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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ItemGait Outcomes in Preschool-aged Children Born Very Preterm( 2021)Children born very preterm (VP; less than 32 weeks’ gestation) have a higher risk of motor impairment and poorer motor outcomes than their term-born peers. The underlying mechanisms of motor impairment and the motor developmental trajectory for infants born preterm are unclear, and the evidence investigating gait characteristics in children born VP is sparse. Four studies were designed to fill this knowledge gap by comprehensively investigating the gait of children born VP in various walking conditions at preschool age: preferred speed, cognitive dual-task, motor dual-task and tandem walking. Study 1 is a systematic review of the evidence on walking onset and gait characteristics in children born preterm (less than 37 weeks’ gestation) compared with term-born peers. The walking onset of infants born VP is delayed by over two months compared with term-born peers. Limited evidence is available about their subsequent gait development and whether these children ‘catch up’ to the typical gait patterns of their peers. The systematic review revealed that the gait of preschool-age children born VP had not yet been investigated. Study 2 is a cross-sectional study which compared the gait variables and step to step gait variability of children born VP with their term-born peers at 4–5 years of age. While the gait of preschool-age children born VP did not differ from their term-born peers when they walked at their preferred speed, differences occurred when walking complexity increased. Key differences included a wider base of support (BOS) in cognitive dual-task, motor dual-task and tandem walking, and higher BOS variability in preferred speed and tandem walking. The wider BOS might indicate an adaptation to maintain balance while walking. Study 3 is a cross-sectional study which examined the gait of preschool-age children born VP at risk for developmental coordination disorder (DCD) compared with their VP peers not at risk. Children at risk for DCD walked with minimal gait differences from those not at risk in preferred speed walking; however, differences emerged when walking demands increased in the other three more challenging walking conditions. This study also found that children at risk for DCD walk with higher gait variability in all four conditions. Similarly to Study 2, one of the key differences included wider BOS in motor dual-task and tandem walking and higher BOS variability in preferred speed, cognitive dual-task and tandem walking, which might reflect greater balance challenges. Finally, a longitudinal study, Study 4, examined the associations between the Alberta Infant Motor Scale (AIMS) and walking ability at 12 months, and motor and gait outcomes at 4–5 years in children born VP. The AIMS total score was associated with poorer balance, wider tandem BOS and higher rates of preschool-age motor impairment. Children with a motor delay at 12 months had lower balance skills and longer double-limb support, but not higher odds of non-cerebral palsy motor impairment at preschool age. Furthermore, this study reveals that early independent walking at 12 months is associated with better balance skills but not gait characteristics at preschool age in children born VP. Overall, the studies undertaken in this thesis demonstrate that preschool-age children born VP are at risk of greater walking impairments than term-born children when walking demand increases. This thesis makes a novel contribution to the understanding of gait development, identifying a high-risk subgroup and predictors of neurodevelopmental outcomes at preschool age in the VP population. Understanding the gait of children born VP is essential to minimising the negative impact on motor development and potential secondary impacts on physical activity, participation, academic achievement and self-esteem. The studies in this thesis establish a foundation for future research exploring walking performance in preschool-age children born VP.
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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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ItemDigitally-delivered exercise for people with knee osteoarthritis( 2021)Knee osteoarthritis (OA) is one of the most common musculoskeletal conditions. Knee OA imposes a substantial individual and societal burden. This burden is projected to increase due to rising obesity rates and an ageing population and become unsustainable for healthcare systems within the next 15 years. In light of this, it is unacceptable that many people with knee OA are not participating in evidence-based and recommended treatments, such as strengthening exercise and physical activity. This is in part due to issues of access to suitably trained health professionals to prescribe and support recommended exercise as well as the challenges people with knee OA experience adhering to regular exercise. This thesis will explore a novel and scalable method of delivering and supporting evidence-based exercise management to people with knee OA. Specifically, this thesis will develop and rigorously evaluate a self-directed digitally-delivered exercise intervention for people with knee OA. Study One involved the development of a 24-week automated mobile phone text message intervention to support exercise adherence for people with knee OA. This study used the Behaviour Change Wheel framework which guided the application of evidence and behaviour change theory. The intervention was designed to promote participation in weekly knee strengthening exercise by targeting common exercise facilitators and barriers experienced by people with knee OA. Study Two reports the methodology of a two-arm parallel-design, assessor- and participant-blinded randomised controlled trial. This study was designed to evaluate a digitally-delivered intervention combining web-based OA and exercise information, physical activity guidance and prescription of a 24-week self-directed knee strengthening regimen (the My Knee Exercise website) supported by the mobile phone intervention designed in Study One, compared to web-based OA and exercise information only (control), in people with knee OA. Primary outcomes were overall knee pain and physical