Physiotherapy - Theses
Permanent URI for this collection
Search Results
1 - 10 of 16
-
ItemThe Circus Project: Co-designing a circus-based intervention to enhance physical activity participation for preschool-aged children born preterm( 2023-08)Preschool-aged children (three-five years) born preterm (<37weeks' gestation) participate in less physical activity compared with term-born peers. Physical activity is essential for all children, as it facilitates the development of motor skills, as well as maintaining and improving skeletal and cardiovascular health. However, for children born preterm, who are at greater risk of long-term developmental impairments, adequate physical activity is likely to have an even greater role. Although physical activity participation interventions do exist, few target children born preterm at the preschool age, and there is limited evidence of collaboration with parents and other key stakeholders. Engaging stakeholders in co-design of interventions is likely to increase the relevance to the end user, and therefore result in increased uptake of healthcare initiatives. Furthermore, children are more likely to engage in an intervention when it is enjoyable, unique, and delivered in a naturalistic leisure setting. The purpose of this thesis was to develop a circus-based intervention in collaboration with key stakeholders to increase participation in physical activity for children born preterm. This was achieved through five iterative studies using an action research framework. A scoping review of the literature (Study 1) explored what was known from published and grey literature about the use of circus activities as a health intervention for children and young people. Fifty-seven of 897 sources of evidence were included, which described 42 unique interventions. The review found emerging evidence of positive health outcomes resulting from circus activities used in general populations and those with defined biopsychosocial challenges (such as cerebral palsy and autism). The review also highlighted opportunities to strengthen the evidence base such as focusing on detailed reporting of intervention elements (such as the use of the TIDieR checklist), increasing research in preschool-aged children, and focusing therapeutic interventions on specific groups of participants with demonstrated need (rather than the general population). A sequential mixed-methods study (Study 2) explored the experiences and needs of key stakeholders (parents of preschool-aged children born extremely preterm (<28 weeks' gestation), clinicians, and circus coaches) in engaging children born preterm in recreational physical activity. Barriers, facilitators, and strategies were identified in the survey (n = 217) and interview (n = 43) results, which had implications for the development of a circus-based physical activity intervention. These included the importance of coaches' specific knowledge and understanding of the preterm experience, programs incorporating holistic outcomes rather than purely physical development, the role of geographical location and cost as key considerations, and the involvement of clinicians in program design, but not delivery. A novel co-design process (P-POD) was then developed to facilitate an authentic transition to an online environment (Study 3). This process was used to co-design the circus-based physical activity intervention with ten key stakeholders, incorporating the findings from the previous studies (Study 4). The resulting intervention was titled CirqAll: Preschool Circus for Premmies and was reported according to the TIDieR checklist. The novel co-design process was evaluated using an explanatory mixed-methods design. Anonymous surveys completed by the co-design participants revealed that P-POD adhered to the guiding principles of co-design and stakeholder involvement. Themes developed from interview data described participants' experiences of the supportive online culture, room for healthy debate, power-sharing, and multiple definitions of success within the process. Finally, a feasibility study using a case series design (Study 5) evaluated the recruitment capability, acceptability and implementation fidelity of the first part of the 3-part co-designed intervention (CirqAll: professional development for circus coaches (CirqAll:PD)). Furthermore, limited efficacy testing was conducted on outcomes of interest including knowledge, skills, and confidence. Results indicated that CirqAll:PD was feasible with some modifications required to reduce attrition prior to larger-scale testing. Furthermore, coaches who completed CirqAll:PD (n = 27) showed improvements in knowledge, skills, and confidence in working with children born preterm from baseline to post-intervention, with improvements retained at three-months. Overall, this thesis developed and evaluated both a novel approach to co-designing paediatric interventions with key stakeholders, and a circus-based physical activity intervention. Findings from this thesis can be used to co-design future interventions, as well as provide a solid foundation for further development and testing of an intervention that may improve physical activity participation for preschool-aged children born preterm.
