Physiotherapy - Theses
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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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ItemEvaluating the effect of self-management interventions on medial tibiofemoral contact force using electromyogram-informed neuromusculoskeletal modelling in people at risk of, and with, established knee osteoarthritis( 2022)Knee osteoarthritis (OA) predominantly involving the medial tibiofemoral compartment is a major public health problem worldwide causing pain, disability, and reduced quality of life. Longitudinal data suggest that higher knee loads during walking are associated with structural disease progression in people with medial knee OA. Higher knee loads during walking are also associated with structural disease onset in high-risk groups such as people who have undergone arthroscopic partial meniscectomy (APM). As there is no cure for OA, conservative interventions such as strengthening exercise and “appropriate” footwear are recommended throughout the OA disease continuum. However, no studies have been able to demonstrate that exercise can reduce knee loads in those at risk of, and with, established knee OA and belief that exercise could generate harmful knee loads continues to exist among patients and clinicians. This ambiguity also extends to footwear interventions, where stable supportive shoe types are recommended in most clinical guidelines despite conflicting biomechanical evidence that suggests flat flexible shoe types may reduce knee loads. A critical limitation of the current body of evidence is the use of the external knee adduction moment (KAM) as a surrogate measure of internal medial tibiofemoral contact force (MTCF). Change in the MTCF does not necessarily correspond directly with change in the KAM, predominantly due to the role internal muscle forces play in stabilizing the knee against these external loads. The use of electromyogram (EMG)-informed neuromusculoskeletal modelling is a promising means to consider the influence of muscle in estimates of internal contact force. However, it has not yet been implemented to estimate loads in knee OA intervention studies. The overarching aim of this thesis is to implement EMG-informed neuromusculoskeletal modelling to estimate MTCF during exercise and footwear interventions in people following APM (high-risk for developing knee OA), and those with established medial knee OA. This thesis first describes secondary analyses from two randomised controlled trials. In Study 1 (Chapter 4), which involved 41 participants aged between 30-50 years with medial APM in the prior 3-12 months, no significant difference in MTCF (peak and impulse) was found following a 12-week functional weightbearing exercise program compared to no intervention. In Study 2 (Chapter 5), which involved 62 participants aged over 50 with medial knee OA and varus malalignment, no significant difference in MTCF (peak or impulse) was found between a 12-week functional weightbearing (WB) and a 12-week non-weightbearing (NWB) quadriceps strengthening exercise program. Interestingly, the functional WB exercise program reduced the external contribution to MTCF, while the NWB quadriceps strengthening program reduced the muscle contribution to MTCF. This thesis then describes two cross-sectional studies, both utilising the same cohort of 28 people over the age of 50 with medial knee OA and varus malalignment. The first (Study 3, Chapter 6) compared the immediate effect of stable supportive and flat flexible shoes on continuous and discrete measures of MTCF during walking. Statistical parametric mapping (SPM) showed lower MTCF in the stable supportive compared to flat flexible shoes during 5-18% of stance phase. For the discrete outcomes, loading impulse, mean loading rate, and max loading rate were lower in stable supportive shoes compared to flat flexible shoes. The second cross-sectional study (Study 4, Chapter 7) evaluated the MTCF and muscle forces during each of three weightbearing exercises (double leg squat, forward lunge, and single-leg heel raise), relative to walking. Results showed that knee extensor and flexor force was higher during squatting and lunging compared to walking, while the MTCF was lower during squatting and heel raises compared to walking. Collectively, this thesis does not provide any evidence that 12-week functional weightbearing exercise programs can change MTCF in people following APM and with medial knee OA and varus malalignment. However, novel findings suggest that stable supportive shoes can reduce aspects of the MTCF compared to flat flexible shoes, suggesting that this shoe type may be most suitable for people with knee OA and varus malalignment. This thesis also provides evidence that common weightbearing exercises (squatting, lunging and heel raises) do not result in harmful increases in MTCF. These exercises may therefore be used safely in clinical settings for people with knee OA and varus malalignment.