Physiotherapy - Theses

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    Histology of the fascial-periosteal interface in lower limb chronic deep posterior compartment syndrome
    Barbour, Timothy D. A. (Timothy David Andrew) (University of Melbourne, 2007)
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    The lived experience of people living with obesity in hospital and the staff who care for them
    Pazsa, Fiona Michelle ( 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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    Multidisciplinary prehabilitation in clinical practice for haematologic patients receiving high dose chemotherapy with autologous stem cell transplant
    Crowe, Jessica ( 2023-04)
    Autologous stem cell transplant (AuSCT) is an intensive treatment for patients with haematologic cancer, with the potential for significant functional and psychological decline. Cancer prehabilitation is a package of care provided prior to major oncological treatment that aims to mitigate this decline. Currently the predominance of prehabilitation evidence is in efficacy trials in surgical cohorts. In these populations, findings for prehabilitation are broadly favourable. Despite this, the uptake of routine prehabilitation into clinical services remains low, especially in Australia. Hence, evidence evaluating implementation and effectiveness of prehabilitation in clinical practice is limited. Research examining prehabilitation in real-world settings is needed to inform further service development. The studies reported in this thesis aimed to (1) evaluate the impact of a new allied health prehabilitation service for haematologic patients receiving AuSCT in a tertiary cancer centre; and (2) identify health care professionals’ (HCPs) perceptions of enablers and barriers to two behaviours: referral for, and delivery of, multidisciplinary prehabilitation prior to AuSCT. Study one analysed 12 months of prospectively collected data. Impact and operational success were investigated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Patients were representative of Australian AuSCT patients on key demographic variables and clinically relevant improvements in outcomes were demonstrated, however missing data were an issue. The service was well adopted by clinicians and fidelity of exercise prescription (Implementation) was moderate. The referral trend over time (Maintenance) was high after the initiation period. Study two was based on the Theoretical Domains Framework (TDF) of behaviour change. Fourteen HCPs at a tertiary cancer centre participated in semi-structured interviews based on the TDF. Novel findings included the predominance of reported enablers in comparison to barriers. Enablers included: the belief that patients will benefit from prehabilitation; and that face-to-face initial assessments and multidisciplinary teamwork are essential. These studies evaluated prehabilitation in clinical practice prior to AuSCT and provided original contributions to knowledge in this area. Evidence informed recommendations for prehabilitation service delivery are presented, that may support implementation of prehabilitation programs in hospital settings where uptake remains low. Findings may not be generalisable to all oncology populations and settings, in particular, organisations in which prehabilitation is not already included in hospital policy. There is scope for further research into prehabilitation implementation solutions, to inform best practice care and improve outcomes.
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    Prehabilitation for individuals having lung cancer surgery
    Shukla, Anna ( 2020)
    Non-small cell lung cancer (NSCLC) is the fourth most commonly diagnosed cancer in males and the fourth most commonly diagnosed cancer in females in Australia. It is the leading cause of cancer-related mortality, being responsible for more deaths than breast, colorectal and prostate cancer combined. Pulmonary resection provides the best chance of a cure for patients with early stage lung cancer. However, pulmonary resection is associated with significant impairment in functional capacity along with a moderate risk of postoperative morbidity, particularly in frail or deconditioned patients. Prehabilitation is defined as “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment that, in the perioperative setting, aims to enhance functional capacity of the individuals to enable them to withstand the stress associated with a procedure”. Prehabilitation can include a care bundle incorporating smoking cessation, diet optimization, psychosocial support and exercise, and aims to identify impairments and deliver targeted interventions that improve patient outcomes. It provides an opportunity to decrease treatment-related morbidity, increase available treatment options for patients who would not otherwise be surgical candidates and facilitate return of patients to the highest possible functional level. There is a growing body of evidence that supports prehabilitation as a means of preparing patients with newly diagnosed cancer for surgery by optimizing their health preoperatively. Enhancing a patient’s preoperative condition may help them withstand the stressors of surgery. Evidence supports the implementation of prehabilitation in the preoperative care pathway of other cancer cohorts, for example colorectal, breast and prostate cancers. Unfortunately, the evidence for the effects of prehabilitation in lung cancer has lagged behind and the use of prehabilitation (specifically the exercise component) for patients with lung cancer is now an emerging area. To date, exercise prior to lung cancer surgery has been shown to be safe and associated with improvements in functional capacity as well as postoperative morbidity (hospital length of stay) and rates of postoperative pulmonary complications), however the feasibility and acceptability of prehabilitation for patients with lung cancer is still unclear. The two studies within this thesis focus on the exercise component of prehabilitation in the context of surgical management of lung cancer in Australia.