-
ItemEvaluating the effect of self-management interventions on medial tibiofemoral contact force using electromyogram-informed neuromusculoskeletal modelling in people at risk of, and with, established knee osteoarthritis( 2022)Knee osteoarthritis (OA) predominantly involving the medial tibiofemoral compartment is a major public health problem worldwide causing pain, disability, and reduced quality of life. Longitudinal data suggest that higher knee loads during walking are associated with structural disease progression in people with medial knee OA. Higher knee loads during walking are also associated with structural disease onset in high-risk groups such as people who have undergone arthroscopic partial meniscectomy (APM). As there is no cure for OA, conservative interventions such as strengthening exercise and “appropriate” footwear are recommended throughout the OA disease continuum. However, no studies have been able to demonstrate that exercise can reduce knee loads in those at risk of, and with, established knee OA and belief that exercise could generate harmful knee loads continues to exist among patients and clinicians. This ambiguity also extends to footwear interventions, where stable supportive shoe types are recommended in most clinical guidelines despite conflicting biomechanical evidence that suggests flat flexible shoe types may reduce knee loads. A critical limitation of the current body of evidence is the use of the external knee adduction moment (KAM) as a surrogate measure of internal medial tibiofemoral contact force (MTCF). Change in the MTCF does not necessarily correspond directly with change in the KAM, predominantly due to the role internal muscle forces play in stabilizing the knee against these external loads. The use of electromyogram (EMG)-informed neuromusculoskeletal modelling is a promising means to consider the influence of muscle in estimates of internal contact force. However, it has not yet been implemented to estimate loads in knee OA intervention studies. The overarching aim of this thesis is to implement EMG-informed neuromusculoskeletal modelling to estimate MTCF during exercise and footwear interventions in people following APM (high-risk for developing knee OA), and those with established medial knee OA. This thesis first describes secondary analyses from two randomised controlled trials. In Study 1 (Chapter 4), which involved 41 participants aged between 30-50 years with medial APM in the prior 3-12 months, no significant difference in MTCF (peak and impulse) was found following a 12-week functional weightbearing exercise program compared to no intervention. In Study 2 (Chapter 5), which involved 62 participants aged over 50 with medial knee OA and varus malalignment, no significant difference in MTCF (peak or impulse) was found between a 12-week functional weightbearing (WB) and a 12-week non-weightbearing (NWB) quadriceps strengthening exercise program. Interestingly, the functional WB exercise program reduced the external contribution to MTCF, while the NWB quadriceps strengthening program reduced the muscle contribution to MTCF. This thesis then describes two cross-sectional studies, both utilising the same cohort of 28 people over the age of 50 with medial knee OA and varus malalignment. The first (Study 3, Chapter 6) compared the immediate effect of stable supportive and flat flexible shoes on continuous and discrete measures of MTCF during walking. Statistical parametric mapping (SPM) showed lower MTCF in the stable supportive compared to flat flexible shoes during 5-18% of stance phase. For the discrete outcomes, loading impulse, mean loading rate, and max loading rate were lower in stable supportive shoes compared to flat flexible shoes. The second cross-sectional study (Study 4, Chapter 7) evaluated the MTCF and muscle forces during each of three weightbearing exercises (double leg squat, forward lunge, and single-leg heel raise), relative to walking. Results showed that knee extensor and flexor force was higher during squatting and lunging compared to walking, while the MTCF was lower during squatting and heel raises compared to walking. Collectively, this thesis does not provide any evidence that 12-week functional weightbearing exercise programs can change MTCF in people following APM and with medial knee OA and varus malalignment. However, novel findings suggest that stable supportive shoes can reduce aspects of the MTCF compared to flat flexible shoes, suggesting that this shoe type may be most suitable for people with knee OA and varus malalignment. This thesis also provides evidence that common weightbearing exercises (squatting, lunging and heel raises) do not result in harmful increases in MTCF. These exercises may therefore be used safely in clinical settings for people with knee OA and varus malalignment.