function (WOMAC function), at 24-weeks. Study Three presents the results of the RCT described in Study Two. In this study 206 people with clinically diagnosed knee OA were recruited from the community across Australia and randomised into one of the two groups. Study findings demonstrate that the self-directed, digitally-delivered exercise intervention resulted in greater improvements in pain and function at 24 weeks, compared to internet-delivered education alone in people with knee OA. These findings may be clinically relevant on a population level. Study Four qualitatively explored participants’ experience and perceptions of using the self-directed digitally-delivered exercise intervention (n=16). Participants had overall positive experiences with the intervention, valuing its simplicity and comprehensiveness, and most appreciated the regular text message contact as an exercise prompt. However, the messages evoked feelings of guilt for some if weekly exercise was not possible. Additionally, a human presence associated with the intervention appeared important. Study Five involved a secondary analysis of data from Study Four and explored if certain baseline participant characteristics were potential moderators of the effect of the self-directed digitally-delivered exercise intervention on changes in pain and function at 24 weeks, compared to the control. Except for pain self-efficacy, which moderated change in function but not pain, only weak evidence was found that the selected baseline patient characteristics moderated intervention outcomes. Collectively, findings of this thesis demonstrate the unsupervised, free-access intervention is an acceptable and efficacious method of providing recommended evidence-based exercise to people with knee OA. Findings of this thesis will inform intervention modifications and can be used to guide the design of future digitally-delivered exercise interventions in people with knee OA or other chronic conditions where exercise is a core treatment.
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ItemMuscle strengthening and neuromuscular control retraining for the treatment of chronic low back pain( 2021)Chronic low back pain (CLBP) is a complex multifactorial condition. There are multiple factors associated with CLBP-related disability, including neuromuscular, behavioural and psychological factors. Traditional assessments of neuromuscular impairments (e.g., lumbar extension strength, lumbar range of motion, the ability to contract lumbar multifidus (LM) and transversus abdominus in isolation) have been shown to be weakly associated with CLBP-related disability. Despite this, exercise interventions, such as strengthening exercises, are efficacious and recommended by clinical practice guidelines for reducing disability in people with CLBP; however, there is presently no indication as to which form of exercise is optimal. A recent study identified a relationship between CLBP-related disability and reduced neuromuscular control of the lumbar extensors. These findings suggest that exercises based on retraining neuromuscular control of these muscles may be efficacious for CLBP patients; however, this has not been subject to experimental investigation. Considering the already determined positive effect of strengthening exercises on disability in this population, a combination of strengthening and novel neuromuscular exercises may yield meaningful clinical changes in CLBP-related disability. Thus, the main aims of this thesis are to i) determine whether the addition of neuromuscular retraining of lumbar extension to a program of general muscle strengthening reduces CLBP-related disability compared to a muscle strengthening program in isolation, and ii) investigate the neuromuscular, biomechanical and psychosocial mechanisms in which neuromuscular control retraining and muscle strengthening may influence CLBP-related disability. Muscles in the lumbar spine work synergistically during movement and functional tasks (e.g., lifting). Specifically, iliocostalis lumborum (IL) plays an important role in movements and stabilisation of the lumbar spine. However, structural changes of the IL are not well understood in people with CLBP. There is also limited understanding of the relationships between changes to lumbar muscle and outcomes such as pain and strength. Therefore, this thesis also aims to iii) establish the reliability of novel muscle morphological and compositional measures of the lumbar extensors via ultrasound imaging; iv) compare CLBP participants with healthy matched controls using novel assessments of lumbar extensor morphology and composition; and v) investigate the relationship and predictive ability of morphological and compositional measures of the lumbar musculature and pain intensity and strength. To address these aims, a randomised controlled trial (RCT; aims i and ii), a reliability study (aim iii) and a cross-sectional study (aims iv and v) were conducted. The RCT investigates the effects of neuromuscular control retraining and strengthening exercises on CLBP-related disability. Details regarding the specific training parameters (i.e., repetitions, sets, time etc.) for the interventions and outcome measures utilised in the RCT are reported in a protocol study (Chapter 4). The RCT (Chapter 5) found that lumbar extensor neuromuscular control retraining in conjunction with strength training conferred no benefit over strength training alone in people with CLBP. However, it established that both interventions resulted in clinically important reductions in disability, pain intensity, and kinesiophobia. The reliability study (Chapter 6) revealed that LM morphology and composition can be assessed reliably by different assessors using ultrasound imaging. Similarly, measures of IL possess excellent test-retest reliability but poor-fair inter-rater reliability. The cross-sectional study (Chapter 7) found CLBP-related changes in lumbar multifidus morphology and IL composition compared with healthy individuals. Furthermore, it was identified that pain-inhibition contributes to decreases in size and contractility of the LM of people with CLBP.
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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.
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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.