Physiotherapy - Theses
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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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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.
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ItemPelvic floor disorders after gynaecological cancer treatment( 2023-05)Gynaecological cancers are the third most common type of cancer in women, accounting for 16% of cancers diagnosed in women worldwide. They include endometrial, cervical, ovarian, vulval, vaginal and fallopian tube cancers. The most common treatments for gynaecological cancer are surgery, most frequently hysterectomy, radiotherapy and chemotherapy. The sequelae of gynaecological cancer treatments impose a substantial burden on survivors and society. Gynaecological cancer survivors experience high rates of pelvic floor disorders, such as urinary incontinence, faecal incontinence and dyspareunia. However, many gynaecological cancer care pathways do not include screening for pelvic floor disorders, or only include screening and referral for sexual dysfunction, but not other pelvic floor disorders. Pelvic floor muscle training, an evidence-based treatment for urinary incontinence, faecal incontinence and dyspareunia in other populations, is currently not recommended in gynaecological cancer care pathways. More data are needed on the prevalence, history and experience of pelvic floor disorders in gynaecological cancer survivors, and the feasibility and effectiveness of pelvic floor muscle training in this population, before such recommendations can be included in gynaecological cancer care pathways. Therefore, this thesis aimed to investigate the prevalence and natural history of pelvic floor disorders after gynaecological cancer treatment, the experience of gynaecological cancer survivors with pelvic floor disorders and their preferences for treatment, and the feasibility and efficacy of pelvic floor muscle training for treating pelvic floor disorders in gynaecological cancer survivors. Study One documented the prevalence of pelvic floor disorders, including urinary incontinence, after gynaecological cancer surgery and involved the assessment of pelvic floor symptoms, health-related quality-of-life and physical activity before and after hysterectomy with or without radiotherapy or chemotherapy for gynaecological cancer. This study used psychometrically sound patient-reported outcomes completed before or in the first week after surgery, 6-weeks after surgery and 3-months after surgery. The prevalence of urinary incontinence and faecal incontinence were high, and rates of sexual activity were low both before and after surgery. Adjuvant therapy (radiotherapy or chemotherapy) was associated with increased odds of having moderate-to-very severe urinary incontinence. Symptoms of pelvic floor disorders 3-months after hysterectomy were associated with lower health-related quality-of-life, but not lower physical activity levels. These findings suggest that clinicians working with gynaecology-oncology patients undergoing hysterectomy may need to consider screening and offering treatment options for pelvic floor disorders. Study Two, a qualitative study, explored the experiences of gynaecological cancer survivors with pelvic floor disorders, and gynaecology-oncology clinicians. This included their attitudes to screening and management of pelvic floor disorders, and their perceptions of barriers and enablers to treatment for pelvic floor disorders after gynaecological cancer treatment. Differences between what participants had experienced and what they felt should happen highlighted a perceived need to improve the screening and management for pelvic floor disorders. Barriers to screening, disclosure and management of pelvic floor disorders identified by both gynaecological cancer survivors and clinicians included patients feeling unwell, emotional, and overwhelmed with the logistics of oncology appointments. Gynaecological cancer survivors also identified discontinuity of care as a barrier to disclosure of pelvic floor disorders, while clinicians identified time pressure as a barrier to screening for pelvic floor disorders. Enablers to screening, disclosure and management of pelvic floor disorders identified by both by gynaecological cancer survivors and clinicians included the patient-clinician relationship and patient agency. Opportunities for improving management included integrating nursing and pelvic floor physiotherapy with oncology appointments and providing streamlined referral pathways for treatment. Gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. Study Three was a systematic review and meta-analysis of conservative pelvic floor muscle therapies for pelvic floor disorders after gynaecological cancer treatment. Five randomised controlled trials and two cohort studies were identified, with moderate-level evidence that pelvic floor muscle training with core exercises (i.e. strengthening deep abdominal pelvic floor muscles, diaphragmatic breathing, and stretching of pelvic girdle muscles) or yoga improves health-related quality-of-life and sexual function, and very low-level evidence that high frequency of vaginal dilator training may reduce vaginal complications after treatment for endometrial and cervical cancer. There were insufficient data for meta-analysis of the effect of conservative pelvic floor therapies on bladder or bowel function. Given the levels of evidence found, a need for further high-quality studies was identified, especially studies investigating conservative pelvic floor muscle therapies for urinary and/or faecal incontinence after gynaecological cancer treatment. Study Four, a cohort clinical trial, investigated the feasibility of recruiting to and delivering