Physiotherapy - Theses
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ItemFalls prevention after stroke(University of Melbourne, 2010)
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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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ItemThe Circus Project: Co-designing a circus-based intervention to enhance physical activity participation for preschool-aged children born preterm( 2023-08)Preschool-aged children (three-five years) born preterm (<37weeks' gestation) participate in less physical activity compared with term-born peers. Physical activity is essential for all children, as it facilitates the development of motor skills, as well as maintaining and improving skeletal and cardiovascular health. However, for children born preterm, who are at greater risk of long-term developmental impairments, adequate physical activity is likely to have an even greater role. Although physical activity participation interventions do exist, few target children born preterm at the preschool age, and there is limited evidence of collaboration with parents and other key stakeholders. Engaging stakeholders in co-design of interventions is likely to increase the relevance to the end user, and therefore result in increased uptake of healthcare initiatives. Furthermore, children are more likely to engage in an intervention when it is enjoyable, unique, and delivered in a naturalistic leisure setting. The purpose of this thesis was to develop a circus-based intervention in collaboration with key stakeholders to increase participation in physical activity for children born preterm. This was achieved through five iterative studies using an action research framework. A scoping review of the literature (Study 1) explored what was known from published and grey literature about the use of circus activities as a health intervention for children and young people. Fifty-seven of 897 sources of evidence were included, which described 42 unique interventions. The review found emerging evidence of positive health outcomes resulting from circus activities used in general populations and those with defined biopsychosocial challenges (such as cerebral palsy and autism). The review also highlighted opportunities to strengthen the evidence base such as focusing on detailed reporting of intervention elements (such as the use of the TIDieR checklist), increasing research in preschool-aged children, and focusing therapeutic interventions on specific groups of participants with demonstrated need (rather than the general population). A sequential mixed-methods study (Study 2) explored the experiences and needs of key stakeholders (parents of preschool-aged children born extremely preterm (<28 weeks' gestation), clinicians, and circus coaches) in engaging children born preterm in recreational physical activity. Barriers, facilitators, and strategies were identified in the survey (n = 217) and interview (n = 43) results, which had implications for the development of a circus-based physical activity intervention. These included the importance of coaches' specific knowledge and understanding of the preterm experience, programs incorporating holistic outcomes rather than purely physical development, the role of geographical location and cost as key considerations, and the involvement of clinicians in program design, but not delivery. A novel co-design process (P-POD) was then developed to facilitate an authentic transition to an online environment (Study 3). This process was used to co-design the circus-based physical activity intervention with ten key stakeholders, incorporating the findings from the previous studies (Study 4). The resulting intervention was titled CirqAll: Preschool Circus for Premmies and was reported according to the TIDieR checklist. The novel co-design process was evaluated using an explanatory mixed-methods design. Anonymous surveys completed by the co-design participants revealed that P-POD adhered to the guiding principles of co-design and stakeholder involvement. Themes developed from interview data described participants' experiences of the supportive online culture, room for healthy debate, power-sharing, and multiple definitions of success within the process. Finally, a feasibility study using a case series design (Study 5) evaluated the recruitment capability, acceptability and implementation fidelity of the first part of the 3-part co-designed intervention (CirqAll: professional development for circus coaches (CirqAll:PD)). Furthermore, limited efficacy testing was conducted on outcomes of interest including knowledge, skills, and confidence. Results indicated that CirqAll:PD was feasible with some modifications required to reduce attrition prior to larger-scale testing. Furthermore, coaches who completed CirqAll:PD (n = 27) showed improvements in knowledge, skills, and confidence in working with children born preterm from baseline to post-intervention, with improvements retained at three-months. Overall, this thesis developed and evaluated both a novel approach to co-designing paediatric interventions with key stakeholders, and a circus-based physical activity intervention. Findings from this thesis can be used to co-design future interventions, as well as provide a solid foundation for further development and testing of an intervention that may improve physical activity participation for preschool-aged children born preterm.
