Physiotherapy - Theses
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ItemEffects of athletic footwear design features on running and landing biomechanics in adolescent and young adult females: Implications for anterior cruciate ligament injury and development of patellofemoral pain syndrome( 2023-12)Emerging evidence indicates that adolescent and young adult females experience a notably higher incidence of non-contact anterior cruciate ligament (ACL) injury and patellofemoral pain (PFP) in comparison to their male and pre- and mid-pubertal counterparts. The increased risk of ACL injury and development of PFP in girls and young women is thought to be associated with their aberrant knee (i.e., increased tri-planar knee kinematics and kinetics) during running and landing tasks. Indeed, excessive tri-planar (i.e., knee flexion, knee valgus and internal tibial rotation) knee biomechanics have been found to increase loads on the ACL and patellofemoral joint (PFJ). For this reason, shoes with a lower shoe pitch and/or medial arch may mitigate loads on the ACL and PFJ as these footwear design features can attenuate tri-planar knee kinematics and kinetics. Whilst previous footwear studies have reported independent effects of shoe pitch and medial arch support on knee joint biomechanics, no previous study has investigated the combined effects of shoe pitch and medial arch support on ACL and PFJ contact forces. With respect to current commercially-available footwear, the influence of their design features - such as the degree of shoe pitch and amount of foot support - on in-vivo knee loads during sports-specific tasks remains largely unknown. To determine the most effective load-modifying footwear design features, it is critical to quantify in-vivo muscle forces and the resultant loads on knee joint structures during sports-specific tasks. However, direct measurement of these forces in-vivo is impractical due to the methodological complexities and ethical concerns. Advanced electromyography (EMG)-informed neuromusculoskeletal (NMSK) computational model provides the alternative approach to directly estimate in-vivo loads on ACL and PFJ. In light of these considerations, this thesis incorporated a series of studies that evaluated the effects of athletic footwear design features on knee and lower limb biomechanics in adolescent and young adult females during sport-specific tasks using advanced computational modelling. Biomechanical datasets for the footwear studies in this thesis were derived from two Australian Research Council-funded projects. Both projects used healthy late/post-pubertal females (Project 1: n = 50, age = 22.0 years; Project 2: n = 24, age = 20.0 years) and evaluated two different sets of footwear during drop-lateral-jump (DLJ) and running tasks. Specifically, Studies 2 and 3 used prototype athletic shoes with modifiable footwear features, including shoe pitch (4mm, 7mm and 10mm) and medial arch support (no support, low support and high support). Study 4 used commercially-available high- and low-support athletic shoes. An EMG-informed NMSK computational model was used to estimate in-vivo muscle forces and resultant loads on the knee joint and soft tissues. Study 1 validated the accuracy of predicted knee joint contact forces obtained from the novel EMG-informed NMSK computational modelling pipeline using in-vivo measurements obtained from the Grand Challenge Competition dataset (2010-2012). Specifically, root-mean-squared error (RMSE) between model-predicted and in-vivo measurements of tibiofemoral joint contact forces were comparable with those reported by previous winners of the Grand Challenge Competitions, with differences less than 10%. In addition, significant (p<0.05) associations were found between (i) model-predicted and EMG-derived muscle activity, and (ii) model-predicted and inverse-dynamics-derived joint moments. Together, these findings demonstrated that the novel NMSK computational model was valid and sufficiently accurate for assessing the effects of athletic footwear design features on in-vivo muscle forces and the resultant loads on knee joint structures during dynamic tasks. Study 2 investigated the effects of modifiable footwear design features on ACL force during the DLJ task, using the biomechanical dataset from Project 1. Results indicated no significant (p<0.05) interaction or main effect of shoe pitch or medial arch support on peak ACL force. Although modifiable footwear design features had no effect on the primary outcome measures, an independent main effect of shoe pitch was found for time-to-peak (TTP) ACL force. Specifically, the 4mm shoe pitch condition resulted in a delayed TTP by 8-12%, compared to 7mm and 10mm pitch conditions. Whilst a delayed TTP observed in the 4mm shoe pitch is representative of a lower ACL loading rate, the magnitude of the absolute reduction (i.e., 3-4 ms) was small and, coupled with the fact that peak ACL forces were similar across pitch variants, these findings likely have negligible practical and real-world implications. Study 3 evaluated the effects of modifiable footwear features on PFJ contact forces and Achilles tendon (AT) force parameters (i.e., peak force, loading rate and cumulative force) during running, using the biomechanical dataset from Project 1. Achilles tendon force was measured because previous studies have demonstrated that certain shoe design features reduce PFJ contact forces but concurrently elevate AT force and vice versa. Results indicated no significant (p<0.05) interaction effect between shoe pitch and medial arch support for any of the temporal or magnitude-related PFJ contact force and AT force parameters. However, an independent main effect of shoe pitch was found for PFJ contact forces parameters. Specifically, the 4mm shoe pitch produced a reduction in all temporal and magnitude-related PFJ contact force parameters by 2-3%, compared to 7mm and 10mm pitch conditions. However, it is important to highlight that the magnitude of reduction in PFJ contact force parameters was relatively small and consequently, shoes with a 4mm pitch are unlikely to confer substantial benefit with respect to lowering the risk of developing PFP. Independent main effects of shoe pitch and medial arch support were also found for AT force parameters. Specifically, the 10mm shoe pitch condition reduced all temporal and magnitude-related AT force parameters by 4-7%, compared with 4mm and 7mm pitch conditions. Also, both low and high medial arch support reduced all the temporal and magnitude-related AT force parameters by 2-5%, compared with the no medial arch support condition. Given the association between elevated