a pelvic floor muscle training intervention via telehealth to treat urinary and/or faecal incontinence after gynaecological cancer surgery. Participants underwent a 12-week physiotherapist-supervised telehealth-delivered pelvic floor muscle training program. The intervention involved seven videoconference sessions with real-time feedback using an intra-vaginal biofeedback device, and a daily home pelvic floor muscle training program. Outcomes of high consent rates, participant engagement and retention, and self-reported acceptability and satisfaction support the feasibility and acceptability of telehealth-delivered pelvic floor muscle training to treat urinary and/or faecal incontinence after gynaecological cancer treatment. In conclusion, the findings of this thesis indicate that patients experienced high rates of pelvic floor disorders before and after gynaecological cancer. Gynaecological cancer survivors wanted more information on pelvic floor disorders and gynaecological cancer survivors and clinicians were supportive of integrated treatment pathways for pelvic floor disorders after gynaecological cancer treatment. There is emerging evidence for pelvic floor muscle training to improve health-related quality of life and sexual function for gynaecological cancer survivors. There is insufficient evidence for pelvic floor muscle training to improve urinary and/or faecal incontinence after gynaecological cancer treatment, however pelvic floor muscle training delivered via telehealth may be feasible and acceptable in this setting. The findings of this thesis have already informed the design of a large randomised controlled trial (ANZCTR registration ACTRN12622000580774) to investigate the clinical efficacy of pelvic floor muscle training delivered via telehealth for urinary incontinence after gynaecological cancer treatment. Future research should investigate which subgroups of patients with gynaecological cancer (e.g. type of gynaecological cancer, stage of cancer or treatment type/combinations) are most at risk of experiencing pelvic floor disorders, and which aspects of intervention (e.g. in-person or telehealth, starting before or after cancer treatment, using pelvic floor muscle training alone or multimodal pelvic floor physiotherapy interventions) provide the most feasible and effective treatment for pelvic floor disorders after gynaecological cancer treatment.
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ItemExercise intervention for adults treated with allogeneic bone marrow transplantation( 2021)Haematological cancers are diagnosed in 50 people per day in Australia and are the second most common cause of cancer-related death in Australia. Treatment for haematological cancer needs to be systemic and often includes chemotherapy, whole-body radiotherapy and/or bone marrow transplantation (BMT). Side-effects of treatment with BMT are multifactorial, associated with the underlying disease, the patient factors (for example comorbidities) and concomitant medications (for example steroids and immunosuppressants). An allogeneic BMT uses stem cells from a healthy donor and is generally higher-risk and higher intensity compared to autologous BMT which uses the patient’s own stem cells. Common symptoms associated with BMT include fatigue, reduced physical function, pain, weight loss, poor health-related quality of life (HRQoL), anxiety and depression. Exercise has potential to improve the physical and psychological burden of BMT, however is not part of routine care before, during or following BMT in many countries globally and particularly in Australia, and more research is required to facilitate this implementation. Study 1 of this thesis is a systematic review synthesising the evidence examining the effect of exercise on outcomes such as functional exercise capacity, HRQoL and healthcare resource usage among adults treated for haematological disease with BMT. This systematic review included 24 randomised controlled trials (RCTs) and 3 prospective non-randomised experimental trials with a total of 2432 participants; and 19 RCTs were included in the meta-analysis. Thirteen studies included only recipients of allogeneic BMT or published subgroup analyses of allogeneic BMT recipients; five studies included only recipients of autologous BMT, and ten studies included a mixed population of allogeneic or autologous BMT. Studies included in this systematic review were generally of poor to moderate methodological quality and there was too much heterogeneity among factors including population, intervention and outcomes to provide conclusions regarding ideal mode and timing of exercise. The Grading of Recommendations Assessment, Development and Evaluation approach was used to evaluate the quality of evidence for each meta-analysis. The meta-analysis found moderate-quality evidence that exercise compared to control (no exercise) improves functional exercise capacity, fatigue and global HRQoL. There was low-quality evidence that exercise compared to control reduces hospital length of stay, improves strength and increases overall body weight. Most of the effects of exercise were more pronounced in allogeneic BMT although this evidence was generally rated low-quality. There were no between-group effects for bone marrow engraftment, physical activity, respiratory function, fat mass or lean body mass, anxiety and depression. No serious adverse events were associated with the exercise interventions. Study 2 of this thesis is a prospective cohort study which primarily aimed to explore the feasibility of ‘late-commencing’ group-based exercise following allogeneic BMT. The phrase ‘late-commencing’ is used as the intervention commenced following hospital discharge at 60-days post-transplant, which is ‘late’ in comparison to the intervention in the