Physiotherapy - Theses
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ItemTendon-aponeurosis strain and clinical features of runners with and without achilles tendinopathy(University of Melbourne, 2010)
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ItemHistology of the fascial-periosteal interface in lower limb chronic deep posterior compartment syndrome(University of Melbourne, 2007)
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ItemObservational gait analysis in hereditary spastic paraplegia: a comparison of the accuracy of gait kinematic analyses in expert and novice physiotherapists( 2014)The aim of this study was to compare the accuracy of observational gait analysis (OGA) in expert and novice physiotherapists when compared to 3-dimensional gait analysis (3DGA) in a cohort of children with hereditary spastic paraplegia (HSP). Visual observation is a key component of physiotherapy assessment, particularly for patients with movement disorders, and gait abnormalities. It has been reported that 94% of physiotherapists uses OGA for gait assessment in everyday practice. Despite the wide use of OGA by physiotherapists, data on the accuracy of OGA is limited to relatively few studies, which have reported varied findings. In clinical practice, it is common for senior clinicians to supervise more junior clinicians based on the assumption that seniors are more accurate in their assessments due to experience. Very few studies have compared the accuracy of OGA of expert and novice physiotherapists. Variation in factors such as the methods of observation, and number of variables for observation have rendered the findings limited and inconclusive. This project sought to compare experts with novices for the accuracy of OGA in children diagnosed with HSP. Children with HSP were selected for investigation because they have gait disorders associated with weakness and spasticity. The 3DGA was chosen as a criterion measure to evaluate the accuracy of the observations, as it is widely considered to be the gold standard for gait analysis because of its ability to accurately capture and quantify complex gait events. The walking patterns of 17 child participants were captured using a 3DGA system and concurrent sagittal plane video recordings. Fifteen experts, each with more than seven years of clinical experience, observed and rated joint angles at the hip, knee, and ankle. Observations were also recorded by a novice group of 15 physiotherapy students and clinicians with less than one year of clinical experience. The ratings by the experts and novices were compared with the criterion scores obtained from the 3DGA system to provide estimates of error. Error score comparisons between experts and novices for each of five variables revealed no significant differences in the accuracy of OGA between the two groups. Further examination of individual observer error scores revealed a wide range of error scores for experts and novices across all variables. The finding of no differences in accuracy between experts and novices for OGA did not support the prediction that expert physiotherapists are more accurate in assessing gait abnormalities using OGA. As clinicians typically observe gait using various methods such as live or video observations, at different speed observations and with different instructional sets, tasks and environments, it is possible that the methodology used in this study may have influenced the results.
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ItemKnee motion and foot speed at and around initial contact in human gait( 2014)Biomechanical analyses have provided detailed information about joint kinematics and kinetics of the gait cycle. Interpretation of this data has largely overlooked (Winter, 1983a), or even misrepresented (Cerny, 1984; Perry, 1992), knee kinematics around initial contact (IC). It has been suggested that heel speed (HS) approaches zero magnitude as a way of preparing the foot for landing at IC and that knee kinematics influence this event (Winter, 1992b). A number of factors, including the re-introduction of ground reaction forces to the leading limb, make IC a complex event within the gait cycle. The aim of this study was to clarify knee joint kinematics at and around IC in human gait. Three hypotheses were tested. Firstly, that knee flexion (KF) precedes IC. Secondly, that the quantum of knee flexion and the percentage of stride spent flexing the knee prior to initial contact are dependent on gait speed. And thirdly, that HS is reduced to near zero magnitude in preparation for contact with the ground at the start of stance phase. Sixteen healthy, young adults participated in this study. A Vicon 3D Infra-red motion analysis system (Oxford Metrics Ltd., Oxford, England) sampling at 120 Hz and AMTI Force Plates (Advanced Mechanical Technology, Inc., Watertown, USA) sampling at 1080 Hz were used to record kinematic and kinetic data from walking trials at each of three self-selected speeds: slow; preferred and fast. Data were extracted representing the timing of the onset of KF prior to IC, the amount of KF occurring between maximum knee extension prior to IC and IC as well as HS at IC. The data were assessed for normality using the Kolmogorov-Smirnov test of normality and through skewness and kurtosis. Friedman’s χ2r statistic and RM MANOVAs were used to investigate differences across gait speed. Post hoc testing was performed with the Wilcoxon test and contrasts testing. KF data were found to be non-normal. At preferred speed 2.6% of stride was taken up flexing the swinging knee 1.4° prior to IC. This rose to 3.5% of stride and 2.3° of flexion prior to IC at fast speed and fell to 2.2% of stride and 0.8° of flexion prior to IC at slow speed. The quantum of KF prior to IC also increased with gait speed. All HS data were normal. Mean HS at IC was 559.7mm•s-1 at preferred speed. Mean HS at IC rose to 841.3 mm•s-1 at fast speed and fell to 391.2 mm•s-1 at slow speed. KF and HS were found to be significantly different across speeds (p < 0.001). Results support the hypothesis that KF occurs prior to IC in human gait. The amount and duration of this KF were dependent upon walking speed. These findings suggest that in human gait a motor control strategy is implemented where the knee flexes in anticipation of initial contact. This repudiates the common perception in the gait literature that the knee is extended, or stable in extension at IC (eg Gage, 1990; Cerny, 1984). Whilst HS does slow late in swing the results of this study do not support the proposition that a function of knee motion prior to IC is to reduce HS to near zero magnitude. The outcomes of this study provide clinicians with crucial information to guide decision making with respect to gait analysis and training.
