Physiotherapy - Theses
Permanent URI for this collection
Search Results
1 - 4 of 4
-
ItemPelvic floor disorders in exercising women( 2023-09)Physical inactivity is a global societal and economic burden, increasing the risk of chronic disease. Women participate in organised sports at lower rates than men and 86% of Australian women do not meet all components of the National Physical Activity Guidelines. Sport and exercise activities may provoke symptoms of pelvic floor (PF) disorders. Pelvic floor symptoms are highly prevalent in exercising women. One in three women report symptoms of urinary incontinence (UI) across all sports and up to 80% of women engaging in high impact sports or heavy weight-lifting report UI and/or anal incontinence (AI). It is therefore important to understand how PF symptoms limit or stop exercise participation in women. The thesis research aimed to: establish the impact of female PF symptoms (UI, AI and pelvic organ prolapse) on sport and exercise participation; determine current PF symptom screening and management within Australian sport and exercise settings; and explore the preferences, barriers and enablers for future PF symptom screening and management within sport and exercise settings from the perspectives of exercising women and health or exercise professionals. Study One was a systematic review of the impact of PF symptoms on sport and exercise. Whilst UI adversely impacted exercise in one in two women, the evidence certainty was low. Important gaps in the knowledge of other PF symptoms (beyond UI) and the degree and nature of impact of all PF symptoms on participation were established. Study Two, an observational, cross-sectional study of 4,556 Australian women with PF symptoms, examined the research gaps determined by systematic review. One in two women stopped a form of exercise they had previously participated in, secondary to PF symptoms. A secondary data analysis (Study Two, Part B) found that women with more severe UI symptoms (OR=4.77; 95% CI:7.24 to 14.37), and higher bother (UI: OR=10.19; 95% CI:7.24 to 14.37; POP: OR=22.38; 95% CI:13.0 to 36.60; AI: OR=29.66; 95% CI: 7.21 to 122.07) were at greater odds of identifying their PF symptoms as a barrier stopping participation (often or all the time). Study Three, a qualitative descriptive study, interviewed symptomatic women (n=23) about their experience of PF symptoms within sport and exercise settings. Symptoms inhibited their ability to participate in exercise in the manner they wanted. Restrictive and complex coping strategies were used to avoid symptom provocation, which limited their spontaneity and enjoyment of sport and exercise. Study Four, an observational, cross-sectional survey study completed by Australian health and exercise professionals (n=636), found that PF symptom screening was not common practice within Australian sports and exercise settings, especially in at-risk groups such as high-impact athletes. Professionals were willing to engage in future screening and management, but required training, resources and access to referral networks prior to implementation. Study Five, an explanatory-sequential mixed methods design, synthesised quantitative and qualitative data (‘following a thread’) exploring symptomatic women’s experience of PF symptom disclosure and screening within sports and exercise settings. Most women had not told anyone about their symptoms due to embarrassment, limited pelvic health knowledge or not being asked. Women conveyed important preferences for future screening and management of PF symptoms within sports settings, including recommendations for how to start a conversation on pelvic health in an acceptable manner. Additional factors to facilitate disclosure, and make sports and exercise settings safer and more inclusive for symptomatic women were explored. Together, this thesis established that PF symptoms stop women from participating in sports and exercise in their preferred manner, limiting enjoyment and increasing the odds of physical inactivity. Currently, women are not usually provided the opportunity to seek help for their symptoms within sports and exercise settings. However, women and professionals felt that the provision of screening, education and management would be acceptable if appropriate support was provided and sensitively and safely implemented.
-
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.
-
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.
-
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.