Physiotherapy - Theses
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ItemExercise intervention for adults treated with allogeneic bone marrow transplantation( 2021)Haematological cancers are diagnosed in 50 people per day in Australia and are the second most common cause of cancer-related death in Australia. Treatment for haematological cancer needs to be systemic and often includes chemotherapy, whole-body radiotherapy and/or bone marrow transplantation (BMT). Side-effects of treatment with BMT are multifactorial, associated with the underlying disease, the patient factors (for example comorbidities) and concomitant medications (for example steroids and immunosuppressants). An allogeneic BMT uses stem cells from a healthy donor and is generally higher-risk and higher intensity compared to autologous BMT which uses the patient’s own stem cells. Common symptoms associated with BMT include fatigue, reduced physical function, pain, weight loss, poor health-related quality of life (HRQoL), anxiety and depression. Exercise has potential to improve the physical and psychological burden of BMT, however is not part of routine care before, during or following BMT in many countries globally and particularly in Australia, and more research is required to facilitate this implementation. Study 1 of this thesis is a systematic review synthesising the evidence examining the effect of exercise on outcomes such as functional exercise capacity, HRQoL and healthcare resource usage among adults treated for haematological disease with BMT. This systematic review included 24 randomised controlled trials (RCTs) and 3 prospective non-randomised experimental trials with a total of 2432 participants; and 19 RCTs were included in the meta-analysis. Thirteen studies included only recipients of allogeneic BMT or published subgroup analyses of allogeneic BMT recipients; five studies included only recipients of autologous BMT, and ten studies included a mixed population of allogeneic or autologous BMT. Studies included in this systematic review were generally of poor to moderate methodological quality and there was too much heterogeneity among factors including population, intervention and outcomes to provide conclusions regarding ideal mode and timing of exercise. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate the quality of evidence for each meta-analysis. The meta-analysis found moderate-quality evidence that exercise compared to control (no exercise) improves functional exercise capacity, fatigue and global HRQoL. There was low-quality evidence that exercise compared to control reduces hospital length of stay, improves strength and increases overall body weight. Most of the effects of exercise were more pronounced in allogeneic BMT although this evidence was generally rated low-quality. There were no between-group effects for bone marrow engraftment, physical activity, respiratory function, fat mass or lean body mass, anxiety and depression. No serious adverse events were associated with the exercise interventions. Study 2 of this thesis is a prospective cohort study which primarily aimed to explore the feasibility of ‘late-commencing’ group-based exercise following allogeneic BMT. The phrase ‘late-commencing’ is used as the intervention commenced following hospital discharge at 60-days post-transplant, which is ‘late’ in comparison to the intervention in the subsequent Study 3. In Study 2, forty-three consecutive adults planned for allogeneic BMT for haematological disease were recruited and conducted baseline outcome testing pre-transplant, then commenced a group-based exercise and education intervention at 60-days post-transplant. The consent rate pre-transplant was 93%, eligibility to commence the intervention post-transplant was 77% (n=33 from 43; due to death, cancellation of transplant, or being medically unwell), and a further 16% (n=7) declined to participate in the intervention. Of the n=26 who commenced the intervention, 81% (n=21) completed it with 81% adherence to the exercise sessions. This study observed significant decline in functional exercise capacity and HRQoL from pre- to 60-days post-transplant; followed by significant improvement in these outcomes from 60-days to completion of intervention. Whilst these results should be interpreted with caution, this significant decline in outcomes raised the question that perhaps intervention is required earlier in the continuum of allogeneic BMT. Thus, Study 3 of this thesis is a prospective cohort study which introduced an ‘early-commencing’ group-based exercise program, defined as ‘early’ as it commenced upon admission to hospital prior to allogeneic BMT, which is early in comparison to the intervention in the aforementioned Study 2. In Study 3, forty-two consecutive adults with haematological disease were recruited and had baseline outcome testing prior to allogeneic BMT, then commenced the group-based exercise intervention upon hospital admission, a median [IQR] of 5.5 [1-7] days prior to BMT. There was 100% consent rate; 83% (n=35) continued the inpatient intervention until hospital discharge and 95% (n=40) completed at least some aspects of final outcome testing at 60-days post-transplant. Fifty-one percent of participants attended the group-based intervention greater than or equal to 3 times per week, and 83% attended greater than or equal to 2 times per week. There were no adverse events associated with the intervention, and the intervention was deemed to be safe and feasible for participants to participate in group-based exercise greater than or equal to 2 times per week during hospitalisation. Except for emotional wellbeing which improved over time, all other outcomes significantly declined during acute hospitalisation and recovered slightly, though not significantly, following discharge. This persistent significant decline suggests there may be biological contributing factors such as transplant toxicities and/or effects from medications such as steroids. It was observed that participants who attended exercise sessions more frequently demonstrated lower signs of clinical frailty