Physiotherapy - Theses
Permanent URI for this collection
Search Results
1 - 4 of 4
-
ItemAdherence to exercise among people with knee osteoarthritis( 2018)Knee osteoarthritis (OA) is a significant cause of pain and disability among older adults worldwide. Evidence and all guidelines recommend exercise as the cornerstone of non-surgical treatment for all people with knee OA. However, the clinical benefits of exercise among people with knee OA have been demonstrated to be modest, and decline from short- to long-term. Poor adherence to exercise programs as prescribed has been suggested as an important factor impacting the effectiveness of these exercise interventions for people with knee OA. This thesis aimed to gain a better understanding of adherence to exercise among people with knee OA through five related studies. Study One examined the presence of common trajectories of self-reported adherence to home exercise programs over time among a large cohort of people with knee OA. Using latent class growth analysis three distinct trajectory groups were identified: a “Rapidly declining adherence” group, a “Gradually declining adherence” group and a “Poor adherence” group. These findings affirmed the importance of monitoring adherence, and identifying interventions and behaviour change techniques to achieve and maintain adherence to exercise long-term. Study Two clarifies the current understanding of interventions targeting adherence to exercise among older adults with knee/hip OA or chronic low back pain by way of a systematic review. Meta-analysis found moderate quality evidence that booster sessions with a physiotherapist may improve exercise adherence in people with lower limb OA. Findings highlighted the limited number and heterogeneous nature of published randomised controlled trials (RCTs) specifically evaluating interventions aimed at increasing exercise adherence. Study Three explored the perspectives of people with knee OA and physiotherapists who treat people with knee OA regarding theory-derived behaviour change techniques (BCTs) to improve adherence to exercise. Results of the online questionnaire identified a mismatch between the BCTs experienced by people with knee OA and used by physiotherapists, and those perceived to be most likely to be effective. A limitation identified in Studies One, Two and Three was the lack of evaluation of the validity and reliability of commonly used self-reported measures of exercise adherence. Study Four used unique concealed accelerometer technology to examine the concurrent validity of exercise diary completion and a retrospective self-rated adherence scale among a cohort of older adults with chronic knee pain undertaking a home strengthening program. Both self-reported measures showed questionable validity, and the self-rated adherence scale also demonstrated less than acceptable test-retest reliability. Finally, using the accelerometer-measured exercise adherence data Study Five examined the effect of home exercise adherence on changes in patient outcomes of pain, function and quadriceps strength over the 12-week intervention. While a significant decline in adherence, and significant improvements in patient outcomes were observed, the level of home exercise adherence was not significantly associated with changes in these outcomes in linear or non-linear models. Taken together, the findings of these studies provide new knowledge of adherence to exercise specifically among people with knee OA. Furthermore, the results of this work raise a number of research questions worthy of future investigation.
-
ItemExploring remote models of physiotherapy service delivery for people with osteoarthritis( 2018)Knee and hip osteoarthritis (OA) is highly prevalent and has a significant burden on both the individual sufferer and society. All current clinical guidelines recommend education and exercise for management of OA, however exercise participation amongst people with OA is sub-optimal. Barriers to exercise uptake and adherence include inequitable access to appropriate healthcare, and difficulties changing behaviour and incorporating exercise into daily life. This thesis explores remote models of service delivery (telerehabilitation) as a potential method of improving exercise participation in people with OA. Specifically, this thesis aimed to explore the perceived acceptability of telerehabilitation services amongst people with OA and physiotherapists, and also investigate physiotherapist training in behaviour change techniques and person-centred care for telephone-delivery. Study 1 involved a survey that investigated the perceptions people with knee and/or hip OA (n=330) have towards the delivery of exercise therapy by a physiotherapist via internet-mediated video and telephone consultations. Participants had overall positive perceptions, acknowledging ease of use and time saving advantages. However, most (>50%) did not agree that they would like the lack of physical contact, that they would be willing to pay for telerehabilitation services, that telephone-delivery would be effective, or that a physiotherapist would be able to adequately monitor their condition via telephone. Study 2 involved a survey that investigated the perceptions of physiotherapists (n=217) towards the delivery of exercise therapy via internet-mediated video and telephone consultations for people with OA. Most physiotherapists agreed such services would save patient’s time and maintain their privacy, but most did not believe they would like the lack of physical contact with patients. In addition, physiotherapists favoured the use of video technologies over telephone, with most feeling uncertain about the safety, effectiveness, usefulness, or acceptability of telephone-delivered care. Study 3 qualitatively explored physiotherapists’ (n=8) perceptions before and after a training program in