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    What is the influence of adjunctive therapy on outcome following botulinum neurotoxin (BoNT­A) injection for focal spasticity in adults with neurological conditions?
    Moore, Elizabeth Jane ( 2016)
    Neurological disorders are the leading cause of disability worldwide. The upper motor neuron syndrome (UMNS) is a common feature of neurological disorders and describes the changes in motor control that can occur in skeletal muscle after an upper motor neuron lesion. Spasticity is one component of the UMNS that leads to a greater degree of motor impairment compared to those not affected by spasticity. The management of focal spasticity is complex and there are a number of clinical indications for which BoNT-A treatment may be prescribed. Patients may be treated for upper or lower limb spasticity, and may have indications related to active/functional ability (i.e., able to walk) or passive/non-functional (i.e., skin integrity, hygiene or pain) outcomes. Botulinum neurotoxin has been established as effective in reducing spasticity in the upper and lower limbs of adults. However, further research is needed to clearly demonstrate whether the reduction in muscle tone translates into improved function. The international consensus statements for the use of BoNT-A treatment in adults suggest that adjunctive therapies should be continued in conjunction with the BoNT-A injection. Despite this recommendation, the evidence for the independent contribution of adjunctive therapies on patient outcomes has not been determined, and limited evidence exists supporting any specific treatment protocols following BoNT-A injection. The aim of this study was to investigate the influence of commonly prescribed adjunctive therapies on goal attainment following BoNT-A injection for focal spasticity in adults with neurological conditions. A group of 31 adults were provided with a prescribed program from an experienced clinician following their BoNT-A injection designed to maximise their outcome. The rate of adherence to the prescribed program was examined after three months to determine if adherence to therapy improved rehabilitation outcomes in terms of goal attainment as measured by the Goal Attainment Scale. The 31 participants had a total of 76 goals. Active indications for treatment made up the majority of the goals (80.3%). Goals were achieved in 43 out of the 76 cases (56.6%; 95% CI = 42.4-69.8%). Therapy adherence was significantly associated with goal attainment (OR = 1.02, p=0.03, 95% CI=1.00 to 1.04). A higher adherence to therapy increased the odds of goal achievement for active indications (OR = 1.03, 95% CI 1.001-1.05, p = 0.01) but not for passive indications. There was no statistically significant interaction between the location of the injection and adherence to the prescribed therapy program on goal attainment (p = 0.28). Overall, active indications for the BoNT-A injection were most reliant on the prescription of adjunctive therapies following BoNT-A injection.
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    Observational gait analysis in hereditary spastic paraplegia: a comparison of the accuracy of gait kinematic analyses in expert and novice physiotherapists
    RAMASWAMY, SURESH ( 2014)
    The aim of this study was to compare the accuracy of observational gait analysis (OGA) in expert and novice physiotherapists when compared to 3-dimensional gait analysis (3DGA) in a cohort of children with hereditary spastic paraplegia (HSP). Visual observation is a key component of physiotherapy assessment, particularly for patients with movement disorders, and gait abnormalities. It has been reported that 94% of physiotherapists uses OGA for gait assessment in everyday practice. Despite the wide use of OGA by physiotherapists, data on the accuracy of OGA is limited to relatively few studies, which have reported varied findings. In clinical practice, it is common for senior clinicians to supervise more junior clinicians based on the assumption that seniors are more accurate in their assessments due to experience. Very few studies have compared the accuracy of OGA of expert and novice physiotherapists. Variation in factors such as the methods of observation, and number of variables for observation have rendered the findings limited and inconclusive. This project sought to compare experts with novices for the accuracy of OGA in children diagnosed with HSP. Children with HSP were selected for investigation because they have gait disorders associated with weakness and spasticity. The 3DGA was chosen as a criterion measure to evaluate the accuracy of the observations, as it is widely considered to be the gold standard for gait analysis because of its ability to accurately capture and quantify complex gait events. The walking patterns of 17 child participants were captured using a 3DGA system and concurrent sagittal plane video recordings. Fifteen experts, each with more than seven years of clinical experience, observed and rated joint angles at the hip, knee, and ankle. Observations were also recorded by a novice group of 15 physiotherapy students and clinicians with less than one year of clinical experience. The ratings by the experts and novices were compared with the criterion scores obtained from the 3DGA system to provide estimates of error. Error score comparisons between experts and novices for each of five variables revealed no significant differences in the accuracy of OGA between the two groups. Further examination of individual observer error scores revealed a wide range of error scores for experts and novices across all variables. The finding of no differences in accuracy between experts and novices for OGA did not support the prediction that expert physiotherapists are more accurate in assessing gait abnormalities using OGA. As clinicians typically observe gait using various methods such as live or video observations, at different speed observations and with different instructional sets, tasks and environments, it is possible that the methodology used in this study may have influenced the results.