at baseline and higher functional exercise capacity at 60-days post BMT. These observations suggest that increased emphasis on pre-transplant assessment of factors such as frailty may aid in targeting exercise interventions at those who need it most. Furthermore, understanding factors that may impact adherence to exercise is important, hence a qualitative study was conducted concurrently. Study 4 of this thesis is a qualitative study which conducted individual semi-structured interviews with 35 participants of Study 2 and Study 3 to characterise experiences and views, including barriers and facilitators, of participation in a group-based exercise program during or after allogeneic BMT. Six major themes were identified including (1) motivation, (2) physical opportunity and (3) capability to exercise; (4) psychosocial effects of group-based exercise; (5) experienced impact of participation in exercise; and (6) intervention design considerations. Main barriers to exercise participation included symptom severity; fluctuating health status; and distance or difficult access to an exercise facility or equipment. Main facilitators included encouragement from healthcare staff; peer-support in a group-based setting; flexibility; education; and ability to measure change. The improvement in emotional wellbeing seen in Study 3, was echoed in participant views which noted that the psychological impact of group-based exercise should not be underestimated. Ultimately the study highlighted the importance of individual exercise preferences, and flexible interventions with consideration of physical and psychological capability, opportunity and motivation to sustain exercise behaviours following BMT. The findings of this thesis support the safety and feasibility of exercise in BMT, and with moderate to low confidence note that exercise improves physical and psychosocial health outcomes. The feasibility of group-based exercise has been established through this thesis, and this approach may have benefits to psychological wellbeing and may be more cost-effective than individual supervised exercise. To build towards implementation of exercise into routine clinical care for adults treated with BMT, large multi-centre, powered, well-designed RCTs are required to confirm efficacy. It is recommended that these RCTs include measurement of pre-transplant frailty, treatment toxicities and use of medications (steroids, immunosuppressants) to determine the influence of these factors on ability of exercise to maintain or improve physical outcomes such as exercise capacity. Future RCTs should be designed in partnership with key stakeholders including patients, caregivers, clinicians, policymakers and administrators to maximise adoption. These RCTs should consider adopting similar principles of intervention and outcome testing that have demonstrated efficacy in previous RCTs and consider group-based elements to maximise psychological wellbeing. Future RCTs should prioritise measurement of cost-effectiveness to ascertain sustainability of the intervention in the real-world context.
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ItemStrategies to prevent respiratory complications after high-risk elective upper abdominal surgery( 2021)Upper abdominal surgery is the most frequently performed surgery type in Australia with approximately 175,000 operations annually and the incidence of surgery is continuing to rise per annum. Despite advances in perioperative practices, postoperative pulmonary complications (PPC) remain a common serious complication following upper abdominal surgery, with high-risk patients even more susceptible. Consequences of a PPC are considerable and a leading cause of postoperative morbidity and mortality. Atelectasis occurs in almost all patients immediately following surgery, and if unresolved, is thought to lead to the development of more severe PPCs including hypoxaemia, airway infection, and respiratory failure. Preoperative physiotherapy reduces PPC rates by half following upper abdominal surgery. However, despite the overall benefit in PPC reduction demonstrated with preoperative physiotherapy, high-risk patients continue to have an increased PPC incidence. Expert opinion and previous meta-analyses recommend the use of prophylactic non-invasive ventilation (NIV) to minimise PPC risk following upper abdominal surgery. Non-invasive ventilation provides positive airway pressure throughout the breath cycle and is suggested to re-open atelectatic alveoli, increase lung volume, and improve gas exchange. However, implementation of prophylactic postoperative NIV has not been adopted into routine physiotherapy clinical practice. The reasons for this low utilisation are hypothesised to be multifactorial and include perceived risks, associated staffing resources, and unknown optimal intervention dosages. No clear consensus exists to guide postoperative NIV management and safety of prophylactic NIV therapy in abdominal surgery has yet to be adequately reported. This thesis addresses some of the gaps in our current understanding of the role of prophylactic NIV therapy within the upper abdominal surgery population. This thesis was undertaken with the overall aim of evaluating the feasibility, safety, and preliminary effectiveness of physiotherapy-led intermittent NIV to reduce PPC incidence following elective upper abdominal surgery, with a focus on those identified preoperatively at higher PPC risk. To achieve this, three studies were completed involving four peer reviewed publications (two published and two currently under review). The first section of this thesis describes a study which was a prospective, pre-post cohort, observational study (study one). The incidence of PPC and the feasibility and safety of physiotherapy-led NIV following upper abdominal surgery were measured in 81 high-risk post-cohort subjects and compared to 101 high-risk pre-cohort subjects who did not receive NIV. In this study, PPC incidence was significantly lower in the post-cohort group and whilst NIV was shown to be safe, several barriers to early delivery of physiotherapy-led