-
ItemThe use of a smartphone app, Baby Moves, and the assessment of early spontaneous movements in infants born extremely preterm and/or extremely low birthweight( 2019)Infants born extremely preterm (EP, <28 weeks’ gestational age) and/or extremely low birthweight (ELBW, <1000 g) are at higher risk of developmental delay and/or disabilities, such as cerebral palsy (CP), compared with infants born at term. Early detection is paramount to ensure that infants who are at the highest risk of developmental delays are identified early to commence intervention and improve functional outcomes. The General Movements Assessment (GMA) involves visual clinical recognition of patterns of spontaneous infant movement from video recordings and is a key assessment for the diagnosis of high-risk CP but is not universally accessible due to resource constraints, such as limited out-patient follow-up services. The Baby Moves smartphone application (app) offers a novel method of allowing clinicians to partner with parents by providing them with a tool to record their infant’s movements via their smartphone to be used for a remote GMA. This thesis explores the feasibility of Baby Moves in a geographical sample of infants born EP/ELBW and at term, and whether there is a relationship between perinatal clinical history, GMA, and motor outcome at 4 months’ corrected age. Furthermore, this thesis investigates the nuances of the GMA in relation to preterm birth. Study 1 is a systematic review of the literature investigated the reported predictive validity of spontaneous infant movements for later CP. Forty-seven studies were identified, with fidgety movements assessed according to the Prechtl GMA found to be the most accurate spontaneous movement for predicting CP. Study 2 is a cohort study, which was conducted within a geographical sample of infants born EP/ELBW and term-matched controls. Of the 226 infants born EP/ELBW and 225 infants born at term who were recruited to the study, at least one video was received from 158 and 188 families of infants born EP/ELBW or at term respectively. This thesis found that families tended to use Baby Moves less if they were of lower sociodemographic status, regardless of whether the infants were born EP/ELBW. Families found Baby Moves easy to use and considered it a secure way to transmit videos. Study 3 analysed the data from infants’ GMA further and the occurrence and trajectories of fidgety movements was explored. Infants tended to have more normal fidgety movements with increasing age within a window of 12-16+6 weeks’ corrected age regardless of birth group (EP/ELBW vs term). More infants born EP/ELBW had absent/abnormal fidgety movements than term-born controls. Study 4 explored the relationships of perinatal variables with absent/abnormal fidgety movements within the EP/ELBW cohort. Brain injury was independently associated with absent/abnormal fidgety movements. Finally, Study 5 assessed 4-month motor outcomes in a sample of 56 infants born EP/ELBW. There was a high rate of motor impairment within this sample. Brain injury was strongly related to poorer 4-month motor outcome and neonatal surgery was independently related to a poorer AIMS score. Absent/abnormal fidgety movements were not associated with 4-month motor outcomes. Findings from this thesis provide insight into the GMA and confirm that smartphone technology can be used with the GMA in a population of infants born EP/ELBW and at term.
-
ItemBike skills training for children with cerebral palsy( 2019)Training targeted towards goals that are meaningful to children with cerebral palsy (CP) and their families is needed to improve function and support participation in physical activities in this population. Riding a two-wheel bike is a common goal for ambulant children with CP, yet little specific evidence exists to guide clinicians and families. This thesis developed and tested a task-specific approach to training bike skills in this population through three studies: 1) a systematic review, 2) a practice survey, and 3) a randomised controlled trial (RCT). Each study used the International Classification of Functioning, Health and Disability (ICF) as a framework. While strong evidence exists for task-specific training (TST) for improved upper limb (UL) function in this population, prior to this thesis the literature regarding TST for gross motor skills, including bike riding, in ambulant children with CP had not been systematically appraised. Thus, Study 1 aimed to systematically evaluate the effectiveness of task-specific gross motor skills training for improving activity and participation outcomes in ambulant school-aged children with CP. This review involved 13 studies of low-to-moderate overall quality and found effects of TST were positive for participation-related outcomes, and mixed for specific skill performance and functional skills, while little or negative effects were found for general gross motor skills. This study identified the need for higher quality studies and reporting that enables evidence synthesis. Given the importance of understanding current practice when designing effectiveness studies, Study 2 involved a survey of 95 physiotherapists (PTs) and occupational therapist (OTs) in Australia about their practices when training two-wheel bike skills in children with CP. This study found that while functional approaches to training and goal-based assessment and evaluation were predominant, overall practices appear highly variable. Moreover, the need to develop and test bike-specific measures and interventions in this population was highlighted. The findings from Studies 1 and 2 informed the design of Study 3. This multi-site assessor-blind RCT aimed to determine if a task-specific approach was more effective than a parent-led home program for attaining individualised two-wheel bike riding goals in ambulant children with CP. Sixty-two children were randomly allocated to either the task-specific approach (n=31) or home program (n=31). The primary finding was that the task-specific program was more effective than the home program for goal attainment at one week post-intervention. Greater odds of goal attainment were retained at three months and evidence of better outcomes following the task-specific program were found for some outcomes related to participation in bike riding, physical activity and self-perception. In addition, there was evidence of mixed effects for functional skills, and little difference in bike skills and health-related quality of life. While each of these studies provides an original contribution to the literature, together they form a significant foundation for evidence on training bike skills in ambulant children with CP. Use of the ICF across the thesis meant findings could be synthesised and enhanced the clinical relevance of the research. Given that an effective approach for attaining two-wheel bike riding goals in this population now exists, training for clinicians to optimise knowledge translation should be developed. Future research should seek to understand relationships between bike skills training and a broader range of ICF domains and levels of function in CP, tailor interventions to individuals and determine longer-term outcomes.
