Physiotherapy - Theses
Permanent URI for this collection
Search Results
1 - 3 of 3
-
ItemQuality of physiotherapy care for people with hip and/or knee osteoarthritis( 2020)Patients with hip and/or knee osteoarthritis (OA) desire high quality of care when managing their condition. Clinical guidelines advocate exercise, weight loss (for people who are overweight or have obesity), and education regarding self-management as first line treatments for OA. Physiotherapists are important providers of such non-surgical interventions. As such, they have a professional responsibility to ensure that the care they provide to people with OA is safe and aligns with best practice. Current quality indicators (QIs) for care of people with hip and knee OA are not designed to specifically assess physiotherapy care. Furthermore, little is known about the experiences of Australian physiotherapists and people delivering and receiving care for knee OA, and if their reported experiences align with the national Clinical Care Standard for knee OA (quality statements that describe the care Australian patients should be offered by health professionals and health services for OA in line with current best evidence). This thesis aims to build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA, by developing QIs to evaluate such care and exploring the experiences of physiotherapists and patients delivering and receiving care for knee OA in Australia. Study One aimed to identify and prioritize the most important clinical guideline recommendations relevant to physiotherapy practice for hip and/or knee OA. A panel of 62 international physiotherapists was invited to first complete an online modified-Delphi survey, followed by a priority-ranking exercise. Recommendations were extracted from two high quality international clinical guidelines for OA. From an initial list of 70 potential recommendations (including seven new recommendations generated by the expert panel), 30 were included in the priority-ranking exercise. The final 30 recommendations were condensed and categorised by content area to convey high quality physiotherapy management for hip and/or knee OA. The top recommendations related to providing exercise, weight management, and education as core treatments; individualised OA management; and communication approaches. Study Two aimed to develop a patient-reported QI tool (the Quality Indicators for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) tool) and to assess its reliability and validity. A conceptual model based on the final 30 recommendations from Study One was used when developing the QUIPA tool, where the four main categories of the final recommendations were synthesized to establish the three subscales of the QUIPA tool. Patient focus groups were conducted to further refine the draft items. To evaluate test-retest reliability, construct validity (hypothesis testing) and criterion validity, patients with hip and/or knee OA (n= 65) were recruited to attend a single physiotherapy session and required to complete the QUIPA tool one, twelve- and thirteen-weeks following their session. Physiotherapists (n= 9) were expected to complete the tool immediately post-consultation. Patient test-retest reliability was assessed between twelve- and thirteen-weeks following their session. Construct validity was evaluated based on three predefined hypotheses. Criterion validity was assessed based on agreement between physiotherapists and participants at week one. The final QUIPA tool comprised 18 items (three subscales). The QUIPA tool demonstrated acceptable test-retest reliability for subscales and total score, but individual items showed inadequate reliability. Construct validity was adequate but criterion validity for individual items, subscales and the total score was poor. The QUIPA tool needs further refinement to improve its clinimetric properties before implementation into clinical practice. Study Three was a qualitative study that explored the experiences of Australian physiotherapists (n= 22, thirteen from major cities, five from inner regional, three from outer regional and one from remote areas) delivering care for people with knee OA and investigated the degree to which their reported experiences aligned with the Australian OA of the Knee Clinical Care Standard. Inductive thematic analysis was conducted, and the interview data were also deductively analysed according to the national Clinical Care Standard. Findings revealed that physiotherapists tended to focus on a biomedically-oriented assessment with little evaluation of psychosocial factors that may impact patients with knee OA. They perceived their primary role as providing goal-focused individualised exercise via short-term episodic care. Knee surgery was considered as a last option but for patients who chose surgery, physiotherapists ‘prepped’ them for the procedure. Patient comorbidity, poor patient adherence and patient desire for a ‘quick fix’ were perceived as clinical challenges. Physiotherapists also described a mismatch between what they know and what they do when it came to manual therapy, imaging, and weight loss advice. They saw weight management, medication, and surgical advice as outside of physiotherapy scope of practice. Overall, physiotherapists’ reported experiences with delivering care for people with knee OA were mostly consistent with the OA of the Knee Clinical Care Standard. Study Four was a qualitative study that explored the experiences of Australians (n= 24, from all six states and two territories of Australia) receiving physiotherapy care for knee OA. Participants generally presented to physiotherapists with a pre-existing OA diagnosis and were mostly comfortable with their existing knowledge about OA. They described accessing physiotherapy through various referral pathways, funding models and modes of delivery. They consulted physiotherapists for various reasons but most commonly for assistance with knee pain and functional impairments. Participants described physiotherapy management as primarily centred on exercise therapy, often supplemented by adjunctive treatments. Participants perceived advice about surgery, medications, and injections as outside of physiotherapists’ domain of care. Participants were generally happy and satisfied with their physiotherapy experiences and described valuing the personalised care they received. They also believed surgery was inevitable for their knee OA. Overall, these results provide evidence from the patients’ perspectives about the important role physiotherapists play in the care of Australians with knee OA. Findings from this thesis build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA. The first two studies lay the groundwork for future design and evaluation of an international patient-reported QI tool for benchmarking quality of physiotherapy care in hip and/or knee OA. Overall, findings from the last two studies indicated that physiotherapy management of knee OA in Australia mostly aligned with the national clinical care standard and that patients were generally happy and satisfied with the physiotherapy care received. Suggested areas to improve care delivered by physiotherapists include increased consideration of psychosocial factors that may influence OA symptoms and prognosis, attention to the language used when discussing OA (i.e. avoid biomedical terms such as ‘wear and tear’ or ‘degenerative’) so that physiotherapists are not contributing to patient misinformation (i.e. joint surgery is inevitable; OA is a ‘degenerative’ or ‘wear and tear’ condition; imaging is required to diagnose OA), increased emphasis on advice and information about losing weight (for patients who need it), pain medications and knee surgery, and offering regular longer-term reviews. Findings also highlight the importance of appropriate funding mechanisms to support Australians to access physiotherapy care for their knee OA both in private and public sectors.
