Physiotherapy - Theses
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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.