-
ItemExploring remote models of physiotherapy service delivery for people with osteoarthritis( 2018)Knee and hip osteoarthritis (OA) is highly prevalent and has a significant burden on both the individual sufferer and society. All current clinical guidelines recommend education and exercise for management of OA, however exercise participation amongst people with OA is sub-optimal. Barriers to exercise uptake and adherence include inequitable access to appropriate healthcare, and difficulties changing behaviour and incorporating exercise into daily life. This thesis explores remote models of service delivery (telerehabilitation) as a potential method of improving exercise participation in people with OA. Specifically, this thesis aimed to explore the perceived acceptability of telerehabilitation services amongst people with OA and physiotherapists, and also investigate physiotherapist training in behaviour change techniques and person-centred care for telephone-delivery. Study 1 involved a survey that investigated the perceptions people with knee and/or hip OA (n=330) have towards the delivery of exercise therapy by a physiotherapist via internet-mediated video and telephone consultations. Participants had overall positive perceptions, acknowledging ease of use and time saving advantages. However, most (>50%) did not agree that they would like the lack of physical contact, that they would be willing to pay for telerehabilitation services, that telephone-delivery would be effective, or that a physiotherapist would be able to adequately monitor their condition via telephone. Study 2 involved a survey that investigated the perceptions of physiotherapists (n=217) towards the delivery of exercise therapy via internet-mediated video and telephone consultations for people with OA. Most physiotherapists agreed such services would save patient’s time and maintain their privacy, but most did not believe they would like the lack of physical contact with patients. In addition, physiotherapists favoured the use of video technologies over telephone, with most feeling uncertain about the safety, effectiveness, usefulness, or acceptability of telephone-delivered care. Study 3 qualitatively explored physiotherapists’ (n=8) perceptions before and after a training program in behaviour change techniques and person-centred principles that was done in preparation for a clinical trial involving the delivery of exercise therapy via telephone. After training, physiotherapists’ perceptions about their role managing patients with OA had changed, increasing their feelings of responsibility to assist their patient with exercise adherence, and they felt confident and prepared to deliver the intervention remotely via telephone. Study 4 evaluated the fidelity of physiotherapists from Study 3 (n=8) to the behaviour change techniques and person-centred principles taught during training, and involved both self- and expert audits of practice telephone consultations. Physiotherapists performed moderately well, but had room for improvement from further practice and/or training. Physiotherapists’ self-ratings of performance generally agreed with expert ratings, however they tended to underestimate their ability to implement some principles and techniques. Study 5 explored the perceptions of people with knee OA (n=20) who participated in a clinical trial involving telephone-delivered exercise therapy by a physiotherapist. Although participants were initially sceptical about receiving care via telephone, they described mostly positive experiences, valuing the sense of undivided focus and attention and feeling confident performing their exercise program without supervision. Study 6 explored how experience delivering exercise therapy via telephone as part of a clinical trial changed physiotherapists’ (n=8) perceptions about such services. Physiotherapists were initially sceptical about the effectiveness of telephone-delivered service models, expressing concern about the lack of physical and visual contact. However, after experience, physiotherapists were pleasantly surprised by the effectiveness of the intervention and by the positive outcomes that they were able to achieve with their participants. Collectively, findings from this thesis suggest that, overall, telerehabilitation is perceived to be an acceptable model of service delivery by people with OA and physiotherapists. Although there was evidence of scepticism about the effectiveness of telephone-delivered care amongst those who are inexperienced, particularly physiotherapists, these perceptions appeared to change with experience. Physiotherapists believed that training in behaviour change techniques and person-centred care helped them communicate effectively via telephone and also changed their perceptions about their role managing patients with OA. Findings from this thesis can be used to inform the future design and implementation of telerehabilitation services and clinician training programs.