-
ItemPrehabilitation for individuals having lung cancer surgery( 2020)Non-small cell lung cancer (NSCLC) is the fourth most commonly diagnosed cancer in males and the fourth most commonly diagnosed cancer in females in Australia. It is the leading cause of cancer-related mortality, being responsible for more deaths than breast, colorectal and prostate cancer combined. Pulmonary resection provides the best chance of a cure for patients with early stage lung cancer. However, pulmonary resection is associated with significant impairment in functional capacity along with a moderate risk of postoperative morbidity, particularly in frail or deconditioned patients. Prehabilitation is defined as “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment that, in the perioperative setting, aims to enhance functional capacity of the individuals to enable them to withstand the stress associated with a procedure”. Prehabilitation can include a care bundle incorporating smoking cessation, diet optimization, psychosocial support and exercise, and aims to identify impairments and deliver targeted interventions that improve patient outcomes. It provides an opportunity to decrease treatment-related morbidity, increase available treatment options for patients who would not otherwise be surgical candidates and facilitate return of patients to the highest possible functional level. There is a growing body of evidence that supports prehabilitation as a means of preparing patients with newly diagnosed cancer for surgery by optimizing their health preoperatively. Enhancing a patient’s preoperative condition may help them withstand the stressors of surgery. Evidence supports the implementation of prehabilitation in the preoperative care pathway of other cancer cohorts, for example colorectal, breast and prostate cancers. Unfortunately, the evidence for the effects of prehabilitation in lung cancer has lagged behind and the use of prehabilitation (specifically the exercise component) for patients with lung cancer is now an emerging area. To date, exercise prior to lung cancer surgery has been shown to be safe and associated with improvements in functional capacity as well as postoperative morbidity (hospital length of stay) and rates of postoperative pulmonary complications), however the feasibility and acceptability of prehabilitation for patients with lung cancer is still unclear. The two studies within this thesis focus on the exercise component of prehabilitation in the context of surgical management of lung cancer in Australia.
-
ItemPreoperative physiotherapy to prevent postoperative pulmonary complications after major abdominal surgery( 2020)Abdominal surgery is the most common major surgical procedure performed in developed countries. After surgery, postoperative pulmonary complications (PPCs) occur frequently and are a primary cause of morbidity, mortality, and prolonged hospital stay. To minimise PPCs, physiotherapy is ubiquitously provided in the postoperative phase in hospitals throughout developed countries. Physiotherapy clinical trials reporting the largest reductions in PPCs have predominately tested preoperative education and training of patients to perform their own breathing exercises after surgery. These trials were generally of low quality and therefore the results lack certainty. Currently, preoperative physiotherapy is rarely provided in Australian and New Zealand hospitals. A well-designed randomised controlled trial (RCT) investigating the benefit of preoperative physiotherapy to reduce PPC in a modern perioperative context was needed. The aims of this thesis were to: consider the physiological basis for preoperative physiotherapy to minimise PPCs; to conduct a narrative and systematic review of research investigating PPC prevention with breathing exercises; and, to design and conduct an RCT, including quantitative, qualitative, and health economic outcomes, assessing the effectiveness of preoperative physiotherapy to minimise PPC after major abdominal surgery. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial was a double-blinded, multicentre, RCT. In pre-admission clinics at three hospitals, 441 patients awaiting major abdominal surgery were randomised to receive an information booklet or an additional education and breathing exercise training session. Education focussed on PPC prevention via self-directed postoperative breathing exercises. A nested mixed-methods study investigated the impact and treatment fidelity of the intervention in 20 consecutive participants. Preventing pneumonia was very important to participants. Intervention participants found preoperative physiotherapy to be interesting and empowering with 94% of remembering the breathing exercises as taught. Following surgery, PPC incidence was halved in the intervention group (adjusted hazard ratio 0.48, 95% confidence interval (CI) 0.35 to 0.75, p=0.001) with a number needed to treat of 7 (95% CI 5 to 14). Intervention participants had significantly reduced pneumonia rates, required fewer antibiotic prescriptions for respiratory infections, less purulent sputum, fewer positive sputum cultures, and were less likely to require oxygen therapy. An integrated health economic analysis found that preoperative physiotherapy had high probability of being cost-effective with an incremental net benefit to hospitals of $4,958 (95% CI $10 to $9,197) for each PPC prevented, given a willingness-to-pay of $45,000 for the service. Quality adjusted life year (QALY) gains were less certain. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. For each PPC prevented, preoperative physiotherapy was likely to cost hospitals less than the costs to treat a PPC. This thesis analysed the evidence for the physiotherapy management of patients having abdominal surgery. A hypothesis for preoperative physiotherapy to minimise PPC after surgery was proposed. This hypothesis was supported with qualitative, primary, secondary, and health economic quantitative outcomes within a multicentre randomised controlled trial, and through a systematic review and meta-analysis. These findings may not be generalisable to all settings and require testing in different surgical populations, cultures, and hospital settings. Effective PPC prophylaxis needs to be investigated for patients unable to attend pre-admission clinics, those having emergency abdominal surgery and in other high-risk populations.