AT load and pathological changes, physically active individuals seeking the management or prevention of AT tendinopathy may benefit by wearing shoes with a higher pitch and/or medial arch support. Study 4 compared the effects of commercially-available ASICS footwear on PFJ contact forces and AT force parameters during running, using the biomechanical dataset from Project 2. For PFJ contact forces parameters, no significant (p<0.05) difference was found for peak PFJ contact forces and PFJ cumulative force between high- and low-support shoes. By contrast, results suggested that PFJ loading rate was 8% lower in high-support shoes compared with low-support shoes. For AT force, differences were found for peak force, loading rate and cumulative force between high- and low-support shoes. Specifically, results demonstrated that wearing high-support shoes was associated with a decrease in all AT force parameters by 4-10% compared with low-support shoes. Given the aforementioned association between elevated AT load and development of Achilles tendinopathy, high-support footwear may offer advantages for runners predisposed to or experiencing Achilles tendinopathy. In conclusion, it is important to highlight that whilst several results from the three footwear studies reached statistical significance, the magnitude of the observed footwear-related changes was relatively small. Hence, the footwear design features investigated in this thesis likely have negligible practical benefits for girls and young women participating in netball or other court sports. For this reason, future studies should explore other footwear design features to identify which are most effective in mitigating detrimental loads imposed on the ACL and PFJ during sports-specific tasks.
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ItemFalls prevention after stroke(University of Melbourne, 2010)
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ItemTendon-aponeurosis strain and clinical features of runners with and without achilles tendinopathy(University of Melbourne, 2010)
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ItemThe reliability and validity of the squeeze test for athletic groin pain in Australian Rules Football players(University of Melbourne, 2009)
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ItemHistology of the fascial-periosteal interface in lower limb chronic deep posterior compartment syndrome(University of Melbourne, 2007)
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ItemUsing behaviour change theory to understand and promote physical activity in adults with chronic lower limb joint pain( 2023-07)Although guidelines recommend physical activity for people with osteoarthritis, most people with osteoarthritis do not meet the recommended levels of physical activity necessary to achieve positive health benefits. This thesis uses behaviour change theory to: - assess integrated dual-process models, including associations between physical activity and non-conscious process of physical activity (prospective study); - evaluate effectiveness of financial incentives to motivate physical activity (systematic review and meta-analysis, plus a narrative case study); -determine patient preferences for physical activity rewards programs (discrete choice experiment). Findings can inform development of physical activity programs for people with osteoarthritis.
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ItemThe lived experience of people living with obesity in hospital and the staff who care for them( 2023-08)Worldwide obesity rates are increasing at an alarming rate (World Health Organization, 2000). As the rate of obesity increases, the number of people admitted to hospital who are obese also increases (World Health Organization, 2000). Caring for people with obesity in hospital is a key challenge for healthcare systems internationally (Rossner, 2002). Research indicates that due to their complex care needs, hospital patients with obesity incur a greater health expenditure per patient and have poorer outcomes compared to patients of normal weight (Buchmueller & Johar, 2015). Caring for people with obesity can be challenging, impacting on the experience of both the person themselves and the staff providing care. There is a gap in the literature regarding care experiences of people with obesity in the inpatient hospital setting. A strong understanding of the consumer perspective is required to ensure care delivery addresses the factors that are perceived to be important to both people with obesity in the hospital context, and the staff that care for them. The overall objective of this thesis was to inform the delivery of safe, effective, and high-quality care for these patients. A scoping review was undertaken to investigate the pre-existing evidence, and establish the known knowledge gaps. Then, qualitative studies were conducted that explored both the perspective of the lived experience of people with obesity in hospital, and the staff that care for them. This work demonstrated that the environment in which care was delivered, including the timely provision and adequacy of infrastructure and equipment, was the most dominant theme for both people with obesity in hospital and the staff that provide care. The design of hospital environments must consider people with obesity and equipment that supports staff to deliver care should be provided early in the admission. This includes low cost, basic care items such as clinical equipment (like appropriately sized blood pressure cuffs), simple assistive technology, gowns, and continence aids. An emphasis on basic principles of patient centred care to enhance interpersonal interactions and maintain patient dignity, along with improved awareness of the impact of weight bias and obesity stigma were also important. Staff suggested that negative attitudes and gaps in staff knowledge may be addressed through role modelling and system wide training programs which include practical skill development, language education, and presentation of the patient perspective to stimulate discussion and reflective practice. The opportunity for staff to debrief following challenging encounters should also be provided. Such programs could be implemented and tested for efficacy in addressing outcomes for this patient cohort, then scaled up if found to be effective. Findings of this thesis provide important insights into future models of care that could be developed and tested and may be transferable to other healthcare settings. Outcomes form the basis for the development of evidence based strategies to improve the care of this vulnerable and often stigmatised cohort.