subsequent Study 3. In Study 2, forty-three consecutive adults planned for allogeneic BMT for haematological disease were recruited and conducted baseline outcome testing pre-transplant, then commenced a group-based exercise and education intervention at 60-days post-transplant. The consent rate pre-transplant was 93%, eligibility to commence the intervention post-transplant was 77% (n=33 from 43; due to death, cancellation of transplant, or being medically unwell), and a further 16% (n=7) declined to participate in the intervention. Of the n=26 who commenced the intervention, 81% (n=21) completed it with 81% adherence to the exercise sessions. This study observed significant decline in functional exercise capacity and HRQoL from pre- to 60-days post-transplant; followed by significant improvement in these outcomes from 60-days to completion of intervention. Whilst these results should be interpreted with caution, this significant decline in outcomes raised the question that perhaps intervention is required earlier in the continuum of allogeneic BMT. Thus, Study 3 of this thesis is a prospective cohort study which introduced an ‘early-commencing’ group-based exercise program, defined as ‘early’ as it commenced upon admission to hospital prior to allogeneic BMT, which is early in comparison to the intervention in the aforementioned Study 2. In Study 3, forty-two consecutive adults with haematological disease were recruited and had baseline outcome testing prior to allogeneic BMT, then commenced the group-based exercise intervention upon hospital admission, a median [IQR] of 5.5 [1-7] days prior to BMT. There was 100% consent rate; 83% (n=35) continued the inpatient intervention until hospital discharge and 95% (n=40) completed at least some aspects of final outcome testing at 60-days post-transplant. Fifty-one percent of participants attended the group-based intervention greater than or equal to 3 times per week, and 83% attended greater than or equal to 2 times per week. There were no adverse events associated with the intervention, and the intervention was deemed to be safe and feasible for participants to participate in group-based exercise greater than or equal to 2 times per week during hospitalisation. Except for emotional wellbeing which improved over time, all other outcomes significantly declined during acute hospitalisation and recovered slightly, though not significantly, following discharge. This persistent significant decline suggests there may be biological contributing factors such as transplant toxicities and/or effects from medications such as steroids. It was observed that participants who attended exercise sessions more frequently demonstrated lower signs of clinical frailty at baseline and higher functional exercise capacity at 60-days post BMT. These observations suggest that increased emphasis on pre-transplant assessment of factors such as frailty may aid in targeting exercise interventions at those who need it most. Furthermore, understanding factors that may impact adherence to exercise is important, hence a qualitative study was conducted concurrently. Study 4 of this thesis is a qualitative study which conducted individual semi-structured interviews with 35 participants of Study 2 and Study 3 to characterise experiences and views, including barriers and facilitators, of participation in a group-based exercise program during or after allogeneic BMT. Six major themes were identified including (1) motivation, (2) physical opportunity and (3) capability to exercise; (4) psychosocial effects of group-based exercise; (5) experienced impact of participation in exercise; and (6) intervention design considerations. Main barriers to exercise participation included symptom severity; fluctuating health status; and distance or difficult access to an exercise facility or equipment. Main facilitators included encouragement from healthcare staff; peer-support in a group-based setting; flexibility; education; and ability to measure change. The improvement in emotional wellbeing seen in Study 3, was echoed in participant views which noted that the psychological impact of group-based exercise should not be underestimated. Ultimately the study highlighted the importance of individual exercise preferences, and flexible interventions with consideration of physical and psychological capability, opportunity and motivation to sustain exercise behaviours following BMT. The findings of this thesis support the safety and feasibility of exercise in BMT, and with moderate to low confidence note that exercise improves physical and psychosocial health outcomes. The feasibility of group-based exercise has been established through this thesis, and this approach may have benefits to psychological wellbeing and may be more cost-effective than individual supervised exercise. To build towards implementation of exercise into routine clinical care for adults treated with BMT, large multi-centre, powered, well-designed RCTs are required to confirm efficacy. It is recommended that these RCTs include measurement of pre-transplant frailty, treatment toxicities and use of medications (steroids, immunosuppressants) to determine the influence of these factors on ability of exercise to maintain or improve physical outcomes such as exercise capacity. Future RCTs should be designed in partnership with key stakeholders including patients, caregivers, clinicians, policymakers and administrators to maximise adoption. These RCTs should consider adopting similar principles of intervention and outcome testing that have demonstrated efficacy in previous RCTs and consider group-based elements to maximise psychological wellbeing. Future RCTs should prioritise measurement of cost-effectiveness to ascertain sustainability of the intervention in the real-world context.
