fat Greek yoghurt with handful of berries
• 80g soya/edamame beans
• 80g Spicy chickpeas – try roasting with cumin and smoked paprika
• Slice of ham with low fat cheese spread* or cottage cheese
• 1 mini cheese or Babybel
• 1 stalk of celery or 2-3 slices of apple with 2 tsp of almond butter
• 1 pack of chicken bites

It is common to have constipation in the early days after these operations because you are not having much food and drink

To help manage constipation:

• Drink plenty of fluids – aim for 2 litres a day a day.
• Add in a laxative such as sodium docusate or senna.
• Add in some high fibre foods where able e.g. vegetables, wholegrain carbohydrates, beans and pulses.
• Keep as active as you can.

Please contact the Bariatric Team or the Bariatric Clinical Nurse Specialist if the above does not work.

If you have any of these, it may be because you are:

• Eating too quickly.
• Not chewing enough.
• Eating too much.
• Drinking with the meal or within half an hour after eating.
• Lying down too soon after eating.

If you suddenly feel unwell with symptoms such as shortness of breath, worsening abdominal pain, fever, limb swelling, unable to tolerate food/fluids, nausea and vomiting please go to the Emergency Department, contact Bariatric Team or GP.

It is common for people to feel tired and to have low energy levels in the early weeks after the procedure. This is usually because it is difficult to get enough calories and protein, also the fact you are losing weight.

Aim to consume at least 60g protein and 800 calories each day. If you are struggling to do this, it can be helpful to include protein shakes to help meet this target.

Tiredness can also, but less commonly, be due to a vitamin or mineral deficiency, so please do ensure you take your multivitamin and mineral supplement once a day.

In the first 6-9 months, it is common to have some hair loss. This also is usually due to not enough calories and protein. Once your weight loss has stopped, this problem usually goes away.

After your procedure you will be eating much smaller portions of food and it can be hard to get all the vitamins and minerals your body needs. Please take the following vitamins and minerals. You can buy these in most supermarkets, chemists, or online.

• 1 A-Z multivitamin tablet once a day.
• 1 vitamin D tablet once a day.

For first 6 weeks these need to be in a chewable form. Once you are on a normal textured diet you can take a tablet form.

Suitable options are:

• Chewable: Superdrug chewable, Centrum chewable
• Tablet: Tesco A-Z, Superdrug A-Z or Aldi A-Z

Dumping syndrome is a less common side effect after ESG. It happens when the lower end of the small intestine (the jejunum) fills too quickly with undigested food from the stomach. There are two types of dumping:

• Early dumping - happens during or right after a meal. Symptoms of early dumping include nausea, vomiting, bloating, cramping, diarrhoea, dizziness and fatigue
• Late dumping - happens 1-3 hours after eating and is usually due to a low blood sugar. Symptoms of late dumping include weakness, sweating and dizziness .

Managing dumping syndrome

• Early dumping syndrome: lie down as soon as you have symptoms, you are likely to feel better after around 30 minutes.
• Late dumping syndrome: have a snack that includes both carbohydrate and protein like a cracker with soft cheese. If you feel very unwell you may need a small glass of orange juice before the cracker to bring your blood sugar back to normal.

To avoid dumping symptoms:

• Avoid chocolate, biscuits, cakes, sweets, desserts, high sugar drinks, high glycaemic index (GI) carbohydrates such as white bread.
• Aim to eat at least 3 times per day (rather than 1 big meal).
• Avoid eating and drinking at the same time – wait 20 minutes.

Losing weight can increase fertility and we strongly recommend that you do not become pregnant for at least 18 months following the procedure. Weight loss can have negative effects on the pregnancy.

After this surgery your oral contraceptives (the pill) may not work. You should use alternative methods of contraception, for example, barrier methods (condoms/cups) if this is a concern.

If you become pregnant following the procedure it is important to let your GP, Obstetrician, Midwife, and Bariatric Team know as soon as possible. You may need extra monitoring during the pregnancy to make sure that you and the baby get enough nutrients to keep healthy.

• Bariatric Coordinators: 0117 414 0855/54
• Bariatric Waiting List Coordinator: 0117 414 8826
• Bariatric Surgery Senior Enhanced Practitioner: 0117 414 2085 or 0755 7312784

• Do gentle abdominal exercises like the ‘Core 4.’ Even if you do not already do regular exercise these will soon feel comfortable.
• Maintain a healthy weight and reduce tummy fat - this will put less pressure on the abdominal muscles.