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ItemPelvic floor disorders in exercising women( 2023-09)Physical inactivity is a global societal and economic burden, increasing the risk of chronic disease. Women participate in organised sports at lower rates than men and 86% of Australian women do not meet all components of the National Physical Activity Guidelines. Sport and exercise activities may provoke symptoms of pelvic floor (PF) disorders. Pelvic floor symptoms are highly prevalent in exercising women. One in three women report symptoms of urinary incontinence (UI) across all sports and up to 80% of women engaging in high impact sports or heavy weight-lifting report UI and/or anal incontinence (AI). It is therefore important to understand how PF symptoms limit or stop exercise participation in women. The thesis research aimed to: establish the impact of female PF symptoms (UI, AI and pelvic organ prolapse) on sport and exercise participation; determine current PF symptom screening and management within Australian sport and exercise settings; and explore the preferences, barriers and enablers for future PF symptom screening and management within sport and exercise settings from the perspectives of exercising women and health or exercise professionals. Study One was a systematic review of the impact of PF symptoms on sport and exercise. Whilst UI adversely impacted exercise in one in two women, the evidence certainty was low. Important gaps in the knowledge of other PF symptoms (beyond UI) and the degree and nature of impact of all PF symptoms on participation were established. Study Two, an observational, cross-sectional study of 4,556 Australian women with PF symptoms, examined the research gaps determined by systematic review. One in two women stopped a form of exercise they had previously participated in, secondary to PF symptoms. A secondary data analysis (Study Two, Part B) found that women with more severe UI symptoms (OR=4.77; 95% CI:7.24 to 14.37), and higher bother (UI: OR=10.19; 95% CI:7.24 to 14.37; POP: OR=22.38; 95% CI:13.0 to 36.60; AI: OR=29.66; 95% CI: 7.21 to 122.07) were at greater odds of identifying their PF symptoms as a barrier stopping participation (often or all the time). Study Three, a qualitative descriptive study, interviewed symptomatic women (n=23) about their experience of PF symptoms within sport and exercise settings. Symptoms inhibited their ability to participate in exercise in the manner they wanted. Restrictive and complex coping strategies were used to avoid symptom provocation, which limited their spontaneity and enjoyment of sport and exercise. Study Four, an observational, cross-sectional survey study completed by Australian health and exercise professionals (n=636), found that PF symptom screening was not common practice within Australian sports and exercise settings, especially in at-risk groups such as high-impact athletes. Professionals were willing to engage in future screening and management, but required training, resources and access to referral networks prior to implementation. Study Five, an explanatory-sequential mixed methods design, synthesised quantitative and qualitative data (‘following a thread’) exploring symptomatic women’s experience of PF symptom disclosure and screening within sports and exercise settings. Most women had not told anyone about their symptoms due to embarrassment, limited pelvic health knowledge or not being asked. Women conveyed important preferences for future screening and management of PF symptoms within sports settings, including recommendations for how to start a conversation on pelvic health in an acceptable manner. Additional factors to facilitate disclosure, and make sports and exercise settings safer and more inclusive for symptomatic women were explored. Together, this thesis established that PF symptoms stop women from participating in sports and exercise in their preferred manner, limiting enjoyment and increasing the odds of physical inactivity. Currently, women are not usually provided the opportunity to seek help for their symptoms within sports and exercise settings. However, women and professionals felt that the provision of screening, education and management would be acceptable if appropriate support was provided and sensitively and safely implemented.