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ItemStrategies to prevent respiratory complications after high-risk elective upper abdominal surgery( 2021)Upper abdominal surgery is the most frequently performed surgery type in Australia with approximately 175,000 operations annually and the incidence of surgery is continuing to rise per annum. Despite advances in perioperative practices, postoperative pulmonary complications (PPC) remain a common serious complication following upper abdominal surgery, with high-risk patients even more susceptible. Consequences of a PPC are considerable and a leading cause of postoperative morbidity and mortality. Atelectasis occurs in almost all patients immediately following surgery, and if unresolved, is thought to lead to the development of more severe PPCs including hypoxaemia, airway infection, and respiratory failure. Preoperative physiotherapy reduces PPC rates by half following upper abdominal surgery. However, despite the overall benefit in PPC reduction demonstrated with preoperative physiotherapy, high-risk patients continue to have an increased PPC incidence. Expert opinion and previous meta-analyses recommend the use of prophylactic non-invasive ventilation (NIV) to minimise PPC risk following upper abdominal surgery. Non-invasive ventilation provides positive airway pressure throughout the breath cycle and is suggested to re-open atelectatic alveoli, increase lung volume, and improve gas exchange. However, implementation of prophylactic postoperative NIV has not been adopted into routine physiotherapy clinical practice. The reasons for this low utilisation are hypothesised to be multifactorial and include perceived risks, associated staffing resources, and unknown optimal intervention dosages. No clear consensus exists to guide postoperative NIV management and safety of prophylactic NIV therapy in abdominal surgery has yet to be adequately reported. This thesis addresses some of the gaps in our current understanding of the role of prophylactic NIV therapy within the upper abdominal surgery population. This thesis was undertaken with the overall aim of evaluating the feasibility, safety, and preliminary effectiveness of physiotherapy-led intermittent NIV to reduce PPC incidence following elective upper abdominal surgery, with a focus on those identified preoperatively at higher PPC risk. To achieve this, three studies were completed involving four peer reviewed publications (two published and two currently under review). The first section of this thesis describes a study which was a prospective, pre-post cohort, observational study (study one). The incidence of PPC and the feasibility and safety of physiotherapy-led NIV following upper abdominal surgery were measured in 81 high-risk post-cohort subjects and compared to 101 high-risk pre-cohort subjects who did not receive NIV. In this study, PPC incidence was significantly lower in the post-cohort group and whilst NIV was shown to be safe, several barriers to early delivery of physiotherapy-led NIV were identified. Due to study methodology, there were significant confounding factors and limitations. Following the publication of this study, a letter to the Editor was published by two international experts in the field of NIV and our response to the letter was published alongside. The second section of this thesis reports on a study protocol for a pilot randomised control trial (RCT), and the findings of this pilot RCT involving 130 high-risks adults undergoing elective upper abdominal surgery (study two). This study aimed to provide preliminary phase 1 feasibility, safety, and effectiveness of additional intermittent physiotherapy-led NIV compared to the provision of continuous high-flow nasal cannula oxygen therapy (HFNC) alone to minimise PPCs, whilst controlling for confounders previously identified in study one. The findings of this study demonstrated that patient consent, recruitment, and follow-up rates were high. Implementation of continuous HFNC was shown to be feasible, with 81% of participants receiving HFNC as per protocol. Physiotherapy-led NIV was delivered safely and provision of early NIV had high treatment fidelity. However, the planned NIV intervention protocol of five sessions over two postoperative days was not feasible, with only 52% of participants receiving NIV as per-protocol. The PPC incidence was similar between groups. Progression to a future definitive trial using this methodology is not recommended. The final section of this thesis reports on a systematic review and meta-analysis evaluating the overall effectiveness of prophylactic NIV and comparing the different NIV intervention approaches used to prevent PPC following upper abdominal surgery (study three). This review identified and meta-analysed data on over 6000 participants from 17 randomised controlled trials. The findings of this review demonstrate prophylactic postoperative NIV therapy does not significantly reduce the incidence of PPC in adults undergoing upper abdominal surgery, including in those identified preoperatively at higher PPC risk. No approach was identified as superior and the routine provision of prophylactic postoperative NIV following upper abdominal surgery is not recommended. The findings of this thesis support the feasibility and safety of physiotherapy-led NIV in the early postoperative period following high-risk elective upper abdominal surgery. However, a planned protocol of five NIV sessions over two postoperative days is not feasible to warrant trial progression. Findings from the systematic review do not support routine provision of prophylactic postoperative NIV in upper abdominal surgery, including in those identified at higher PPC risk. A protocol of continuous postoperative HFNC is feasible, well tolerated, and acceptable in a high-risk abdominal surgical population. Future directions for the field include examining whether postoperative NIV may benefit selected high-risk patients, i.e., those who demonstrate signs of respiratory deterioration, or those who are unable to participate in early mobilisation following upper abdominal surgery. Future superiority studies are also required to test the benefits of prophylactic continuous HFNC on PPC incidence compared to standard care following high-risk upper abdominal surgery.