• Avoid driving for at least 4 weeks after laparoscopic (keyhole) surgery. After open surgery avoid driving for at least 6 weeks, if your wounds have healed. You should also check with your insurance company.
• Avoid strenuous (very physical) activity for 8 weeks. This includes heavy lifting, pulling, pushing, or awkward movements like stretching and twisting.
• Support your stoma when you sneeze or cough.
• Use the bed roll method to get out of bed.

• You can start doing more strenuous activity while using a support belt:
  • You will discuss this and be measured for it during your post-surgery clinic review.
  • You should still avoid very heavy lifting and awkward movements.
  • When moving smaller items follow correct manual handling advice.
• Continue your abdominal exercises to build your strength:
  • We advise you not to wear the support belt when doing this so you can feel your core muscles engage.

• Smoking (4x greater risk of developing a parastomal hernia).
• Persistent coughing due to COPD or asthma.
• Being overweight or having a large abdominal girth (measurement around your waist), particularly greater than 100cm.
• Being generally unfit.
• Lifting heavy items with poor manual handling technique.

Intra-abdominal pressure (IAP) is the pressure inside the abdomen (tummy). Reducing IAP can help reduce the risk of hernia developing. Using safe ways to lift and move things (manual handling), and learning how to breathe well can help lower IAP. 

Deep breathing can help your core muscles to work more efficiently by engaging the core.

• Take a slow deep breath in through your nose.
• Expanding your abdomen and ribcage out.
• Exhale slowly out through your mouth, feeling your ribs move back inwards.
• Repeat 5-6 times.

Do not hold your breath when doing an exercise or lifting task. When exerting effort, breathe out to lower your IAP.

If the abdomen domes/pushes out during exercise (or lifting) and you can feel a raise in pressure, this is a sign of increased IAP. Stop doing any movement or exercise that causes this. Move into a better position and adjust your breathing to reduce the increase in IAP.

• Try to avoid anything that may raise IAP including:
• Preventing nausea and vomiting.
• Managing long term coughing and by seeking support from your GP or respiratory team.
• Urostomy and colostomy patients should maintain good diet and hydration to prevent constipation.
• Support your abdomen/stoma with a rolled-up towel/pillow/hand when coughing, sneezing, or blowing your nose.

• Proteins are made up of amino acids. These give your body energy and help cells renew; this helps build and heal muscles. Increasing how much protein you have before surgery will help to build supplies and condition your body. Keeping this up after surgery will help with healing and strength.

High protein foods include:

• Fortified yogurt and drinks.
• Protein powders you can add to soups and smoothies.
• Foods like fish, turkey, and chicken.
• Dairy.
• These all help repair and regain muscle tissue.

• To avoid putting strain on your abdomen in the first stages of recovery (up to 2-3 months post-surgery), use the log roll technique to get in and out of bed. Please ask your stoma nurse or physiotherapist about this.

This is important immediately after surgery

Getting out of bed

• Raise one knee at a time and roll onto your side, moving your entire body in one movement.
• Lower your legs over the side of the bed.
• Use your arm furthest away from the bed to push yourself up into a sitting position.

Getting into bed

• Sit on the side of the bed with the back of your knees against the bed.
• Lower your body to the bed surface with use of your arm, furthest away from the side of the bed you are going to lay on.
• Slowly lift both legs onto the bed to meet your body, keeping your knees bent.
• Roll onto your back and slowly lower one leg at a time.

Tummy tightening breathing deep core-back

• Lie on your back, on the bed, or floor with your knees bent.
• Take a deep breath in.
• As you exhale, draw your abdominal muscles down towards your spine and ribs towards your pelvis.
• Hold this contraction for 2-3 seconds while still breathing. Then release and repeat 5 times.
• Slowly build up to holding the contraction for 10-15 seconds and repeat 5-10 times.

Deep core side

• Lie on your side with knees bent.
• Allow your stomach to drop toward the floor.
• Take a deep breath in and exhale, drawing your abdominal muscles in and towards your back, pulling your ribs toward your pelvis, and lifting your tummy away from the floor.
• Hold the contraction for 2-3 seconds then release and repeat 5 times.
• Slowly build up to holding the contraction for 10-15 seconds and repeat 5-10 times.

Pelvic tilt

• Lie on your back, on the bed/floor with your knees bent.
• Press your lower back into the bed or floor.
• Rock your pelvis up towards your head, feeling a tightening in your tummy and bottom muscles, slightly pulling your ribs and pelvis together.
• Hold the contraction for a second and return to the neutral position. Repeat 5 times - build to 20 repetitions.