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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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ItemPerineal muscle stiffness in women with and without vulvodynia( 2014)The studies reported in this thesis focused upon: (i) objectively measuring the muscle stiffness of the perineal muscles of the pelvic floor in two different cohorts of women - those asymptomatic of pelvic floor dysfunction, and those symptomatic of vulvodynia; (ii) demonstrating if differences in perineal muscle stiffness existed between these cohorts; and, (iii) establishing if an association between perineal muscle stiffness and vulval pain was present in women with vulvodynia. A test-retest, intra- and inter-tester cross-sectional study of the MyotonPro™ (a myotonometer) to obtain objective measures of muscle stiffness of the perineal muscles in asymptomatic and symptomatic (vulvodynia) cohorts was conducted. The results of this study demonstrated that the MyotonPro™ showed good to very good reliability in measuring muscle stiffness in both cohorts. No difference in muscle stiffness was observed between rest and contracted muscle states which may have been due to difficulties with accuracy of measurement during the contraction state. Further research is needed to provide certainty regarding the ability to detect perineal muscle contraction accurately with the MyotonPro™. With the objective measures of muscle stiffness obtained in this study, the next stage was to compare the two cohorts. A cross-sectional study aimed to determine if differences existed in perineal muscle stiffness between the asymptomatic and symptomatic (vulvodynia) cohorts. The results of this study demonstrated significant differences between the cohorts at rest, with increased muscle stiffness in women with vulvodynia compared to women without vulvodynia. This finding confirms reports from clinical observation; that women with vulvodynia have increased muscle stiffness in the pelvic floor. This provided the rationale to investigate the association between muscle stiffness and pain in women with vulvodynia. Lastly, a cross-sectional study was performed to determine the relationship between perineal muscle stiffness and pain in women with vulvodynia, using both the Short Form McGill Pain Questionnaire and the Numeric Rating Scale for Pain. Whilst a positive correlation between muscle stiffness and pain was expected, results revealed a lack of correlation, using either tool. The lack of correlation may have been due to a number of factors including that perineal muscle stiffness and pain do not correlate in women with vulvodynia; or muscle stiffness and pain only correlate at the moment of provocation of pain; or the lack of correlation may have been due to the moderately low severity of pain reported by this cohort. In conclusion, the results of these studies have provided objective measures of muscle stiffness of the perineal muscles in women with and without vulvodynia. The cross-sectional study showed that women with vulvodynia have significantly increased muscle stiffness in their perineal muscles compared to asymptomatic women. Future studies into the effect of provocation of pain during muscle measures may provide further insight into the relationship between pain and muscle stiffness in the perineal muscles.
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ItemThe Melbourne pusher scale: a reliability and validity study( 2003)The pushing phenomenon in stroke patients has been more extensively researched in recent years. Previous studies have concentrated on examining the incidence, causes and functional outcome for these patients, however, the validity for this research has been questioned due to the lack of use of a psychometrically sound assessment scale for pushing. The first aim of the current study was to develop a clear, concise, ordinal pushing scale, the Melbourne Pusher Scale, that would measure the severity of pushing in acute stroke patients. The second aim was to determine the reliability and validity of the Melbourne Pusher Scale in measuring the pushing phenomenon. The study involved 30 acute stroke patients for the inter-rater reliability and validity studies, 20 acute stroke patients for the intra-rater reliability, and 15 control subjects for the validity study. The Melbourne Pusher Scale was found to have strong inter-rater reliability (Kappa statistic= 0.91) as well as strong intra-rater reliability (Kappa statistic= 0.92). The investigation of concurrent validity of the scale found the Melbourne Pusher Scale to have some validity. Further research using video analysis in a larger sample may aid in the validation of this scale. Not only is the Melbourne Pusher Scale the first such scale to have psychometric analysis documented, it is the first reliable scale that measures the severity of pushing. The Melbourne Pusher Scale may aid in future research into the cause and management of the pushing phenomenon, more accurate clinical decision-making and the effective use of relevant health care resources for these acute stroke patients.
