Physiotherapy - Theses
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ItemSystematic investigation of early-phase trial designs for upper limb therapy post-stroke( 2022)A lack of early-phase trials to systematically investigate dose and target population during intervention development is a likely reason for non-pharmacological stroke recovery trials falling short of the outcomes expected by researchers and clinicians and needed by people living with stroke. The overall objective of the work presented in this thesis was to systematically investigate dose, target population and decision-logic of early-phase trial designs in non-pharmacological stroke recovery. To achieve the objective, Study 1 developed the tools required to appraise early-phase trials of preclinical and clinical non-pharmacological stroke recovery motor interventions and embedded them in an accompanying protocol for a systematic scoping review. Study 2 executed the systematic scoping review and demonstrated a lack of published and high-quality preclinical and clinical early-phase stroke recovery motor trials that explicitly aimed to investigate dose. Study 3 established a lack of Phase I stroke trials that were registered or funded. Collectively, these studies resulted in original contributions in the form of (a) a systematic discovery pipeline tool, (b) an Early Phase Research Quality Checklist, and (c) an understanding that systematic early-phase research is rarely completed. The above findings provided an essential basis for in-depth investigation of the adaption of early-phase trial designs for application to the domain of clinical non-pharmacological stroke recovery motor interventions. As a part of this investigation, Study 3 developed a decision support tool to guide the design of Phase I non-pharmacological trials that can escalate more than one dose dimension. Study 4 utilised the decision support tool to guide the design and implementation of a multidimensional Phase I dose-ranging trial of an upper limb motor intervention delivered early post-stroke. This trial is ongoing, with the current tolerable dose being three 15-minute upper limb sessions per day. Finally, Study 5 investigated the impact of target population selection on the generalisability of upper limb motor trials conducted early post-stroke. Participant sampling was found to be a complex process that needs to be adequately reported and systematically undertaken to ensure an appropriate balance between internal and external validity. Overall, these studies have resulted in the original contributions in the form of: (d) a Phase I decision support tool, (e) confirmation that a multidimensional Phase I dose-ranging trial is feasible to implement, (f) confirmation that the current tolerable dose range is higher than usual care upper limb therapy provided early post-stroke in Australia, (g) an understanding that a lack of reporting in trials is impacting generalisability, and (h) an understanding that broadening eligibility criteria alone is unlikely to improve generalisability. Collectively, these contributions have enriched early-phase stroke recovery research by identifying barriers to its completion and providing solutions to support its uptake and quality. The completed research provides a sound basis for ongoing work to demonstrate the benefits of embedding intervention development through a systematic discovery pipeline approach within the confines of intervention complexity and the heterogeneous context of stroke. Adopting a systematic approach to intervention development via early-phase trials is achievable and likely a crucial step in bringing the field closer to identifying practice-changing interventions.
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ItemCritical Illness Survivorship: Rehabilitation and Recovery( 2021)Survivors of critical illness can experience significant physical disability during their recovery, delaying return to activities of daily living, all negatively impacting their health-related quality of life. Level one evidence supports the implementation of physical rehabilitation programs to address these short term sequalae. However, recent large randomized controlled trials measuring longer term physical function and health-related quality of life do not report sustained improvement. To better understand this phenomenon, investigations into the role of patient characteristics in responsiveness to physical rehabilitation and critical illness recovery is an emerging research area and is the focus of this thesis. The first study of this thesis is a narrative review, where 12 randomized controlled trials with conflicting results for the beneficial effects of physical rehabilitation on the physical function, health-related quality of life and health care utilization outcomes of critically ill adults were identified from a comprehensive and systematic literature search. Through critical evaluation of these randomized controlled trials and additionally relevant studies, a theoretical construct was developed for the research of this thesis and to advance the field. In brief, the core components of the theoretical construct are in searching for the responder; investigation into potential modifiers of physical rehabilitation outcomes (including patient characteristics); tailoring rehabilitation interventions to address known physical impairments; and deciphering the prime time for responsiveness to these interventions based on patients biological and physiological recovery. Lastly, the conclusion that more research is needed on the optimal prescription parameters of physical rehabilitation programs to guide clinical practice with consideration to facilitators and barriers to implementation of the intervention is reached. The second study is a systematic review examining the association between indicators of social and economic position within society (socioeconomic position) and health outcomes following critical illness. Ten studies were included in this systematic review, with a strong focus on mortality despite survivorship being the identified challenge for critical care in the 21st century. The higher mortality rates and poorer health-related quality of life reported