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ItemPrehabilitation in major cancer surgery: A focus on feasibility and barriers( 2021)Abdominal cancer surgery is the most common major surgical procedure performed in developed countries, however post-operative morbidity are high. Post-operative complications are common and associated with an increased morbidity and prolonged hospital stay whilst also contributing significant costs to the healthcare system. Prehabilitation aims to deliver interventions in the preoperative period to minimise the development of these complications and hasten recovery. The current evidence for prehabilitation for improving preoperative status is favourable, however its carry over into improvements in post-operative outcomes remain controversial and feasibility amongst high-risk patients in the real world setting unclear. An investigation into the feasibility of prehabilitation for the high-risk abdominal surgery population is needed. The studies within this thesis aimed to (1) identify, evaluate and synthesis the evidence examining the effect of prehabilitation with exercise on postoperative outcomes following abdominal cancer surgery (2) explore the acceptability of prehabilitation from the perspective of patients (3) investigate the feasibility of delivering a prehabilitation intervention to high-risk patients and (4) evaluate the current and likely future impact of a telehealth preoperative education package for patients preparing for major abdominal cancer surgery. Study 1 critically examined the literature, through a systematic review and meta-analysis, and found that multimodal prehabilitation programs were superior to unimodal programs at improving functional capacity prior to major abdominal cancer surgery as well as reducing hospital length of stay. However there was no difference in the number of postoperative complications, hospital re-admissions or postoperative mortality. Heterogeneity in the literature and a lack of consistency amongst outcome measures limited the ability to measure the effect of prehabilitation on post-operative complications. Study 2 explored the acceptability of prehabilitation from the patient perspective. Adult patients prior to major abdominal surgery were surveyed prior to the commencement of any prehabilitation program prior to major abdominal surgery. The results indicated that prehabilitation was a largely unknown concept for patients preparing for major cancer surgery. The survey found that although 82% of patients had not previously heard of prehabilitation, the majority of patients (71%) expressed interest in participating. Based on participants responses, several key recommendations for researchers, clinicians and policy makers designing prehabilitation programs in the future were developed. Results indicated that programs should be sensitive to the individual’s financial situation, recommended by treating health professionals (preferably doctors), delivered in convenient locations (preferably home) and telehealth interventions should be carefully chosen with the patient. Study 3 investigated the feasibility of a prehabilitation program, designed and conducted using the principles for high-risk patients awaiting major abdominal cancer surgery gained from Study 2. The findings showed trends to improvements in preoperative cardiorespiratory fitness. More research is needed to improve exercise fidelity reporting and adherence to exercise interventions within this complex group. Study 4 was conducted based on the findings of Study 3 to further explore the feasibility of providing a prehabilitation intervention to high-risk patients awaiting major abdominal surgery using a telehealth intervention developed to overcome distances required to travel to the hospital. Participants were delivered an online webinar consisting of six modules of prehabilitation information including the evidence behind prehabilitation, respiratory care bundle including breathing exercises and advice on oral hygiene, exercise prehabilitation, nutrition before surgery, psychological preparedness before surgery as well as pain management after surgery. Findings demonstrated that the webinar was well received, was memorable and had a positive effect on behaviour change within the two weeks after the session. Implementation within this study was examined using the RE-AIM framework and seven recommendations are provided for researchers, clinicians and/or policy makers to assist with implementation of similar programs in the future. These studies analysed the evidence for prehabilitation in the management of patients prior to major abdominal cancer surgery. Prehabilitation within this group was proposed to be feasible within the real-world setting. The evidence provided in this thesis consists of several recommendations regarding feasibility within this high-risk group that should be considered when designing and implementing prehabilitation interventions as well as for future research studies. They present an original contribution to knowledge in this area. These findings may not be generalisable to all settings and may require further research in different surgical populations, settings and healthcare systems. The literature base for prehabilitation needs to grow to fully determine its effectiveness and implementation strategies designed with patient input to maximise their impact.