NIV were identified. Due to study methodology, there were significant confounding factors and limitations. Following the publication of this study, a letter to the Editor was published by two international experts in the field of NIV and our response to the letter was published alongside. The second section of this thesis reports on a study protocol for a pilot randomised control trial (RCT), and the findings of this pilot RCT involving 130 high-risks adults undergoing elective upper abdominal surgery (study two). This study aimed to provide preliminary phase 1 feasibility, safety, and effectiveness of additional intermittent physiotherapy-led NIV compared to the provision of continuous high-flow nasal cannula oxygen therapy (HFNC) alone to minimise PPCs, whilst controlling for confounders previously identified in study one. The findings of this study demonstrated that patient consent, recruitment, and follow-up rates were high. Implementation of continuous HFNC was shown to be feasible, with 81% of participants receiving HFNC as per protocol. Physiotherapy-led NIV was delivered safely and provision of early NIV had high treatment fidelity. However, the planned NIV intervention protocol of five sessions over two postoperative days was not feasible, with only 52% of participants receiving NIV as per-protocol. The PPC incidence was similar between groups. Progression to a future definitive trial using this methodology is not recommended. The final section of this thesis reports on a systematic review and meta-analysis evaluating the overall effectiveness of prophylactic NIV and comparing the different NIV intervention approaches used to prevent PPC following upper abdominal surgery (study three). This review identified and meta-analysed data on over 6000 participants from 17 randomised controlled trials. The findings of this review demonstrate prophylactic postoperative NIV therapy does not significantly reduce the incidence of PPC in adults undergoing upper abdominal surgery, including in those identified preoperatively at higher PPC risk. No approach was identified as superior and the routine provision of prophylactic postoperative NIV following upper abdominal surgery is not recommended. The findings of this thesis support the feasibility and safety of physiotherapy-led NIV in the early postoperative period following high-risk elective upper abdominal surgery. However, a planned protocol of five NIV sessions over two postoperative days is not feasible to warrant trial progression. Findings from the systematic review do not support routine provision of prophylactic postoperative NIV in upper abdominal surgery, including in those identified at higher PPC risk. A protocol of continuous postoperative HFNC is feasible, well tolerated, and acceptable in a high-risk abdominal surgical population. Future directions for the field include examining whether postoperative NIV may benefit selected high-risk patients, i.e., those who demonstrate signs of respiratory deterioration, or those who are unable to participate in early mobilisation following upper abdominal surgery. Future superiority studies are also required to test the benefits of prophylactic continuous HFNC on PPC incidence compared to standard care following high-risk upper abdominal surgery.
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ItemPrehabilitation in major cancer surgery: A focus on feasibility and barriers( 2021)Abdominal cancer surgery is the most common major surgical procedure performed in developed countries, however post-operative morbidity are high. Post-operative complications are common and associated with an increased morbidity and prolonged hospital stay whilst also contributing significant costs to the healthcare system. Prehabilitation aims to deliver interventions in the preoperative period to minimise the development of these complications and hasten recovery. The current evidence for prehabilitation for improving preoperative status is favourable, however its carry over into improvements in post-operative outcomes remain controversial and feasibility amongst high-risk patients in the real world setting unclear. An investigation into the feasibility of prehabilitation for the high-risk abdominal surgery population is needed. The studies within this thesis aimed to (1) identify, evaluate and synthesis the evidence examining the effect of prehabilitation with exercise on postoperative outcomes following abdominal cancer surgery (2) explore the acceptability of prehabilitation from the perspective of patients (3) investigate the feasibility of delivering a prehabilitation intervention to high-risk patients and (4) evaluate the current and likely future impact of a telehealth preoperative education package for patients preparing for major abdominal cancer surgery. Study 1 critically examined the literature, through a systematic review and meta-analysis, and found that multimodal prehabilitation programs were superior to unimodal programs at improving functional capacity prior to major abdominal cancer surgery as well as reducing hospital length of stay. However there was no difference in the number of postoperative complications, hospital re-admissions or postoperative mortality. Heterogeneity in the literature and a lack of consistency amongst outcome measures limited the ability to measure the effect of prehabilitation on post-operative complications. Study 2 explored the acceptability of prehabilitation from the patient perspective. Adult patients prior to major abdominal surgery were surveyed prior to the commencement of any prehabilitation program prior to major abdominal surgery. The results indicated that prehabilitation was a largely unknown concept for patients preparing for major cancer surgery. The survey found that although 82% of patients had not previously heard of prehabilitation, the majority of patients (71%) expressed interest in participating. Based on participants responses, several key recommendations for researchers, clinicians and policy makers designing prehabilitation programs in the future were developed. Results indicated that