Physiotherapy - Theses
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ItemFeasibility, safety and efficacy of dance for people with Parkinson's disease: a pilot study( 2013)The purpose of this thesis is to investigate the safety, feasibility and efficacy of dance for people with Parkinson’s disease (PD). Parkinson’s disease is a progressive neurological condition that is characterised by slow gait, reduced movement amplitude, tremor, rigidity, postural instability and diminished health-related quality of life (HRQOL). Physiotherapy and therapeutic exercise aimed at improving gait and balance are argued to be an important component in the management of PD and have been shown to improve gait function, mobility, balance and HRQOL in some individuals. Given the progressive and long term nature of the disease, it is important for people with PD to have access to a wide variety of exercise options so that they can remain active. Recent reports indicate that dance is emerging as an alternative to traditional exercise programs for people with PD, however there is little information regarding the safety and feasibility of dance interventions. A systematic review and critical appraisal was conducted with the aim of identifying studies that provide reports of safety, feasibility, intervention delivery and the efficacy of dance interventions for people with PD. The identified studies were of low to moderate methodological quality and design and the reporting of safety and feasibility outcomes was inconsistent. Whilst attrition was well reported, it was challenging to conclude the level of adherence and the occurrence of adverse events during dance classes due to limited reporting of these outcomes. The level of supervision provided, provision of instructor training and advice and the selection of music and movement choices was also not well reported. The results of a between-group synthesis of balance and mobility data showed a trend towards improvement in these outcomes following a dance intervention when compared to controls. These findings present limited evidence to support the efficacy of dance for people with PD. A group of nine Australians living with mild to moderate PD participated in a pilot case-series study to determine the safety, feasibility and efficacy of a six-week contemporary dance program. Safety and feasibility outcomes evaluated included the occurrence of adverse events, attrition, adherence and participant satisfaction. The effect of the dance program on gait function, functional mobility, balance, balance and gait self-efficacy and HRQOL was examined prior to the intervention, immediately post-intervention and at three months. The contemporary dance program was found to be a feasible and safe activity for people with PD in terms of attrition, adherence and adverse events. Attrition was low, with eight and seven participants completing follow-up assessments at post intervention and three-months respectively. Adherence was high with participants completing 78% of all available dance classes. Significant improvements in gait hypokinesia were observed immediately post-intervention compared to baseline measures and continued to improve three-months later. Significant improvements in functional mobility, relative to baseline were seen at post-intervention with a trend toward improvement noted at three-months. Despite improvements in gait function, there was little to no change observed for measures of balance, gait and balance self-efficacy and HRQOL. These results provide evidence to further support the safety and feasibility of dance for people with mild to moderate PD, and support the need for large randomized controlled trials to determine the efficacy and outcomes of dance therapy. Participant satisfaction is commonly regarded as an important component of quality health care and may influence the successful implementation of new interventions into clinical practice. Two focus groups were conducted after the pilot study with the purpose of gaining insight into the experiences and attitudes of the contemporary dance participants and to explore participant satisfaction within the context of feasibility. Thematic analysis revealed that participants were satisfied with the intervention and considered contemporary dance to be an acceptable form of exercise. The focus groups also revealed that the participants had a strong emotional reaction to the dance classes and identified several emotional, physical and cognitive benefits. This thesis has provided further knowledge to suggest that dance is a safe and feasible exercise alternative for some people with mild to moderate PD. Furthermore, this thesis has provided new evidence to support the efficacy of a short duration contemporary dance program to improve aspects of physical function and HRQOL. Although future work is needed, this research provides clinicians with evidence that supports the implementation of dance into clinical practice where it can benefit individuals living with Parkinson’s disease.