for critically ill adults with a lower socioeconomic position signal that a social gradient exists in critical care. This may indicate a clinical subgroup that would derive benefit from multimodal and interdisciplinary interventions to potentially alter their recovery trajectory. For the third and final study a systematic review and an individual participant data meta-analysis of randomized controlled trials was performed to examine the interaction between the treatment group (intervention vs control) and patient characteristics (comorbidity, age, sex and illness severity) for the performance-based physical function (at hospital discharge, three and six months) and health-related quality of life (at three, six and 12 months) outcomes of critically ill adults. From the four randomized controlled trials included, totaling a combined sample size of over 800 participants, comorbidity modified the effect of physical rehabilitation for the health-related quality of life instrument (Physical Component Summary score of the 12-item and 36-item Short Form Health Surveys). Specifically, the Physical Component Summary scores were higher (better) for multimorbid patients (defined as Functional Comorbidity Index score >=2) who were allocated to the intervention group at the three and six but not 12 month follow up time points. We hypothesize that this study has implications for future trial design, where a stratified approach (Functional Comorbidity Index <=1 and >=2) may reduce sample size calculations. We recommend that clinicians prioritize the provision of a structured individualized physical rehabilitation program to multimorbid patients as a subgroup that derives significant benefit from this intervention. In conclusion, the findings of this thesis navigate the path forward for rehabilitation research in critical care. This area, both in research and clinical practice, has previously been plagued by the heterogeneity of the patient population. The identification of a target group of critically ill patients (multimorbid, Functional Comorbidity Index score >= 2) provides direction clinically and for future investigations into the effects of physical rehabilitation. Ultimately leading to the progression of the field to provide patients with the right intervention at the right time in their recovery trajectory to improve their outcomes following critical illness.
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ItemBike skills training for children with cerebral palsy( 2019)Training targeted towards goals that are meaningful to children with cerebral palsy (CP) and their families is needed to improve function and support participation in physical activities in this population. Riding a two-wheel bike is a common goal for ambulant children with CP, yet little specific evidence exists to guide clinicians and families. This thesis developed and tested a task-specific approach to training bike skills in this population through three studies: 1) a systematic review, 2) a practice survey, and 3) a randomised controlled trial (RCT). Each study used the International Classification of Functioning, Health and Disability (ICF) as a framework. While strong evidence exists for task-specific training (TST) for improved upper limb (UL) function in this population, prior to this thesis the literature regarding TST for gross motor skills, including bike riding, in ambulant children with CP had not been systematically appraised. Thus, Study 1 aimed to systematically evaluate the effectiveness of task-specific gross motor skills training for improving activity and participation outcomes in ambulant school-aged children with CP. This review involved 13 studies of low-to-moderate overall quality and found effects of TST were positive for participation-related outcomes, and mixed for specific skill performance and functional skills, while little or negative effects were found for general gross motor skills. This study identified the need for higher quality studies and reporting that enables evidence synthesis. Given the importance of understanding current practice when designing effectiveness studies, Study 2 involved a survey of 95 physiotherapists (PTs) and occupational therapist (OTs) in Australia about their practices when training two-wheel bike skills in children with CP. This study found that while functional approaches to training and goal-based assessment and evaluation were predominant, overall practices appear highly variable. Moreover, the need to develop and test bike-specific measures and interventions in this population was highlighted. The findings from Studies 1 and 2 informed the design of Study 3. This multi-site assessor-blind RCT aimed to determine if a task-specific approach was more effective than a parent-led home program for attaining individualised two-wheel bike riding goals in ambulant children with CP. Sixty-two children were randomly allocated to either the task-specific approach (n=31) or home program (n=31). The primary finding was that the task-specific program was more effective than the home program for goal attainment at one week post-intervention. Greater odds of goal attainment were retained at three months and evidence of better outcomes following the task-specific program were found for some outcomes related to participation in bike riding, physical activity and self-perception. In addition, there was evidence of mixed effects for functional skills, and little difference in bike skills and health-related quality of life. While each of these studies provides an original contribution to the literature, together they form a significant foundation for evidence on training bike skills in ambulant children with CP. Use of the ICF across the thesis meant findings could be synthesised and enhanced the clinical relevance of the research. Given that an effective approach for attaining two-wheel bike riding goals in this population now exists, training for clinicians to optimise knowledge translation should be developed. Future research should seek to understand relationships between bike skills training and a broader range of ICF domains and levels of function in CP, tailor interventions to individuals and determine longer-term outcomes.