-
ItemToward relationship-centred care: patient-physiotherapist interaction in private practice( 2017)Interacting with patients is integral to the practice of physiotherapy. Notably, however, empirically derived knowledge about how physiotherapists interact with their patients is limited, particularly in the private practice setting. In addition, heavily promoted approaches for interacting with patients, such as patient-centred care and the biopsychosocial approach, have been adopted from the medical profession, are not derived from research evidence, and therefore may not adequately reflect how physiotherapists interact with patients in physiotherapy practice. Thus, this qualitative research had two aims: first, to detail how patients and physiotherapists interact in private practice; second, to consider how the research findings related to promoted healthcare interaction approaches. Methodologically, the research incorporated features of both ethnography and grounded theory. Observations of 52 consultations, as well as in-depth interviews with 9 patient and 9 physiotherapist participants, were undertaken. Data comprised field notes and audio-recordings of observations and interviews, and were analyzed iteratively using principles of thematic analysis and grounded theory. The data analysis yielded two central and complementary themes. The theme ‘physiotherapist-led communication’ encapsulates how physiotherapists directed the style and content of communication to achieve clinical goals by providing structure, making decisions, and focussing on biomedical aspects. The second theme, ‘adapting to build rapport’, describes how physiotherapists incorporated adaptive communication such as eye contact, body language, touch, casual conversation, and humour into their interactions with patients. These adaptations were often intuitively enacted, were responsive to individual patient characteristics, and functioned to build rapport. The findings neither clearly correlated to features of patient-centred care nor to the biopsychosocial approach. Rather, the findings portrayed a dynamic integration of clinical and responsive communication that fostered the development of a trusting relationship between patient and physiotherapist. These results extend knowledge of interactions in physiotherapy by providing detailed descriptions of interactional elements that incorporated patient and physiotherapist perspectives. Furthermore, the findings explain how rapport was developed between patient and physiotherapist with trust as an underlying construct. Relationship-centred care and relational notions of trust are discussed as alternative explanations for how patients and physiotherapists interact in private practice. These findings and explanations have the potential to benefit educators, physiotherapists and, by extension, patients, by offering a framework for education and the practice of patient-physiotherapist interactions.
-
ItemMeasurement and prevention of muscle atrophy in acute spinal cord injury( 2017)Traumatic spinal cord injury (SCI) is a devastating event, resulting in rapid and extensive deterioration of musculoskeletal tissue due to denervation, which further progresses due to lifelong paralysis. Secondary sequelae of muscle atrophy, such as diabetes, heart disease and osteoporosis contribute to a profile of premature aging in this population. The aims of this program of research were to 1) describe changes in musculoskeletal tissue after spinal cord injury, and the manner and mechanisms by which they might be affected by early exercise, 2) analyze the current evidence regarding the effects of early exercise after SCI, 3) compare and contrast different methods of measuring muscle changes, 4) determine the effects on muscles and body composition of exercise commenced within four weeks after traumatic SCI, and 5) examine the validity of bioelectrical impedance methods to assess body composition in acute SCI. Passive Cycling (PC) and Functional Electrical Stimulation Cycling (FESC) have shown benefits in chronic SCI, but it is unknown how early after injury these interventions may be safely applied. A systematic review was undertaken to critically assess the current evidence on the efficacy of exercise initiated early after traumatic SCI. Eleven studies provided level II evidence showing positive effects of early exercise on muscle, possibly related to load intensity of the protocol. A randomised controlled trial (SCIPA Switch-On) was conducted to determine the safety and relative effectiveness of FESC and PC initiated within four weeks. The results were unable to detect a significant benefit on thigh muscle cross-sectional area of one intervention over the other. However, these results were explained in part by a) lack of statistical power to detect between-group differences, b) a concomitant neurological recovery of lower limb motor function in some participants in both groups, and c) and unexpected positive effects on some participants in the PC group. A novel and salient finding of the study was promising, in that thigh muscle atrophy was attenuated in both groups, relative to expectations if the intervention had had no trophic or anti-catabolic effect (2). Three quarters (75%) of the participants in both groups experienced < 30% reduction in thigh muscle CSAmax, signifying an attenuation of