Knee rolls

• Lie on your back on the bed or floor with your knees bent.
• Keep your knees and thighs together, exhale. Slowly drop your knees as far as is comfortable, rotating your pelvis and hips to one side.
• Keep your shoulders fixed to the floor as you roll. Inhale and breathe normally, and hold the position for a few seconds. Drop your knees a little to start with, and work on increasing this over time.
• Exhale and return your knees up to the starting position, use your core muscles to draw them up slowly. Repeat on alternate side 10-15 times.

Seated knee lifts

• Sit toward the edge of a chair with your back straight and unsupported (not leaning back).
• Engage your deep core, pulling your tummy toward your spine and breathe normally. Lift one foot from the floor a short distance, hold for 2 seconds
• then return foot flat to the floor.
• Repeat 10-20 times on alternate sides. You can increase the height you raise your foot from the floor over time.

Hip bridge

• Exhale and pull your tummy toward your spine, tilt your pelvis toward your head and lift your tailbone off the floor. Raise up a short way pushing from your heels, curling up through your spine.
• Breathe in and normally, holding the position for 2 seconds.
• Exhale and slowly lower yourself curling your spine back to the floor, relax and repeat 10-15 times.

Leg slides

• Lie on your back on the bed/floor with knees bent up and core pulled toward your spine.
• Exhale and slide one foot slowly away from you straightening your leg and breathe in. Exhale and slowly draw your foot back to the starting position. Keep control of the core by pulling it towards your spine. Repeat on alternate sides 10-20 times.
• As you get stronger you could increase the intensity by raising the opposite arm to leg up, and rotating it back past your head to your ear. Move the arm and opposite leg at the same time.

Knee circles

• Lie on the bed/floor or sit in a chair with your back straight and unsupported, exhale, pull your core towards your spine to engage your deep core, breathe normally.
• Exhale and lift one knee to 90 degrees (right angle), breathe normally keeping the core engaged.
• Circle the leg making a clear movement to one side, towards the chest, towards the opposite knee and to the back completing a full circle.
• Lower the foot back to the floor and repeat on the opposite side, alternating 10-20 times.

Hip bridge and inner thigh squeeze

• Lie on the bed/floor with your knees bent up and place a small ball or rolled up towel between your knees and hold firmly.
• Exhale and pull your tummy towards your spine, tilt your pelvis towards your head and lift your tailbone off the floor. Raise your body up, curling your spine off the surface, pushing from your heels until your body runs straight from your head to your knees.
• Breathe in and normally, holding the position for 2-5 seconds. Exhale and lower your body back to the floor curling your spine flat. Repeat 15-20 times.

Half superman with arms

• Start on your hands and knees, making sure hands are positioned under your shoulders, and hips over your knees.
• Pull your core to your spine to engage your deep abdominal muscles.
• Slide one hand away from you, keeping your arm stretched out, until your hand just leaves the floor. Hold the position for 2-5 seconds and slowly return your hand to the starting position. Always keep control of your core.
• Repeat on alternate sides 15-20 times.

Half superman with legs

• Start on your hands and knees, making sure hands are positioned under your shoulders, and hips over your knees.
• Pull your core to your spine to engage your deep abdominal muscles.
• Slowly slide your foot away from you until your leg is straight and your foot lifts away from the floor. Hold this position for 2-5 seconds keeping your core engaged. Slowly return your foot back to the starting position.
• Repeat on alternate legs 15-20 times.

Standing knee lifts

• Stand tall with your back straight and core pulled towards your spine. Hold onto the back of a chair with one or both hands for stability if needed.
• Exhale and slowly lift one knee up as far as is comfortable, breathe out and normally while holding the position for 2-5 seconds, maintaining control of your core. Exhale and lower your foot to the floor.
• Repeat on alternate legs 15-20 times.
• To make this a little harder and if your balance is good – raise both arms above your head and proceed to lift one knee at a time alternately.

Continue the previous exercises alongside these.

Toe tap

• Lie on the bed/floor or with your knees bent up and engage your core, pulling your tummy to the spine. Exhale and pull one knee up to 90 degrees (right angle) followed by the second knee.
• Breathe in, and on exhale tap one foot down to the floor while keeping the opposite leg still. Breathe in as you bring the leg back up and repeat on the opposite side.
• Repeat 5 to 20 times on each side.

Full superman

• Start on your hands and knees, making sure hands are positioned under your shoulders, and hips over your knees. Pull your core to your spine to engage your deep abdominal muscles.
• Slowly straighten out your right leg and left arm until both your foot and hand are off the floor. Start by raising a short distance off the floor and increasing this over time, if not able to lift parallel with the body to start with. Control your pose keeping the core engaged and not overextending the arm or leg.
• Hold the pose for a few seconds, increasing this over time.
• Return your arm and leg slowly to the start position and repeat on the opposite side.
• Repeat 20 times.