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ItemRehabilitation in inoperable lung cancer( 2018)Worldwide lung cancer is the second most frequently diagnosed cancer. In Australia it is the leading cause of cancer burden and death. The overwhelming majority of people are diagnosed once the disease has spread beyond the primary site. Lung cancer is associated with high levels of poorly controlled symptoms, a decline in physical function, low physical activity (PA) levels and poor health-related quality of life (HRQoL) compared to the healthy population. For people with operable non-small cell lung cancer (NSCLC) increased PA levels are associated with improvements in HRQoL, exercise capacity, fatigue, and psychological distress. Increased exercise capacity at diagnosis of inoperable NSCLC is associated with improved survival. Further research regarding the effects of exercise interventions is required in populations with inoperable NSCLC as the majority of studies conducted to date in this population have either been single-group studies or small randomised controlled trials which are frequently subject to high rates of attrition and lack longer-term follow-up of outcomes. The first aim of this thesis was to conduct a systematic review of outcome measures that have been utilised to assess PA levels in lung cancer and report on the psychometric properties of included measures. The second aim of this thesis was to conduct a randomised controlled trial (RCT) to determine the effects of home-based multi-disciplinary rehabilitation both during and following treatment for inoperable NSCLC and report on quantitative and qualitative outcomes. The systematic review identified significant variation in the measurement of PA in lung cancer; 34 articles utilising 21 different outcome measures were included in the review. Seventeen (50%) studies used performance-based measures, such as accelerometers or pedometers, to quantify PA and the remaining studies used patient self-report measures, such as the Godin Leisure Time Exercise (GLTEQ) or the International Physical Activity (IPAQ) questionnaires. Only two studies used both performance-based and self-reported methods of PA measurement. Eighteen (53%) studies reported on the psychometric properties of the outcomes used to measure PA in lung cancer and the quality of those that did was commonly rated as ‘fair’ or ‘poor’. Reflective of the increased research activity and interest in this area, an update of this systematic review performed in 2018 identified an additional 31 articles measuring PA in lung cancer. Updated findings were consistent with the original review with 14 articles (45%) reporting utilisation of performance-based outcome measures and 19 (61%) including patient-reported outcomes. Again, only two articles measured PA using both methods of measurement. For articles retrieved in the updated review, the IPAQ was the most frequently used questionnaire, this is in contrast to the published review where the GLTEQ was most commonly used. The RCT assessed the efficacy of home-based multi-disciplinary rehabilitation both during and following treatment for inoperable NSCLC. Participants randomised to the intervention group received an eight-week rehabilitation package of care, delivered by a combination of home-visits and telephone calls, involving exercise (aerobic and resistance), behaviour change techniques to support increased exercise and PA and early initiation of patient-centred symptom self-management support. Following the initial eight-week program intervention participants received reduced frequency telephone contact to support exercise behaviours until trial completion at six months. Quantitative outcomes were measured at baseline (prior to randomisation), nine weeks and six months post-baseline and included: exercise capacity (six-minute walk distance (6MWD), the primary outcome), PA levels (performance-based using accelerometers and patient self-report), muscle strength (quadriceps and handgrip), patient reported outcomes (symptom severity and distress, HRQoL, mood, exercise motivation, exercise self-efficacy and resilience) and survival. Ninety-two participants were recruited and 78 (all participants who provided data for at least one follow-up measure) were included in modified intention-to-treat analyses. Adherence to the aerobic component of the exercise program was 65%. There were no significant between-group differences for measures of physical function, mood, self-efficacy or resilience at either follow-up time point. However, a significant interaction effect was demonstrated between group allocation and time across the three study timepoints for the 6MWD; indicating that the temporal pattern