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ItemThe Circus Project: Co-designing a circus-based intervention to enhance physical activity participation for preschool-aged children born preterm( 2023-08)Preschool-aged children (three-five years) born preterm (<37weeks' gestation) participate in less physical activity compared with term-born peers. Physical activity is essential for all children, as it facilitates the development of motor skills, as well as maintaining and improving skeletal and cardiovascular health. However, for children born preterm, who are at greater risk of long-term developmental impairments, adequate physical activity is likely to have an even greater role. Although physical activity participation interventions do exist, few target children born preterm at the preschool age, and there is limited evidence of collaboration with parents and other key stakeholders. Engaging stakeholders in co-design of interventions is likely to increase the relevance to the end user, and therefore result in increased uptake of healthcare initiatives. Furthermore, children are more likely to engage in an intervention when it is enjoyable, unique, and delivered in a naturalistic leisure setting. The purpose of this thesis was to develop a circus-based intervention in collaboration with key stakeholders to increase participation in physical activity for children born preterm. This was achieved through five iterative studies using an action research framework. A scoping review of the literature (Study 1) explored what was known from published and grey literature about the use of circus activities as a health intervention for children and young people. Fifty-seven of 897 sources of evidence were included, which described 42 unique interventions. The review found emerging evidence of positive health outcomes resulting from circus activities used in general populations and those with defined biopsychosocial challenges (such as cerebral palsy and autism). The review also highlighted opportunities to strengthen the evidence base such as focusing on detailed reporting of intervention elements (such as the use of the TIDieR checklist), increasing research in preschool-aged children, and focusing therapeutic interventions on specific groups of participants with demonstrated need (rather than the general population). A sequential mixed-methods study (Study 2) explored the experiences and needs of key stakeholders (parents of preschool-aged children born extremely preterm (<28 weeks' gestation), clinicians, and circus coaches) in engaging children born preterm in recreational physical activity. Barriers, facilitators, and strategies were identified in the survey (n = 217) and interview (n = 43) results, which had implications for the development of a circus-based physical activity intervention. These included the importance of coaches' specific knowledge and understanding of the preterm experience, programs incorporating holistic outcomes rather than purely physical development, the role of geographical location and cost as key considerations, and the involvement of clinicians in program design, but not delivery. A novel co-design process (P-POD) was then developed to facilitate an authentic transition to an online environment (Study 3). This process was used to co-design the circus-based physical activity intervention with ten key stakeholders, incorporating the findings from the previous studies (Study 4). The resulting intervention was titled CirqAll: Preschool Circus for Premmies and was reported according to the TIDieR checklist. The novel co-design process was evaluated using an explanatory mixed-methods design. Anonymous surveys completed by the co-design participants revealed that P-POD adhered to the guiding principles of co-design and stakeholder involvement. Themes developed from interview data described participants' experiences of the supportive online culture, room for healthy debate, power-sharing, and multiple definitions of success within the process. Finally, a feasibility study using a case series design (Study 5) evaluated the recruitment capability, acceptability and implementation fidelity of the first part of the 3-part co-designed intervention (CirqAll: professional development for circus coaches (CirqAll:PD)). Furthermore, limited efficacy testing was conducted on outcomes of interest including knowledge, skills, and confidence. Results indicated that CirqAll:PD was feasible with some modifications required to reduce attrition prior to larger-scale testing. Furthermore, coaches who completed CirqAll:PD (n = 27) showed improvements in knowledge, skills, and confidence in working with children born preterm from baseline to post-intervention, with improvements retained at three-months. Overall, this thesis developed and evaluated both a novel approach to co-designing paediatric interventions with key stakeholders, and a circus-based physical activity intervention. Findings from this thesis can be used to co-design future interventions, as well as provide a solid foundation for further development and testing of an intervention that may improve physical activity participation for preschool-aged children born preterm.