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ItemNo Preview AvailableUnderstanding and promoting physical activity participation for children born preterm( 2021)Children born preterm are at greater risk of motor impairment, including cerebral palsy (CP) and developmental coordination disorder, compared with children born at term. Despite the important role participation, including participation in physical activity (PA), plays in promoting motor development, very little is known about participation for children born preterm at preschool age. Participation includes two components: attendance and involvement. It is a complex phenomenon, influenced by environmental and personal factors, and is recognised as an important outcome for children with motor impairment. This thesis aims to better understand correlates of participation for preschool age children born preterm, as well as means of promoting participation for this group. Study one focused on correlates of participation. It compared community participation for preschool age children born at <30 weeks’ gestation (VP) and at term, and explored motor impairment and social risk as possible correlates of participation. Perceived environmental barriers and facilitators of community participation were also assessed. Children born VP participated less frequently in community activities compared with children born at term. Higher social risk was associated with poorer participation outcomes for children born VP but not term, while there was little evidence motor impairment was associated with community participation. Finally, parents of children born VP perceived greater environmental barriers to participation compared with parents of children born at term. Study two was a systematic review exploring the efficacy of movement-based interventions for preschool age children (3-6 years), with or at risk of motor impairment, including children born preterm (<37 weeks’ gestation). This review highlighted the scarcity of randomised controlled trials (RCTs) or quasi RCTs exploring movement-based interventions for this age group. Overall, movement-based interventions did not significantly improve body structure and function or activity outcomes, while the heterogeneity of intervention design and study quality made it difficult to establish definite conclusions. In particular, there were no studies that assessed participation as an outcome. Study three explored the feasibility and acceptability of a novel intervention known as Dance PREEMIE (a Dance PaRticipation intervention for Extremely prEterm children with Motor Impairment at prEschool age), which aimed to improve PA participation for preschool age children born extremely preterm (<28 weeks’ gestation) or extremely low birthweight (<1000g), with motor impairment. Children enrolled in Dance PREEMIE were allocated to a weekly community dance class (8 weeks duration) taught by dance teachers who received study-specific training. Dance PREEMIE was feasible to implement in Melbourne, Australia. Classes were well-attended and enjoyable for children, while dance teachers reported improved self-efficacy for teaching children with motor impairment after the training. Overall, Dance PREEMIE was acceptable to both parents of participating children and dance teachers. Findings from this thesis indicate that preschool age children born preterm have poorer participation outcomes compared with their term born peers, and present evidence on the feasibility and acceptability of Dance PREEMIE, a novel PA participation intervention.