programs should be sensitive to the individual’s financial situation, recommended by treating health professionals (preferably doctors), delivered in convenient locations (preferably home) and telehealth interventions should be carefully chosen with the patient. Study 3 investigated the feasibility of a prehabilitation program, designed and conducted using the principles for high-risk patients awaiting major abdominal cancer surgery gained from Study 2. The findings showed trends to improvements in preoperative cardiorespiratory fitness. More research is needed to improve exercise fidelity reporting and adherence to exercise interventions within this complex group. Study 4 was conducted based on the findings of Study 3 to further explore the feasibility of providing a prehabilitation intervention to high-risk patients awaiting major abdominal surgery using a telehealth intervention developed to overcome distances required to travel to the hospital. Participants were delivered an online webinar consisting of six modules of prehabilitation information including the evidence behind prehabilitation, respiratory care bundle including breathing exercises and advice on oral hygiene, exercise prehabilitation, nutrition before surgery, psychological preparedness before surgery as well as pain management after surgery. Findings demonstrated that the webinar was well received, was memorable and had a positive effect on behaviour change within the two weeks after the session. Implementation within this study was examined using the RE-AIM framework and seven recommendations are provided for researchers, clinicians and/or policy makers to assist with implementation of similar programs in the future. These studies analysed the evidence for prehabilitation in the management of patients prior to major abdominal cancer surgery. Prehabilitation within this group was proposed to be feasible within the real-world setting. The evidence provided in this thesis consists of several recommendations regarding feasibility within this high-risk group that should be considered when designing and implementing prehabilitation interventions as well as for future research studies. They present an original contribution to knowledge in this area. These findings may not be generalisable to all settings and may require further research in different surgical populations, settings and healthcare systems. The literature base for prehabilitation needs to grow to fully determine its effectiveness and implementation strategies designed with patient input to maximise their impact.
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ItemNo Preview AvailableUnderstanding and promoting physical activity participation for children born preterm( 2021)Children born preterm are at greater risk of motor impairment, including cerebral palsy (CP) and developmental coordination disorder, compared with children born at term. Despite the important role participation, including participation in physical activity (PA), plays in promoting motor development, very little is known about participation for children born preterm at preschool age. Participation includes two components: attendance and involvement. It is a complex phenomenon, influenced by environmental and personal factors, and is recognised as an important outcome for children with motor impairment. This thesis aims to better understand correlates of participation for preschool age children born preterm, as well as means of promoting participation for this group. Study one focused on correlates of participation. It compared community participation for preschool age children born at <30 weeks’ gestation (VP) and at term, and explored motor impairment and social risk as possible correlates of participation. Perceived environmental barriers and facilitators of community participation were also assessed. Children born VP participated less frequently in community activities compared with children born at term. Higher social risk was associated with poorer participation outcomes for children born VP but not term, while there was little evidence motor impairment was associated with community participation. Finally, parents of children born VP perceived greater environmental barriers to participation compared with parents of children born at term. Study two was a systematic review exploring the efficacy of movement-based interventions for preschool age children (3-6 years), with or at risk of motor impairment, including children born preterm (<37 weeks’ gestation). This review highlighted the scarcity of randomised controlled trials (RCTs) or quasi RCTs exploring movement-based interventions for this age group. Overall, movement-based interventions did not significantly improve body structure and function or activity outcomes, while the heterogeneity of intervention design and study quality made it difficult to establish definite conclusions. In particular, there were no studies that assessed participation as an outcome. Study three explored the feasibility and acceptability of a novel intervention known as Dance PREEMIE (a Dance PaRticipation intervention for Extremely prEterm children with Motor Impairment at prEschool age), which aimed to improve PA participation for preschool age children born extremely preterm (<28 weeks’ gestation) or extremely low birthweight (<1000g), with motor impairment. Children enrolled in Dance PREEMIE were allocated to a weekly community dance class (8 weeks duration) taught by dance teachers who received study-specific training. Dance PREEMIE was feasible to implement in Melbourne, Australia. Classes were well-attended and enjoyable for children, while dance teachers reported improved self-efficacy for teaching children with motor impairment after the training. Overall, Dance PREEMIE was acceptable to both parents of participating children and dance teachers. Findings from this thesis indicate that preschool age children born preterm have poorer participation outcomes compared with their term born peers, and present evidence on the feasibility and acceptability of Dance PREEMIE, a novel PA participation intervention.