muscle atrophy against previous reports (2-4). Exploratory analysis of changes in muscle volumes found that 9-13 weeks of FESC resulted in higher whole thigh volumes than PC for most participants. Furthermore, hypertrophy of hamstrings and quadriceps volume was moderately and significantly correlated with frequency of FESC, and to a lesser extent, frequency of PC. Lastly, a groundbreaking interdisciplinary observational study was undertaken to validate the use of bioelectrical impedance analysis (BIA), a bedside measure of FFM, against the ‘gold standard’ deuterium dilution method, for measurement of body composition in acute SCI. The data showed that although predictive equations from BIA are population-specific and most published equations are not valid in acute SCI, one equation (5) was able to predict FFM in acute SCI with minimal bias (0.6kg) for group means. However, due to a dispersion of ±5.1kg, further study is needed to validate this measure for clinical evaluation of individuals. This finding is clinically relevant because gold-standard measures of FFM were able to predict total energy requirements (TEE) better than currently used clinical dietetic predictive equations. Thus, BIA, a clinically feasible and valid bedside measure of FFM could provide, for the first time, an objective tool to guide dietetic practice, pending replication of the study, ideally with a larger sample size. In conclusion, the findings of this thesis indicate that a) BIA is an accurate, though possibly imprecise, measure of FFM in acute SCI, and b) supervised FESC and PC interventions are not harmful, and are potentially beneficial, and may be utilized in the clinical setting for medically stable patients with acute SCI. Within the field of rehabilitation, is it imperative to explore and document the practical details and effects of exercise interventions initiated early after SCI, as this thesis has endeavoured to do, for this establishes a critical foundation upon which to build evidence-based practice that endeavours to achieve excellent patient outcomes.
-
ItemManual dexterity evaluation in people with Parkinson's disease( 2016)Manual dexterity is frequently compromised in people with Parkinson’s disease (PD). Poor dexterity can contribute to limitations in activities of daily living, and may restrict employment and leisure activities. Because manual dexterity limitations may be a focus of physiotherapy or occupational therapy treatments for people with PD, measurement of therapy outcomes requires access to tools with known reliability and validity. Evidence for these properties in groups with PD is limited, and there are no widely accepted methods for evaluating dexterity in people with this debilitating disorder. To address this gap, the primary aim of this thesis was to gain a comprehensive understanding of the measurement properties and applicability of tools used for the evaluation of dexterity in individuals with PD. The first study surveyed groups of Australian physiotherapists and occupational therapists to gain an understanding of upper limb assessment methods. This revealed the widespread use of non-standardised techniques, and measurement tools with untested measurement properties in people with PD. The second study, a systematic review of the literature, identified measures used for arm and hand evaluation in PD research. Studies investigating the measurement properties of these tools in PD were retrieved and critically appraised, finding incomplete evidence for their measurement properties, principally validity and responsiveness. Next, conceptual frameworks were developed to assist in identifying tools that may be sensitive to the specific changes in dexterity observed in PD. These frameworks linked knowledge of PD-related impairments and activity limitations to an existing framework of manual dexterity skills. In a measurement tool selection process, the new frameworks were applied, in conjunction with other criteria, to tools identified in the survey and systematic review. As a result, the Nine Hole Peg Test (NHPT) and Purdue Pegboard Test (PPT) were selected for further exploration of their reliability and validity in a sample of people with PD. The test-retest reliability of NHPT and PPT subtest scores, recorded one week apart during the ‘on’ phase and at the ‘end of dose’, was investigated in a sample with mild to moderate PD. Reliability was moderate to good (ICCs ≥ 0.75) and minimal detectable change values represented less than 25% of mean group scores for most subtests. To examine interrater reliability, physiotherapists and occupational therapists scored visual recordings of NHPT and PPT performance. All subtests showed good relative interrater reliability (ICCs > 0.99). The construct validity of NHPT and PPT scores was also explored. Known groups validity was supported by the significantly poorer performance of this sample with PD, when compared with normative values. Moderate associations existed between self-reported limitations in manual performance and NHPT and PPT scores recorded in the ‘on’ phase (ρ = 0.31 – 0.51), providing new evidence for the convergent validity of these tools. More affected hand (MAH) scores were more closely associated with dexterity performance than dominant hand scores. To extend these findings, the final study explored the construct validity of NHPT