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ItemDevelopmental outcomes and rates of early intervention at two years in infants born extremely preterm or extremely low birth weight( 2013)This thesis investigated the rates of developmental delay, neurosensory disability and early intervention at two years in a cohort of extremely preterm and/or extremely low birthweight (EP/ELBW) infants. These infants are at higher risk of impairments such as cerebral palsy (CP) or delayed development than term born infants, thus rates of impairment are a key outcome indicator. Timely access to early intervention (EI) services for EP/ELBW children with delays is recognised as important yet little is known about appropriate access to EI in Victoria, Australia. Follow-up of EP/ELBW children at two years provides a snapshot of early development and access to EI services. A systematic review and critical evaluation of the literature reporting two-year neurodevelopmental outcomes for EP/ELBW infants was performed. Rates of developmental delay and neurosensory impairments were identified in infant cohorts from the post surfactant era. Rates of CP ranged from 5% to 76% with most studies reporting rates between 10% and 20%. Most studies used the Bayley assessment to report neurodevelopmental outcome. The most prevalent developmental impairment was cognitive delay or motor delay without CP with the majority of studies reporting rates in the 15% to 40% range. Rates of delay were highest in studies from the USA compared to Australia, Europe and Asia. Methodological variability limited direct comparisons between studies and meta-analysis was not considered appropriate. A retrospective cohort study of EP/ELBW infants from the Royal Women’s Hospital (RWH) at two years corrected age was performed. Developmental outcomes of 109 children were assessed using the Bayley-III assessment tool with children classified as no delay (≥ -1 SD) mildly (<-1 to -2 SD), moderately (<-2 to -3SD) or severely delayed (<-3SD). The follow-up rate was 50% (n=109) of survivors to discharge. With reference to Bayley-III test norms, cognitive delay occurred in 18% (n=19), language delay in 29% (n=29) and motor delay in 19% (n=19) of children. A control group assessed with the Bayley-III by the Victorian Infant Collaborative Study group (VICS) provided an additional representative group against which to reference the outcomes. The VICS control group mean values were 108.9 (14.4) for cognitive, 108.3 (14.8) for language and 118.4 (16.7) for motor development. The rates of delay increased significantly for most categories when referenced to the VICS norms with the concurrent comparator group identified as important in accurately determining rates of delay. Neurosensory assessment identified a 7% rate of CP and there were no children with blindness or deafness. A retrospective audit was performed from a subcohort of this RWH EP/ELBW cohort, comprising 80 children with data reporting receipt of EI in the first two years. The rate of receipt of EI during the first two years was 68% (n=54). Birthweight significantly predicted the receipt of EI (OR 0.79; 95%CI 0.63-1.00, p=0.045). Children with moderate to severe delay were more likely to be receiving EI than those with no delay (OR 4.20; 95%CI 1.41-12.52; p=0.01) and all children with CP were receiving EI at two years. There was an unmet need for EI with at least 20% of children with moderate to severe delay and 35% with mild delay not receiving EI. There were also a large proportion (60.5%) of children with no delay at two years who received EI. A questionnaire used to capture EI services information identified that over 75% of families utilised two or more therapy disciplines in the first two years. Waiting times were reported as an area of concern despite overall satisfaction with EI services. This thesis identified rates of neurodevelopmental impairment and receipt of EI for a cohort of EP/ELBW children from the RWH. Whilst follow-up rates were low, this study identified rates of delay and disability comparable to cohorts from Australia, Europe and Asia. The rates of EI utilisation were high, however the targeting of EI to children with delays was variable. The goal for EP/ELBW children is to provide timely and targeted intervention and early developmental surveillance is needed to achieve this. Areas for future research have been identified for children born EP/ELBW to inform clinical decision-making and assist in the strategic planning for regional services.