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ItemQuality of physiotherapy care for people with hip and/or knee osteoarthritis( 2020)Patients with hip and/or knee osteoarthritis (OA) desire high quality of care when managing their condition. Clinical guidelines advocate exercise, weight loss (for people who are overweight or have obesity), and education regarding self-management as first line treatments for OA. Physiotherapists are important providers of such non-surgical interventions. As such, they have a professional responsibility to ensure that the care they provide to people with OA is safe and aligns with best practice. Current quality indicators (QIs) for care of people with hip and knee OA are not designed to specifically assess physiotherapy care. Furthermore, little is known about the experiences of Australian physiotherapists and people delivering and receiving care for knee OA, and if their reported experiences align with the national Clinical Care Standard for knee OA (quality statements that describe the care Australian patients should be offered by health professionals and health services for OA in line with current best evidence). This thesis aims to build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA, by developing QIs to evaluate such care and exploring the experiences of physiotherapists and patients delivering and receiving care for knee OA in Australia. Study One aimed to identify and prioritize the most important clinical guideline recommendations relevant to physiotherapy practice for hip and/or knee OA. A panel of 62 international physiotherapists was invited to first complete an online modified-Delphi survey, followed by a priority-ranking exercise. Recommendations were extracted from two high quality international clinical guidelines for OA. From an initial list of 70 potential recommendations (including seven new recommendations generated by the expert panel), 30 were included in the priority-ranking exercise. The final 30 recommendations were condensed and categorised by content area to convey high quality physiotherapy management for hip and/or knee OA. The top recommendations related to providing exercise, weight management, and education as core treatments; individualised OA management; and communication approaches. Study Two aimed to develop a patient-reported QI tool (the Quality Indicators for Physiotherapy Management of Hip and Knee Osteoarthritis (QUIPA) tool) and to assess its reliability and validity. A conceptual model based on the final 30 recommendations from Study One was used when developing the QUIPA tool, where the four main categories of the final recommendations were synthesized to establish the three subscales of the QUIPA tool. Patient focus groups were conducted to further refine the draft items. To evaluate test-retest reliability, construct validity (hypothesis testing) and criterion validity, patients with hip and/or knee OA (n= 65) were recruited to attend a single physiotherapy session and required to complete the QUIPA tool one, twelve- and thirteen-weeks following their session. Physiotherapists (n= 9) were expected to complete the tool immediately post-consultation. Patient test-retest reliability was assessed between twelve- and thirteen-weeks following their session. Construct validity was evaluated based on three predefined hypotheses. Criterion validity was assessed based on agreement between physiotherapists and participants at week one. The final QUIPA tool comprised 18 items (three subscales). The QUIPA tool demonstrated acceptable test-retest reliability for subscales and total score, but individual items showed inadequate reliability. Construct validity was adequate but criterion validity for individual items, subscales and the total score was poor. The QUIPA tool needs further refinement to improve its clinimetric properties before implementation into clinical practice. Study Three was a qualitative study that explored the experiences of Australian physiotherapists (n= 22, thirteen from major cities, five from inner regional, three from outer regional and one from remote areas) delivering care for people with knee OA and investigated the degree to which their reported experiences aligned with the Australian OA of the Knee Clinical Care Standard. Inductive thematic analysis was conducted, and the interview data were also deductively analysed according to the national Clinical Care Standard. Findings revealed that physiotherapists tended to focus on a biomedically-oriented assessment with little evaluation of psychosocial factors that may impact patients with knee OA. They perceived their primary role as providing goal-focused individualised exercise via short-term episodic care. Knee surgery was considered as a last option but for patients who chose surgery, physiotherapists ‘prepped’ them for the procedure. Patient comorbidity, poor patient adherence and patient desire for a ‘quick fix’ were perceived as clinical challenges. Physiotherapists also described a mismatch between what they know and what they do when it came to manual therapy, imaging, and weight loss advice. They saw weight management, medication, and surgical advice as outside of physiotherapy scope of practice. Overall, physiotherapists’ reported experiences with delivering care for people with knee OA were mostly consistent with the OA of the Knee Clinical Care Standard. Study Four was a qualitative study that explored the experiences of Australians (n= 24, from all six states and two territories of Australia) receiving physiotherapy care for knee OA. Participants generally presented to physiotherapists with a pre-existing OA diagnosis and were mostly comfortable with their existing knowledge about OA. They described accessing physiotherapy through various referral pathways, funding models and modes of delivery. They consulted physiotherapists for various reasons but most commonly for assistance with knee pain and functional impairments. Participants described physiotherapy management as primarily centred on exercise therapy, often supplemented by adjunctive treatments. Participants perceived advice about surgery, medications, and injections as outside of physiotherapists’ domain of care. Participants were generally happy and satisfied with their physiotherapy experiences and described valuing the personalised care they received. They also believed surgery was inevitable for their knee OA. Overall, these results provide evidence from the patients’ perspectives about the important role physiotherapists play in the care of Australians with knee OA. Findings from this thesis build on the current understanding of the quality of care provided by physiotherapists to people with hip and/or knee OA. The first two studies lay the groundwork for future design and evaluation of an international patient-reported QI tool for benchmarking quality of physiotherapy care in hip and/or knee OA. Overall, findings from the last two studies indicated that physiotherapy management of knee OA in Australia mostly aligned with the national clinical care standard and that patients were generally happy and satisfied with the physiotherapy care received. Suggested areas to improve care delivered by physiotherapists include increased consideration of psychosocial factors that may influence OA symptoms and prognosis, attention to the language used when discussing OA (i.e. avoid biomedical terms such as ‘wear and tear’ or ‘degenerative’) so that physiotherapists are not contributing to patient misinformation (i.e. joint surgery is inevitable; OA is a ‘degenerative’ or ‘wear and tear’ condition; imaging is required to diagnose OA), increased emphasis on advice and information about losing weight (for patients who need it), pain medications and knee surgery, and offering regular longer-term reviews. Findings also highlight the importance of appropriate funding mechanisms to support Australians to access physiotherapy care for their knee OA both in private and public sectors.