behaviour change techniques and person-centred principles that was done in preparation for a clinical trial involving the delivery of exercise therapy via telephone. After training, physiotherapists’ perceptions about their role managing patients with OA had changed, increasing their feelings of responsibility to assist their patient with exercise adherence, and they felt confident and prepared to deliver the intervention remotely via telephone. Study 4 evaluated the fidelity of physiotherapists from Study 3 (n=8) to the behaviour change techniques and person-centred principles taught during training, and involved both self- and expert audits of practice telephone consultations. Physiotherapists performed moderately well, but had room for improvement from further practice and/or training. Physiotherapists’ self-ratings of performance generally agreed with expert ratings, however they tended to underestimate their ability to implement some principles and techniques. Study 5 explored the perceptions of people with knee OA (n=20) who participated in a clinical trial involving telephone-delivered exercise therapy by a physiotherapist. Although participants were initially sceptical about receiving care via telephone, they described mostly positive experiences, valuing the sense of undivided focus and attention and feeling confident performing their exercise program without supervision. Study 6 explored how experience delivering exercise therapy via telephone as part of a clinical trial changed physiotherapists’ (n=8) perceptions about such services. Physiotherapists were initially sceptical about the effectiveness of telephone-delivered service models, expressing concern about the lack of physical and visual contact. However, after experience, physiotherapists were pleasantly surprised by the effectiveness of the intervention and by the positive outcomes that they were able to achieve with their participants. Collectively, findings from this thesis suggest that, overall, telerehabilitation is perceived to be an acceptable model of service delivery by people with OA and physiotherapists. Although there was evidence of scepticism about the effectiveness of telephone-delivered care amongst those who are inexperienced, particularly physiotherapists, these perceptions appeared to change with experience. Physiotherapists believed that training in behaviour change techniques and person-centred care helped them communicate effectively via telephone and also changed their perceptions about their role managing patients with OA. Findings from this thesis can be used to inform the future design and implementation of telerehabilitation services and clinician training programs.
-
ItemPost-traumatic knee osteoarthritis after anterior cruciate ligament reconstruction: Psychological, functional and biomechanical factors and the effect of a targeted brace( 2015)Post-traumatic knee osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) is prevalent in younger adults and has the potential to cause substantial knee-related symptoms and limit physical function. Physical and psychological impairments are likely to adversely affect quality of life and work participation. Knowledge of modifiable risk factors associated with knee OA post-ACLR has the greatest capacity to lead to new interventions that could change the natural history of knee OA. What are the modifiable factors associated with knee OA post-ACLR? Section A of this thesis describes the results of two cross-sectional studies which revealed that individuals with knee OA five to 12 years post-ACLR have worse knee confidence and greater kinesiophobia compared with individuals who have no OA five to 12 years post-ACLR. In individuals with knee OA five to 20 years post-ACLR, those with worse knee confidence have worse knee-related symptoms, poorer function, greater kinesiophobia, and poorer perceived self-efficacy and health-related quality of life. Section B of this thesis investigated knee biomechanics during walking in individuals post-ACLR. Pooled data from a systematic review revealed that, compared to healthy controls and uninjured contralateral knees, ACLR knees have abnormal knee biomechanics, particularly in the sagittal plane. Systematic review findings also revealed that the type of graft (hamstring or patellar) and time post-surgery could also influence knee biomechanics. A cross-sectional study also evaluated biomechanics in people with lateral knee OA post-ACLR. Compared to healthy controls, individuals with lateral knee OA five to 20 years post-ACLR had greater knee flexion and lower knee internal rotation angles, as well as greater pelvic anterior tilt, and hip flexion angles. Is there a potential intervention for modifiable risk factors associated with knee OA post-ACLR? A targeted knee brace was investigated for individuals with knee OA post-ACLR. First, a within-subject randomized study investigated the immediate and four-week effects of a targeted knee brace on knee-related symptoms and function in individuals with knee OA post-ACLR. The brace produced improvements in knee-related symptoms immediately and following four weeks of intervention. Second, a within-subject randomized study evaluated the immediate effects of varus bracing on gait characteristics in individuals with lateral knee OA post-ACLR. Results revealed that the unloader brace significantly altered gait characteristics associated with lateral knee OA post-ACLR. Overall, this thesis sheds light on some of the modifiable risk factors associated with knee OA post-ACLR, and investigated one targeted intervention with the potential to improve quality of life of individuals with knee OA post-ACLR. Targeting psychological, functional and biomechanical risk factors in individuals post-ACLR may aid in optimal recovery, and slowing disease progression in individuals with knee OA post-ACLR.