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ItemMobility characteristics in children with hereditary spastic paraplegia( 2013)The aim of this thesis was to investigate characteristic deviations in mobility and gait in children with hereditary spastic paraplegia (HSP). Hereditary spastic paraplegia is a neurodegenerative condition which is most commonly associated with limitations in functional mobility and gait dysfunction. Little quantitative information has been published describing the common mobility and gait deficits in children with HSP. The previous literature has not addressed the best measurement tools to quantify mobility nor has it provided objective evidence for changes in functional mobility over time in children with this condition. Although a small number of studies exist describing the kinematic gait deficits of children with HSP, results are limited to the sagittal plane of movement. A better understanding of the mobility and gait characteristics that are unique to this population would enable physiotherapists to provide a more holistic service to children and families with HSP. A greater depth of knowledge could help clinicians to develop more accurate hypotheses of the causative factors in gait and mobility disturbances, thereby facilitating the prioritisation of treatment techniques towards the most affected areas. A systematic literature review identified and critically evaluated outcome measures to quantify functional mobility in children with HSP. Evidence regarding the psychometric properties of functional mobility measures in this population was found to be limited. Three measurement tools were identified that clinicians may consider when assessing mobility in children with this condition. The outcome measures were the Gillette Functional Assessment Questionnaire, the Functional Mobility Scale and the Gross Motor Function Measures. The Functional Assessment Questionnaire and the Functional Mobility Scale were incorporated into three subsequent studies. A longitudinal study of retrospective data documented changes in functional mobility over time. Thirty children with HSP were assessed over an average of four years. Contrary to beliefs, analysis of functional mobility levels for the entire cohort demonstrated minimal changes over the period of assessment. Functional mobility over longer distances exhibited statistically significant improvements (p < .001). Functional mobility in the school environment was the only exception, with more children demonstrating a tendency towards deterioration over time. In general, the results indicate that not all children with HSP deteriorate in functional mobility over time. An analysis of retrospective kinematic gait data from 17 children with HSP confirmed that gait deviations existed in all three planes of movement when compared with the gait kinematics of unimpaired children. Overall, the deficits in the sagittal plane concurred with the previously published literature for children with HSP. The coronal plane revealed previously unreported kinematic gait deviations, including a reversal of the usual pattern of pelvic obliquity. These results confirm that kinematic deficits exist in all three planes of movement in children with HSP. Given the deviations at the proximal joints, further research is also warranted to describe the deficits at the trunk in children with this condition. A prospective study focussed on describing the kinematic deviations at the trunk, pelvis and hips in 11 children with HSP. Movements of the trunk and pelvis were found to be particularly compromised in the sagittal and coronal planes. These segments demonstrated larger amplitudes and subsequent increases in the ranges of movement. Although pelvic rotation showed little deviation when compared to unimpaired children, increased amplitudes of pelvic rotation were strongly associated with higher levels of functional mobility. These findings indicate that the trunk can be affected in some children with HSP. Further research is necessary to determine the cause of trunk and lower limb deficits in children with HSP. This thesis is the first to provide an in-depth analysis of mobility in children with HSP. Outcome measures were identified that can be utilised by physiotherapists when assessing children with this condition. The findings regarding mobility and gait characteristics in children with HSP are likely to assist physiotherapists and other health professionals to focus clinical assessments towards the most affected segments and planes. This information forms a foundation for future studies of mobility in HSP. In particular, the findings indicate the need for further investigations of longitudinal changes in mobility and the effectiveness of physiotherapy techniques in children with HSP. Ultimately, this new knowledge may help to improve the education of children and families with HSP, prioritise physiotherapy treatment plans and enable the best possible outcomes in children with this complex, neurological condition.