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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.
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ItemEnhancing physiotherapy care delivered via telehealth( 2023-05)Traditionally, physiotherapy services have been delivered in-person, in clinical settings. Telehealth, an alternate mode of service delivery, was not commonly used in physiotherapy practice until the recent COVID-19 pandemic when physiotherapists were forced to rapidly adopt telehealth and deliver care remotely, predominantly via videoconferencing and/or telephone. For many, this occurred in the context of limited experience or training in the use of telehealth. This is unsurprising given physiotherapy training at the prelicensure level predominately focuses on the assessment and management of patients consulting for in-person care. A lack of knowledge, skills, training, and competence using the technology required have been identified by physiotherapists as barriers to implementing telehealth in clinical practice. This thesis will explore the required skills needed by physiotherapists to deliver quality care via videoconferencing and the telephone, the confidence of physiotherapy students and new graduates in delivering care via videoconference, and the current state of telehealth education and training in Australian physiotherapy entry-to-practice programs. Specifically, this thesis will: i) develop core capability frameworks for physiotherapists delivering care via videoconferencing and the telephone; ii) investigate Australian physiotherapy students and recent graduates’ confidence delivering care via videoconferencing; and iii) explore the experiences of university educators incorporating telehealth education into entry-to-practice physiotherapy programs in Australian universities. Study one used an international consensus process to investigate what capabilities are ‘core’ for physiotherapists to deliver quality care via videoconferencing. Over three rounds of online surveys, participants in an international Delphi panel and steering group (n = 130) from 32 countries rated their agreement (via a Likert or numerical rating scale) about whether each capability was essential for physiotherapists to deliver quality care via videoconferencing. The final framework comprised 60 specific capabilities across seven domains: compliance (n = 7 capabilities); patient privacy and confidentiality (n = 4); patient safety (n = 7); technology skills (n = 7); telehealth delivery (n = 16); assessment and diagnosis (n = 7); and care planning and management (n = 12). Using similar methods to study one, Study two investigated the required core capabilities for physiotherapists delivering telephone-based care. Over three rounds of online surveys, participants in an international Delphi panel (n =71) from 17 countries rated their agreement (via Likert or numerical rating scale) about whether each capability was essential for physiotherapists to deliver telephone-based care. The final framework comprised 44 individual capabilities across six domains: compliance (n = 7); patient privacy and confidentiality (n = 4); patient safety (n = 7); telehealth delivery (n = 9); assessment and diagnosis (n = 7); and care planning and management (n = 10). Study three involved a national online cross-sectional survey to determine the self-reported confidence of final year Australian physiotherapy entry-to-practice students (including 2021 or 2022) and recent graduates (graduating year 2020 or 2021) in their capability to deliver care via videoconferencing. A total of 343 participants from 20 Australian universities across 6 of 8 states and territories rated their confidence (using a 4-point Likert scale) in performing the 60 capabilities from the international core capability framework developed in Study one. Overall, most (75-100%) participants were confident in the domain ‘telehealth delivery’, many (51-74%) were confident in domains of ‘patient privacy and confidentiality’, ‘patient safety’, ‘assessment and diagnosis’, ‘care planning and management’, and only some (25-50%) were confident in ‘technology skills’ and ‘compliance’. Study four involved qualitative interviews to explore university educators’ attitudes to telehealth education and experiences incorporating telehealth education into entry-to-practice physiotherapy programs in Australia. A total of 16 university educators from 14 universities across 6 states and territories participated in semi-structured interviews that were conducted via Zoom. Three themes (with associated subthemes) were identified: i) telehealth education has a role in contemporary physiotherapy practice (COVID-19 pandemic was a driver for telehealth education, acknowledgement that telehealth is here to stay, and identified areas of focus for telehealth education and training); ii) telehealth education and training vary substantially (content delivered and assessment of telehealth competency are ad-hoc and student exposure to telehealth on clinical placements is inconsistent); iii) challenges in telehealth education (finding space and time in the curriculum, as well as insufficient knowledge and expertise of staff, are challenges for implementation of telehealth education, however, course and subject development and/or reviews provide opportunities for implementing telehealth education and training). Collectively, findings from this thesis provide best practice recommendations for delivering physiotherapy care via videoconferencing and telephone, identify areas where Australian physiotherapy students and recent graduates require further training in telehealth practice, and provide recommendations for implementing telehealth education and training in physiotherapy programs. These findings can be used as a foundation to improve the quality of physiotherapy care delivered by telehealth and support the future development of telehealth curricula in university physiotherapy programs and professional development initiatives.