-
ItemGait modification strategies for people with medial knee osteoarthritis( 2012)Knee osteoarthritis, most commonly occurring in the medial compartment, is a leading cause of pain and disability among the elderly. During gait, greater compressive load in the medial compartment is a major risk factor for osteoarthritis. As there is currently no cure, interventions which can reduce compressive loads are needed, because of their potential to slow disease progression. Evaluated during gait, the knee adduction moment is a commonly used surrogate measure of medial knee load and a marker for medial knee osteoarthritis progression. One of the conservative biomechanical approaches which may reduce the knee adduction moment is gait modification, or gait retraining. However, little is known about the strategies and their effects on medial knee load. Firstly, a systematic literature review was conducted to identify gait modifications. Of the 14 gait modifications identified in 24 studies, four strategies demonstrated greatest ability to reduce the knee adduction moment. Several limitations of previous studies were identified, such as poor reporting of methods, inclusion of participants without osteoarthritis, no evaluation of symptoms and limited information regarding the amount of modification required. Because of demonstrated ability to reduce a parameter of the knee adduction moment in cohorts, the following modifications were investigated in separate studies involving participants with symptomatic medial knee osteoarthritis: use of a cane on the contralateral side, increased lateral trunk lean and altered foot progression angle. The effects of contralateral cane use on knee load and pain were investigated in 23 individuals. Participants placed pre-determined magnitudes of support through the cane. Findings showed reductions in all knee load parameters, with a dose-response relationship. Likely due to biomechanical advantages, the technique of cane use influenced the load-reducing efficacy, such as cane positioning and timing of support. Whilst there were no changes in pain with cane use, individuals with greater severity of pain and varus malalignment reduced load more effectively. The effects of ipsilateral trunk lean gait on the knee adduction moment and pain were investigated in 22 individuals. Participants walked with varying magnitudes of trunk lean. Results demonstrated dose-response reductions in all knee load parameters, whilst pain remained unchanged. Timing of the gait modification mediated the efficacy of load reduction. Lastly, effects of altered foot progression angle on pain, the knee adduction and knee flexion moments were investigated in 22 individuals. Participants walked with varying degrees of toe-in and toe-out gait. Whilst pain remained unchanged, toe-in gait reduced the knee adduction moment during early stance but increased the knee flexion moment, knee adduction impulse and late stance adduction moment. Toe-out gait demonstrated opposite effects to toe-in gait. Furthermore, pain and malalignment demonstrated significant mediating effects for some outcomes. This thesis reports new and clinically relevant information on gait modifications for people with medial knee osteoarthritis. It was discovered that participant characteristics, the magnitude of modification and technique of performance altered the efficacy of load reduction achieved by gait modification strategies. Although future longitudinal evaluations are required, gait modifications investigated in this thesis may have potential to slow osteoarthritis progression via load reduction.