of 6MWD results was significantly different between the groups. This difference may be in part due to the timing of exercise with respect to treatment for lung cancer, with less decline in 6MWD observed for the intervention group in the long-term (between baseline and six months) than during the initial treatment phase (between baseline and nine weeks). At six-month follow-up statistically and clinically significant between-group differences favouring the intervention group were found for symptom severity levels, HRQoL and exercise motivation. The intervention group survival benefit at censoring for data analyses was not statistically significant, however at a median of 230 days greater than the usual care group, is of likely clinical importance for those with inoperable disease. Following the initial eight weeks of the program 25 intervention group participants completed semi-structured interviews regarding their views and experiences of program involvement. The majority of participants found the program acceptable and reported multiple physical and mental health benefits including improved strength and fitness, motivation and prevention of boredom. Program enablers included: having supportive family and friends; advice and support from expert health professionals; the perception that the exercise program had been individually tailored to be achievable; having ongoing program monitoring and modification as required by the program physiotherapists; and having a program which consisted of exercise that participants found familiar and enjoyable. Barriers to exercise program completion were symptom exacerbations and poor weather. Adherence to exercise was reportedly increased by use of simple activity trackers and exercise diaries and receiving weekday exercise text message reminders. Few participants watched the study DVD of resistance exercises that was provided to them; most feeling it was not required or reporting they did not have the technology to watch the DVD. Recommendations for future research to improve outcomes for people with lung cancer include greater consensus regarding utilisation of a core set of validated outcomes to measure PA. Where possible to employ both patient-reported and performance-based methods of PA measurement. The findings from the RCT support the benefits of the rehabilitation package of care delivered both during and following treatment for inoperable NSCLC. However, the significant interaction between time and group allocation for the 6MWD indicates the need to consider the timing of exercise in relation to lung cancer treatment. Routine self-monitoring of symptoms should be embedded into lung cancer care pathways; electronic self-reported data could be used to trigger an alert for clinician follow-up of symptoms above a given threshold. Future studies should implement strategies to improve exercise adherence and ensure target training intensities are met. This could involve remote monitoring of exercise sessions or the use of online ‘virtual’ exercise groups, formulating alternative indoor exercise plans and implementing flexible program designs incorporating largely home-based exercise with supervised hospital or community-based sessions as needed.
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ItemPhysical function in patients following surgery for colorectal cancer( 2016)Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second most common cancer in females worldwide. Surgery is the usual treatment for CRC, however post-operative morbidity can be high. Post-operative problems can include symptoms such as anxiety, depression, and bowel, bladder and sexual dysfunction, poor functional exercise capacity, and low levels of physical activity. These highly distressing problems can negatively impact patients’ health-related quality of life (HRQoL). Although the current evidence is strong for physical activity for patients with CRC, there is limited evidence for optimal bowel management in patients who have undergone surgical treatment for CRC. In addition, there are no validated instruments for measuring pelvic floor symptoms and functional exercise capacity in both colon and rectal cancer. This thesis aimed to (1) determine the validity and applicability of a bladder and bowel symptom-specific questionnaire and three field walking tests for the CRC population; (2) comprehensively understand the changes in pelvic floor symptoms and physical and psychological outcomes in patients before and six months after surgery for CRC; (3) investigate the feasibility of implementing a general rehabilitation program incorporating the international physical activity guidelines for patients following surgery for CRC; (4) explore changes in