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ItemPrehabilitation for individuals having lung cancer surgery( 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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ItemPreoperative physiotherapy to prevent postoperative pulmonary complications after major abdominal surgery( 2020)Abdominal surgery is the most common major surgical procedure performed in developed countries. After surgery, postoperative pulmonary complications (PPCs) occur frequently and are a primary cause of morbidity, mortality, and prolonged hospital stay. To minimise PPCs, physiotherapy is ubiquitously provided in the postoperative phase in hospitals throughout developed countries. Physiotherapy clinical trials reporting the largest reductions in PPCs have predominately tested preoperative education and training of patients to perform their own breathing exercises after surgery. These trials were generally of low quality and therefore the results lack certainty. Currently, preoperative physiotherapy is rarely provided in Australian and New Zealand hospitals. A well-designed randomised controlled trial (RCT) investigating the benefit of preoperative physiotherapy to reduce PPC in a modern perioperative context was needed. The aims of this thesis were to: consider the physiological basis for preoperative physiotherapy to minimise PPCs; to conduct a narrative and systematic review of research investigating PPC prevention with breathing exercises; and, to design and conduct an RCT, including quantitative, qualitative, and health economic outcomes, assessing the effectiveness of preoperative physiotherapy to minimise PPC after major abdominal surgery. The Lung Infection Prevention Post Surgery Major Abdominal with Pre-Operative Physiotherapy (LIPPSMAck-POP) trial was a double-blinded, multicentre, RCT. In pre-admission clinics at three hospitals, 441 patients awaiting major abdominal surgery were randomised to receive an information booklet or an additional education and breathing exercise training session. Education focussed on PPC prevention via self-directed postoperative breathing exercises. A nested mixed-methods study investigated the impact and treatment fidelity of the intervention in 20 consecutive participants. Preventing pneumonia was very important to participants. Intervention participants found preoperative physiotherapy to be interesting and empowering with 94% of remembering the breathing exercises as taught. Following surgery, PPC incidence was halved in the intervention group (adjusted hazard ratio 0.48, 95% confidence interval (CI) 0.35 to 0.75, p=0.001) with a number needed to treat of 7 (95% CI 5 to 14). Intervention participants had significantly reduced pneumonia rates, required fewer antibiotic prescriptions for respiratory infections, less purulent sputum, fewer positive sputum cultures, and were less likely to require oxygen therapy. An integrated health economic analysis found that preoperative physiotherapy had high probability of being cost-effective with an incremental net benefit to hospitals of $4,958 (95% CI $10 to $9,197) for each PPC prevented, given a willingness-to-pay of $45,000 for the service. Quality adjusted life year (QALY) gains were less certain. Improved cost-effectiveness and QALY gains were detected when experienced physiotherapists delivered the intervention. For each PPC prevented, preoperative physiotherapy was likely to cost hospitals less than the costs to treat a PPC. This thesis analysed the evidence for the physiotherapy management of patients having abdominal surgery. A hypothesis for preoperative physiotherapy to minimise PPC after surgery was proposed. This hypothesis was supported with qualitative, primary, secondary, and health economic quantitative outcomes within a multicentre randomised controlled trial, and through a systematic review and meta-analysis. These findings may not be generalisable to all settings and require testing in different surgical populations, cultures, and hospital settings. Effective PPC prophylaxis needs to be investigated for patients unable to attend pre-admission clinics, those having emergency abdominal surgery and in other high-risk populations.