MAH scores in a large sample of people with mild to severe PD. Data for this study were collected by researchers in The Netherlands as part of the ParkinsonNet trial (Keus et al., 2010; Munneke et al., 2010). Participants who prioritised manual activity limitations as principal functional limitations had poorer NHPT MAH scores than those prioritising limitations in other activities such as walking or transfers (p < 0.001). NHPT MAH scores were also moderately associated with self-reported dexterity performance (ρ = 0.41, p < 0.001), adding evidence for construct validity. This thesis found that Australian clinicians had deficiencies in their understanding of upper limb and dexterity measurement tools applicable to people with PD. The lack of high quality evidence to guide measurement tool selection was also highlighted in the systematic review. The thesis contributed new conceptual frameworks to identify specific features of dexterity loss in PD, which may be important in evaluation and treatment. Reliability and validity studies furthered the understanding of these measurement properties for the NHPT and PPT, both currently used by clinicians and researchers. There is presently no international consensus around the most suitable methods for measuring dexterity in PD. By adding to the limited knowledge of dexterity measures and their measurement properties in this clinical group, the findings of this thesis have the potential to assist clinicians and researchers in appropriate measurement tool selection, and the interpretation of measurement scores.
-
ItemActive video game technologies for balance rehabilitation after stroke( 2016)Standing balance deficits are frequent and disabling following stroke; however, optimal assessment and treatment for balance problems remains unclear. The past decade has seen the increasing emergence and clinical uptake of active video game technologies. The purpose of this thesis was to investigate the utility of active video games, in particular the Nintendo Wii, for balance rehabilitation following stroke. A comprehensive, narrative literature review of balance assessment and treatment following stroke was completed. Force platform technologies were found to provide a higher level of objective information on balance performance than clinical tests, but were inaccessible for most clinical settings. The Wii Balance Board (WBB) presented a valid and potentially feasible alternative; however, its clinimetric properties had not been investigated in a post-stroke sample. Active video games, such as the Wii Fit, demonstrated equivalence or superiority in efficacy to more traditional balance training approaches in emerging recent studies, but trials were generally small. Importantly, they provided little insights into feasibility, nor guidance in clinical implementation. A cross-sectional study was conducted to investigate the reliability, validity and feasibility of WBB-based tests of balance in an outpatient stroke setting. Thirty participants were tested on two occasions, one week apart. Five WBB-based standing balance tests demonstrated excellent test-retest reliability (ICC2,k = 0.82 to 0.98) and were poorly to moderately associated (r = 0.04 to 0.61) with performance in four clinical tests of balance and mobility. Minimal detectable change scores, floor and ceiling effects were investigated, to further inform the utility of the WBB variables. These tests were deemed feasible in terms of the time to complete and ease of use. A pilot randomised controlled trial was undertaken to investigate the feasibility and preliminary efficacy of a Wii Fit balance training program in an inpatient setting. Thirty participants (time since stroke, mean (SD) = 25 (18) days), randomised to Wii Fit balance or Wii Sports upper limb training, completed three Wii-based sessions per week over two or four weeks in addition to standard therapy. Feasibility of the Wii training was considered satisfactory based on adherence, acceptability and safety. Greater improvements in balance (i.e., the Step Test and WBB variables) were demonstrated by the Wii Fit balance group. Finally, a comprehensive, theory-based decision-making framework was developed for implementing active video game game-based balance training following stroke. It provides a resource to guide training decisions considering different aspects of the individual, task and environment, underpinned by motor learning theory. This framework may support future clinical and research applications of these technologies. This thesis found the WBB to be a reliable and potentially feasible force platform alternative for low-cost research and clinical use. Wii Fit training was found to be acceptable and safe in an inpatient stroke rehabilitation setting, and the efficacy results can inform the design of future trials. A decision-making framework for active video game implementation is proposed as a potentially valuable clinical resource to guide practice and future research. This thesis provides a substantial contribution to the knowledge in this field and may contribute to improved quality of stroke care in the future.
-
ItemWhat is the influence of adjunctive therapy on outcome following botulinum neurotoxin (BoNTA) injection for focal spasticity in adults with neurological conditions?( 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.