patient centred functional and pelvic floor outcomes following the rehabilitation program; and (5) identify and synthesize current evidence for the effectiveness of pelvic floor muscle training for bowel dysfunction in patients who have undergone CRC surgery. Study 1 and Study 2 examined the validity and applicability of instruments/tests used in the measurement of functional exercise capacity and bladder and bowel symptoms of patients with CRC. The studies found that one pelvic floor symptom-specific instrument and two functional exercise capacity field walking tests are suitable (valid and applicable) for use with patients with CRC. The findings from Study 1 and Study 2 support the choice of outcome measures used in the subsequent studies in this thesis. Study 3 examined the pelvic floor symptoms, physical and psychological outcomes of patients undergoing surgery for CRC in a prospective observational study design. Adult patients with stage I-III CRC completed pelvic floor symptom-specific questionnaires (the Australian Pelvic Floor Questionnaire and the International Consultation on Incontinence Questionnaire Bowel module and Urinary Incontinence short form module) and questionnaires on physical activity levels, anxiety, depression, and HRQoL before and six months following surgery. The main findings were that patients experience significant bowel symptoms and persistent low physical activity levels for up to 6 months following CRC surgery. These results suggest the need for interventions such as rehabilitation programs or exercise interventions to increase levels of physical activity and address bowel symptoms in patients following CRC surgery. Therefore, Study 4, a prospective non-randomized quasi-control study, was undertaken to investigate the feasibility of implementing international guidelines within an oncology rehabilitation program in patients following CRC surgery and to explore changes in patient centred functional and pelvic floor outcomes following the rehabilitation program. The findings showed that implementation in the oncology rehabilitation program was feasible, and patients who have undergone the rehabilitation program had improvements in bladder and bowel symptoms, depression and HRQoL. Study 5, a pilot study nested within Study 4, was conducted to further explore the changes in bladder and bowel symptoms and pelvic floor muscle clinical outcomes measured using digital rectal examination, anorectal manometry and transperineal ultrasound in patients following a general oncology rehabilitation program. Findings demonstrated improved bowel symptoms from pre- to post-rehabilitation program in patients following surgery for CRC. This suggests that general exercise may have positive effects on pelvic floor symptoms in patients following surgery for CRC. However, the evidence is stronger for targeted pelvic floor muscle training/exercise than general exercise on pelvic floor symptoms in non-cancer populations, and patients with CRC behave differently to those with non-cancer diagnoses in terms of symptoms and treatment (i.e. surgical approaches and side effects of chemotherapy (CT) and radiotherapy (RT)). Study 6 summarizes the current evidence on the effectiveness of pelvic floor muscle training on bowel dysfunction in patients who have undergone CRC surgery by systematic literature reviews. This review identified eight studies of level III-2 to IV evidence that reported improvements in patient-reported measures of bowel function and the HRQoL of patients who have undergone pelvic floor muscle training following CRC surgery. This systematic review identified gaps in the literature and revealed that there is a need for randomized controlled trials to provide high levels of evidence of pelvic floor muscle training for CRC populations. In conclusion, the studies outlined in this thesis identified the importance of bowel problems following CRC surgery and suggest that an oncology rehabilitation program may be clinically feasible for CRC. Pelvic floor muscle training is widely used in the incontinence population, and the systematic review suggests that randomized controlled trials are needed to confirm the effectiveness of pelvic floor muscle training in CRC population. Given the small sample size, the evidence in this thesis must be regarded as preliminary. Future research should investigate which subgroups of patients with CRC (i.e. low functional exercise capacity or physical activity levels or high levels of comorbidity at baseline) to target with exercise interventions and which intervention (i.e. general exercise, pelvic floor muscle training, or a combination of both) is more effective in improving pelvic floor outcomes in patients with CRC.