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ItemPhysical therapies for Achilles tendinopathy( 2012)Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews for the conservative management of AT provide useful summaries of the available evidence; however, they lack key quality components of systematic reviews. This thesis sought to provide an updated synthesis of the evidence for physical therapies in AT management by conducting a systematic review and meta-analysis (where possible). Inclusion was limited to randomised controlled trials (RCTs) and those with a high risk of bias were excluded. The findings from individual RCTs supported the use of eccentric exercise (EE) in the management of AT. Pooled data suggested additional benefits using laser therapy as an adjunct intervention and similar outcomes when shock wave therapy (SWT) is utilised as an alternative to EE. Despite its common use in clinical practice, the review found only one RCT that evaluated the use of foot orthoses (FO) in AT, but it was excluded due to a high risk of bias. Its findings indicate that FO are more effective than a control group that did not receive treatment. FO are proposed to correct altered biomechanics at the ankle, reducing disproportionate loading across the Achilles tendon. Thus, the second aim of this thesis was to evaluate the immediate rearfoot kinematic and kinetic effects of FO in male runners with AT. A within-participant study of thirteen adult males compared two conditions: (i) prefabricated semi-rigid FO, and (ii) no orthoses during shod running. The results found significantly reduced ankle eversion excursion with the use of FO and no differences for other variables. These findings demonstrated that the immediate effect of FO reduced rearfoot eversion motion in male runners to parameters similar to asymptomatic runners. This effect may lead to a beneficial treatment response. However, further studies are needed to determine the long term biomechanical effects in people with AT and its role in improving pain and function outcomes. In summary, this thesis identified EE, EE with laser therapy and SWT as interventions with evidence of efficacy for AT management. While FO are commonly used in the management of AT there is a paucity of high quality evidence, limiting the current understanding of their role in treatment. This thesis found an immediate reduction in ankle eversion excursion, which is a mechanism that may result in a beneficial treatment response.
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ItemThe effect of pool temperature on body temperature during aqua-aerobic exercise in pregnancy( 2012)Medical guidelines encourage women to exercise during pregnancy but not to overheat. Therefore many pregnant women choose to exercise in water. However, the temperature of the water may affect body temperature response to exercise. The aim of this study was to examine this response to a range of water temperatures found in community swimming pools in which women are exercising and to obtain data to inform guidelines for appropriate water temperatures when pregnant women are undertaking aqua-aerobic exercise. Thermometer selection was based on results of an initial study, Study 1, which compared an infra-red tympanic membrane thermometer and an infra-red temporal artery thermometer for their reliability to measure near core (body) temperature. A repeated measures design was used and temperatures in twenty young adults were measured before and after 15 minutes of moderate intensity exercise on a stationary bicycle. The tympanic thermometer was found to be reliable and performed better than the temporal thermometer after exercise. For Study 2, body temperature responses of 109 women in the second and third trimester of pregnancy were examined during an aqua-aerobics class. Tympanic temperature was measured at rest pre-immersion (T1), after 35 minutes of moderate intensity aqua-aerobic exercise (T2), after a further 10 minutes of light exercise and stretching while still in the water (T3) and finally on departure from the facility (T4). The range of water temperatures in seven community pools used in the study was from 28.8°C to 33.4°C. Results showed that body temperature increased by mean 0.16°C (SD 0.35) at T2, was maintained at this level at T3 and had returned to pre-immersion resting values at T4. Regression analysis demonstrated that the temperature response was not related to the temperature of the water. Covariates, air temperature and humidity, had no effect on the body temperature response. The participants were grouped according to water temperature and analysis of variance demonstrated no difference in body temperature response between the cooler, medium and warmer water temperature groups. However, the number of participants in the warmer water group was too small to make firm conclusions about water temperatures between 32.1°C and 33.4°C. The study concluded that healthy pregnant women maintain body temperatures within safe limits during moderate intensity aqua-aerobic exercise conducted in pools that are heated up to 32°C and probably up to 33°C. This study supports the British obstetric guidelines for exercise during pregnancy which state that water temperature up to 32°C is safe for aerobic exercise and suggests that the previous Australian guidelines for maximum water temperature of 28°C were too restrictive. The study has provided evidence to inform guidelines for maximal water temperatures for aqua-aerobic exercise during pregnancy.