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ItemMotor performance and postural control in very preterm compared to term children at preschool age( 2013)Background: Preschool age children born very preterm, <30 weeks’ gestation, that do not have a major neurological condition such as cerebral palsy may present with motor impairments and reduced postural control compared with children born at term. Preschool age is an important time in child development, where there is greater complexity in children’s motor skill in which postural control is fundamental in contributing to stability and execution of movement. Persisting or emerging motor delay may become evident at preschool age and may affect the child’s performance which can have an impact on successful transitioning to school. There is little known on motor performance and postural control in very preterm children compared with term children at preschool age. Objectives: This thesis explored the motor performance and postural control of very children born <30 weeks’ gestational age at 4-5 years. The aims were as follows: • To review the literature on motor performance and postural control in preterm preschool age children, including a review of assessment tools relating to motor outcome and postural control. • To compare motor performance and postural control in very preterm and term children aged 4-5 years. • To determine the relationship between children’s level of motor performance and their postural control at age 4-5 years. Methods: A cohort of 105 very preterm preschool age children and a control group of 40 term-born children at 4-5 years of age were assessed on two motor outcome assessments and an assessment of postural control, the Wii Balance Board that has not been previously used in the paediatric population. Results: Overall very preterm children showed poorer motor performance compared with term children. A greater proportion of VPT children compared with term children had motor impairment when assessed with the NSMDA and the MABC-2. Very preterm children had reduced postural control compared with their term peers. They demonstrated greater postural sway in balance tasks that had various sensory conditions, dual tasking as well as static balance tasks. Reduced functional performance was also observed in VPT children in dynamic balance tasks compared with term children. There was a negative relationship between motor impairment and postural control in all preschool age children. This indicated that children with a motor impairment demonstrated reduced postural control. Overall lower motor performance scores on the NSMDA and MABC-2 were correlated with increased postural sway and reduced functional performance in balance tasks. The child’s body mass had a significant effect on postural sway when adjusted for VPT/term group. Conclusion: A greater proportion of VPT children compared with term children have reduced motor performance and reduced postural control at preschool age. Postural control is an important component in motor performance. Identifying children with reduced postural control and motor impairments is important in order to provide intervention to improve motor skills and to assist with school transitioning. The Wii Balance Board was a useful tool in the assessment of postural control in children, and could be used in preschool age children as part of a battery of assessments. Further research to determine the developmental progression of motor skills and balance in VPT children at later ages would be of benefit.
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ItemEngagement in physical activity following a diagnosis of non-small cell lung cancer( 2013)Lung cancer is the most prevalent type of cancer worldwide and associated with the highest mortality. Individuals with non-small cell lung cancer (NSCLC) experience symptoms which frequently lead to a vicious cycle of inactivity and functional decline. Whilst there is a strong body of research published regarding the physical activity levels of many cancer types and the role of exercise in the management of cancer, limited work has been performed in NSCLC. This first study of the thesis was a systematic review which synthesized the measurement properties of outcomes used to assess physical activity, functional capacity and muscle strength of individuals with NSCLC. Thirteen outcome measures were identified. Functional capacity was assessed using the six- and twelve-minute walk tests; incremental- and endurance-shuttle walk tests; and the stair-climbing test. Physical activity was assessed using accelerometers and pedometers. Muscle strength was assessed using five different tests. Thirty-one studies were identified which investigated the measurement properties of these outcome measures in NSCLC, most reporting on the criterion or construct validity of the tests. Little work has been done regarding reliability or responsiveness. Further studies are needed to establish measurement properties of standardised field tests for individuals with NSCLC to allow the most appropriate choice for clinical practice and when designing research trials. Study 2 was a multi-site prospective observational study where the physical activity levels of individuals with NSCLC were measured across the trajectory of disease. Fifty participants with newly diagnosed stage I-IIIB NSCLC and 35 similar-aged healthy individuals were included. At diagnosis individuals with NSCLC were engaged in lower levels of physical activity than similar-aged healthy individuals and had worse functional capacity, strength, nutritional status, HRQoL, and higher levels of depression. Over six months individuals with NSCLC experienced a decline in self-reported physical activity, functional capacity and strength. Higher levels of physical activity were associated with better functional capacity, strength, nutritional status and HRQoL; and lower levels of depression, anxiety and symptoms. In study 3 a systematic review was performed to synthesize the role of exercise in NSCLC. Sixteen studies were included in the review. No studies were conducted in Australia. Results demonstrated that exercise intervention for individuals with NSCLC is safe before and after treatment. Interventions pre-operatively or post-treatment are associated with positive benefits on functional capacity, symptoms and some domains of HRQoL. The majority of studies were small case series therefore results should be viewed with caution until larger randomised controlled trials (RCTs) are completed. A pilot randomised controlled trial was conducted as Study 4, which assessed the safety and feasibility of exercise intervention for individuals following lung resection in an Australian population. Fifteen participants were allocated to the control or exercise intervention group. Results demonstrated that the exercise intervention was safe and feasible. The uptake rate for outpatient exercise was 57%, similar to previous trials, however adherence was excellent within the sub-group of participants who attended. The findings of this thesis strongly support the need for targeted exercise interventions to enhance physical activity levels and prevent the debilitating functional decline that occurs after a diagnosis of NSCLC.