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ItemAssessment and rehabilitation for intensive care unit acquired weakness( 2014)Intensive care unit-acquired weakness (ICU-AW) is a significant problem for individuals who are critically ill. Longitudinal studies have demonstrated ongoing impairments in muscle strength and physical functioning five years post initial critical illness. This resultant morbidity significantly affects survivors’ ability to carry out daily activities, return to work and resume family duties. Muscle wasting has been shown to occur early and rapidly within the first week of an ICU admission. There is a strong and growing body of research on the potential benefit of rehabilitation and a wide range of endpoints have been used to evaluate efficacy in clinical trials within respect to muscle mass, muscle strength and functional outcomes. However, there has been limited research undertaken to specifically examine the clinimetric properties of outcome measures utilised in the ICU and the role of non-volitional exercise strategies such as electrical muscle stimulation (EMS). This thesis addresses some of these gaps in our current understanding in terms of assessment and rehabilitation of individuals with critical illness. The first part of this thesis reports on a systematic review undertaken to examine the clinimetric properties (reliability, validity and responsiveness) of outcome measures used to evaluate muscle mass, muscle strength and functional outcomes. The subsequent three studies report on the development of a two-tier approach to the diagnosis of ICU-AW in clinical practice; the reliability of different neuromuscular ultrasound imaging approaches in the assessment of muscle echointensity; and the clinical utility of ultrasonography in a longitudinal observational study. The second part of this thesis is focused on the safety, feasibility and efficacy of EMS and functional electrical stimulation (FES) cycling. A systematic review was undertaken to synthesise the evidence regarding the safety and efficacy of EMS in the ICU setting. Greatest attenuation of muscle mass changes appears to be seen in individuals with less acuity and the chronically critically ill. There are significant methodological limitations within the studies conducted to date. These limitations include: small sample sizes, heterogeneity in terms of outcome measures used and no follow up beyond intervention cessation. Therefore it is currently unknown what the long-term efficacy of EMS might be. Functional electrical stimulation cycling was shown to be safe, feasible and on preliminary examination using a case-control study methodology to potentially improve functional outcomes and reduce the incidence and duration of delirium. The methodology for a randomised controlled trial examining the efficacy of FES-cycling on muscle mass, muscle strength and functional outcomes are also presented. The findings of this thesis strongly support the need for targeted early rehabilitation strategies, which may assist in preventing the debilitating and negative consequences that occur as a result of being critically unwell. The need for a standardised approach to the diagnosis of ICU-AW and the measurement of efficacy are also identified, to enable generalizability across studies to improve the recovery trajectory and thus reduce the burden of post intensive care syndrome on survivors and their families.
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ItemWhich factors influence the physical activity levels of people with severe traumatic brain injury when they are discharged home from hospital?( 2014)Restrictions in mobility following moderate to severe traumatic brain injury (TBI) are common. Limited evidence indicates that physical activity levels of individuals with TBI are insufficient for health maintenance. Transition from hospital to home is a challenging period for these individuals. Factors which influence activity levels during this transition period are currently unknown. This study aims to identify which factors were associated with greater activity levels during the transition period from inpatient discharge to home in individuals with TBI.
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ItemFeasibility, safety and efficacy of dance for people with Parkinson's disease: a pilot study( 2013)The purpose of this thesis is to investigate the safety, feasibility and efficacy of dance for people with Parkinson’s disease (PD). Parkinson’s disease is a progressive neurological condition that is characterised by slow gait, reduced movement amplitude, tremor, rigidity, postural instability and diminished health-related quality of life (HRQOL). Physiotherapy and therapeutic exercise aimed at improving gait and balance are argued to be an important component in the management of PD and have been shown to improve gait function, mobility, balance and HRQOL in some individuals. Given the progressive and long term nature of the disease, it is important for people with PD to have access to a wide variety of exercise options so that they can remain active. Recent reports indicate that dance is emerging as an alternative to traditional exercise programs for people with PD, however there is little information regarding the safety and feasibility of dance interventions. A systematic review and critical appraisal was conducted with the aim of identifying studies that provide reports of safety, feasibility, intervention delivery and the efficacy of dance interventions for people with PD. The identified studies were of low to moderate methodological quality and design and the reporting of safety and feasibility outcomes was inconsistent. Whilst attrition was well reported, it was challenging to conclude the level of adherence and the occurrence of adverse events during dance classes due to limited reporting of these outcomes. The level of supervision provided, provision of instructor training and advice and the selection of music and movement choices was also not well reported. The results of a between-group synthesis of balance and mobility data showed a trend towards improvement in these outcomes following a dance intervention when compared to controls. These findings present limited evidence to support the efficacy of dance for people with PD. A group of nine Australians living with mild to moderate PD participated in a pilot case-series study to determine the