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    Knee motion and foot speed at and around initial contact in human gait
    McKenzie, David S. ( 2014)
    Biomechanical analyses have provided detailed information about joint kinematics and kinetics of the gait cycle. Interpretation of this data has largely overlooked (Winter, 1983a), or even misrepresented (Cerny, 1984; Perry, 1992), knee kinematics around initial contact (IC). It has been suggested that heel speed (HS) approaches zero magnitude as a way of preparing the foot for landing at IC and that knee kinematics influence this event (Winter, 1992b). A number of factors, including the re-introduction of ground reaction forces to the leading limb, make IC a complex event within the gait cycle. The aim of this study was to clarify knee joint kinematics at and around IC in human gait. Three hypotheses were tested. Firstly, that knee flexion (KF) precedes IC. Secondly, that the quantum of knee flexion and the percentage of stride spent flexing the knee prior to initial contact are dependent on gait speed. And thirdly, that HS is reduced to near zero magnitude in preparation for contact with the ground at the start of stance phase. Sixteen healthy, young adults participated in this study. A Vicon 3D Infra-red motion analysis system (Oxford Metrics Ltd., Oxford, England) sampling at 120 Hz and AMTI Force Plates (Advanced Mechanical Technology, Inc., Watertown, USA) sampling at 1080 Hz were used to record kinematic and kinetic data from walking trials at each of three self-selected speeds: slow; preferred and fast. Data were extracted representing the timing of the onset of KF prior to IC, the amount of KF occurring between maximum knee extension prior to IC and IC as well as HS at IC. The data were assessed for normality using the Kolmogorov-Smirnov test of normality and through skewness and kurtosis. Friedman’s χ2r statistic and RM MANOVAs were used to investigate differences across gait speed. Post hoc testing was performed with the Wilcoxon test and contrasts testing. KF data were found to be non-normal. At preferred speed 2.6% of stride was taken up flexing the swinging knee 1.4° prior to IC. This rose to 3.5% of stride and 2.3° of flexion prior to IC at fast speed and fell to 2.2% of stride and 0.8° of flexion prior to IC at slow speed. The quantum of KF prior to IC also increased with gait speed. All HS data were normal. Mean HS at IC was 559.7mm•s-1 at preferred speed. Mean HS at IC rose to 841.3 mm•s-1 at fast speed and fell to 391.2 mm•s-1 at slow speed. KF and HS were found to be significantly different across speeds (p < 0.001). Results support the hypothesis that KF occurs prior to IC in human gait. The amount and duration of this KF were dependent upon walking speed. These findings suggest that in human gait a motor control strategy is implemented where the knee flexes in anticipation of initial contact. This repudiates the common perception in the gait literature that the knee is extended, or stable in extension at IC (eg Gage, 1990; Cerny, 1984). Whilst HS does slow late in swing the results of this study do not support the proposition that a function of knee motion prior to IC is to reduce HS to near zero magnitude. The outcomes of this study provide clinicians with crucial information to guide decision making with respect to gait analysis and training.
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    Which factors influence the physical activity levels of people with severe traumatic brain injury when they are discharged home from hospital?
    Hamilton, Megan Jane ( 2014)
    Restrictions in mobility following moderate to severe traumatic brain injury (TBI) are common. Limited evidence indicates that physical activity levels of individuals with TBI are insufficient for health maintenance. Transition from hospital to home is a challenging period for these individuals. Factors which influence activity levels during this transition period are currently unknown. This study aims to identify which factors were associated with greater activity levels during the transition period from inpatient discharge to home in individuals with TBI.
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    Feasibility, safety and efficacy of dance for people with Parkinson's disease: a pilot study
    Twyerould, Rebecca Louise ( 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.