safety, feasibility and efficacy of a six-week contemporary dance program. Safety and feasibility outcomes evaluated included the occurrence of adverse events, attrition, adherence and participant satisfaction. The effect of the dance program on gait function, functional mobility, balance, balance and gait self-efficacy and HRQOL was examined prior to the intervention, immediately post-intervention and at three months. The contemporary dance program was found to be a feasible and safe activity for people with PD in terms of attrition, adherence and adverse events. Attrition was low, with eight and seven participants completing follow-up assessments at post intervention and three-months respectively. Adherence was high with participants completing 78% of all available dance classes. Significant improvements in gait hypokinesia were observed immediately post-intervention compared to baseline measures and continued to improve three-months later. Significant improvements in functional mobility, relative to baseline were seen at post-intervention with a trend toward improvement noted at three-months. Despite improvements in gait function, there was little to no change observed for measures of balance, gait and balance self-efficacy and HRQOL. These results provide evidence to further support the safety and feasibility of dance for people with mild to moderate PD, and support the need for large randomized controlled trials to determine the efficacy and outcomes of dance therapy. Participant satisfaction is commonly regarded as an important component of quality health care and may influence the successful implementation of new interventions into clinical practice. Two focus groups were conducted after the pilot study with the purpose of gaining insight into the experiences and attitudes of the contemporary dance participants and to explore participant satisfaction within the context of feasibility. Thematic analysis revealed that participants were satisfied with the intervention and considered contemporary dance to be an acceptable form of exercise. The focus groups also revealed that the participants had a strong emotional reaction to the dance classes and identified several emotional, physical and cognitive benefits. This thesis has provided further knowledge to suggest that dance is a safe and feasible exercise alternative for some people with mild to moderate PD. Furthermore, this thesis has provided new evidence to support the efficacy of a short duration contemporary dance program to improve aspects of physical function and HRQOL. Although future work is needed, this research provides clinicians with evidence that supports the implementation of dance into clinical practice where it can benefit individuals living with Parkinson’s disease.
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ItemHealth-related quality of life, physical function and rehabilitation in survivors of critical illness( 2010)The primary objective of the thesis was to investigate health-related quality of life and rehabilitation prescription in Australian ICU survivors. The first major component of the thesis examines the measurement of health-related quality of life in Australian ICU survivors in a prospective, longitudinal pre-post study design. Adult patients admitted to an Australian ICU for longer than 48 hours completed health-related quality of life instruments (the Short Form-36 and the Assessment of Quality of Life) at pre-admission and six months following ICU discharge. Health utilities were also calculated using the AQoL and SF-6D and the measurement properties (reliability, validity, responsiveness and sensitivity) of these two multi-attribute utility instruments were compared in the critical illness population. The second major component of the thesis examines rehabilitation prescription in Australian ICU survivors and reports the development of a physical function outcome measure (the ‘Physical Function in ICU Test’) for use in the debilitated critical illness population. The test battery was subsequently validated in 40 participants of a randomized controlled trial investigating early rehabilitation in patients admitted to ICU. Participants also underwent a pilot exercise training program in the ICU whilst mechanically ventilated and adverse events were recorded. The main findings of the investigation into health-related quality of life demonstrated that participants admitted to Australian ICUs report worse health-related quality of life than the normal population at pre-admission and follow-up. However, survivors report a return to pre-admission health-related quality of life at follow-up with improvements seen in some social functioning and psychological domains of health-related quality of life. Physical functioning health-related quality of life was most affected in comparison with the normal population. The comparison of the two health utility scores demonstrated that the utilities were not interchangeable and the SF-6D had two main problems of a lower boundary and restricted range and poor reliability which may affect its use for cost-utility analysis in the critical illness population. The main findings of the second component of the thesis were that exercise is widely prescribed by physiotherapists working in Australian ICUs. The physical functioning outcome measure that was developed was reliable and responsive to change and there was high adherence to pilot exercise training sessions with few adverse events in mechanically ventilated patients with a tracheostomy. The final study demonstrated that the outcome measure has a degree of validity in the critical illness population, however further study is required to validate the test on larger sample sizes and scoring the test battery may also provide valuable information in future studies. In conclusion, although health-related quality of life in patients admitted to Australian ICUs was worse than the general population, survivors reported improvements over time in some dimensions. Rehabilitation is widely used in the critical illness population and preliminary findings suggest that further investigation of exercise training in this population could be evaluated with larger trials. Future research should consider which specific groups of critical illness survivors to target with intervention and which multi-attribute utility instruments are most appropriate for cost-utility analysis in the critical illness population.