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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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ItemPelvic floor disorders in women with breast cancer( 2022)Problems related to bladder, bowel, sexual and pelvic floor (PF) muscle function are collectively termed PF disorders. Previous literature suggests that women with breast cancer may experience PF disorders at higher rates following cancer treatment than prior to cancer treatment. A causal pathway for this observation has not been clearly established. Pelvic floor muscle training (PFMT), the first-line management for treating PF disorders such as urinary incontinence (UI) and pelvic organ prolapse (POP), currently does not appear in breast cancer clinical care pathways. More data about PF disorders in women with breast cancer are required before PFMT can be included in clinical care pathways. Therefore, the aim of this thesis was to investigate PF disorders in women with breast cancer. While the abrupt precipitation of female sexual dysfunction (FSD) after breast cancer treatments is well documented, much less is known about bladder and bowel symptoms in this population. Study one, a systematic review and meta-analysis, assessed the prevalence and impact of bladder and bowel disorders in women with breast cancer. Results showed that 33% of women with breast cancer reported experiencing bladder disorders and 18% reported bowel disorders. The impact of bladder and bowel disorders in studies that used cancer-specific questionnaires was rated as low. Further studies using validated PF-specific questionnaires are required to assess the prevalence and impact of PF symptoms in this population. To address the research gap identified in the previous study, study two, a cross-sectional study, was conducted to compare the prevalence, distress and impact of PF disorders between women with and without breast cancer. Women in this study with breast cancer had a higher prevalence (although not significant) of UI, and significantly higher distress and impact of UI compared to women without breast cancer. These findings highlight that more studies are needed to understand which subgroups of women with breast cancer (e.g., women who have undergone a specific type of cancer treatment such as chemotherapy) may be most at risk of developing these symptoms. Study three, a secondary analysis of data collected as part of the previous cross-sectional study (study 2), was conducted to determine the prevalence of PF disorders according to breast cancer characteristics such as breast cancer stage and treatment type. Women in this study who underwent chemotherapy experienced the highest rates of UI (79%) and FI (24%) although this association was not statistically significant. The impact of PF disorders also appeared to increase with more time after breast cancer diagnosis. This demonstrates that the screening and treatment of PF disorders may be indicated as women enter the survivorship phase of their cancer recovery. Sexual dysfunction is another symptom that has been reported to have long-term negative impacts in women with breast cancer. Sexual function in women with breast cancer who experience UI has not been investigated. Study four, a matched control study using data collected as part of study two, compared the prevalence and severity of sexual dysfunction in matched women with and without breast cancer who experienced UI. Women who participated in this study with breast cancer and experience of UI reported significantly higher rates and severity of sexual dysfunction than women with UI of the same age, body mass index and parity without breast cancer. This finding adds to the existing body of literature that highlights the burden of FSD in women with breast cancer, and implies that clinicians may wish to consider the impact of UI when addressing FSD in this population. Study five, a cross-sectional study, compared the PF muscle function in women with and without breast cancer. The group of women in this study with breast cancer had reduced PF muscle strength and poorer relaxation ability compared to women without breast cancer. This suggests that PF therapies such as PF muscle training or relaxation techniques may be a therapeutic target to improve PF muscle function in women with breast cancer. Additionally, there is a need to better understand whether women with breast cancer who experience PF disorders are interested in seeking treatment for these symptoms during, or after breast cancer treatment. Study six, a qualitative study, explored the experiences of women with breast cancer who had PF disorders, and their perceived enablers and barriers to the uptake of treatment for PF disorders during their breast cancer recovery. Women in this study were divided as to whether they felt resigned to, or bothered by PF disorders. Their reactions to the experiences of PF disorders acted as a barrier or enabler to accessing treatment for PF disorders. For those who are interested in treatment for their symptoms, further research is required to investigate whether PF muscle therapies are a feasible treatment option for women with breast cancer. No trials to date have tested the feasibility of implementing a PFMT program in women with breast cancer. Study seven, a pilot clinical trial, assessed the feasibility of recruiting into a PFMT delivered via telehealth to treat UI in women with breast cancer. Women underwent a 12-week individualised PFMT program using a home-based intra-vaginal pressure biofeedback device (femfit). The consent rate was 100%. A significant decline in the prevalence, frequency and severity of UI was observed in this feasibility study following treatment. Pelvic floor muscle strength increased significantly from pre- to post-intervention, a mean difference of 4.8 mmHg (95%CI 3.9, 5.5). This indicated that PFMT delivered via telehealth may potentially be beneficial in treating UI, particularly stress UI in women with breast cancer. In conclusion, the findings of this thesis highlight that women with breast cancer may experience PF disorders, particularly UI, at a higher magnitude than women without breast cancer. Women with breast cancer who are bothered by their PF symptoms are interested in receiving information and treatment for PF disorders. This indicates that there may be a role of PF physiotherapy in addressing PF disorders in this population. While further research is required, these findings present an opportunity to place PF physiotherapy in breast cancer care pathways to ultimately improve the quality of life in women with breast cancer.
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ItemSystematic investigation of early-phase trial designs for upper limb therapy post-stroke( 2022)A lack of early-phase trials to systematically investigate dose and target population during intervention development is a likely reason for non-pharmacological stroke recovery trials falling short of the outcomes expected by researchers and clinicians and needed by people living with stroke. The overall objective of the work presented in this thesis was to systematically investigate dose, target population and decision-logic of early-phase trial designs in non-pharmacological stroke recovery. To achieve the objective, Study 1 developed the tools required to appraise early-phase trials of preclinical and clinical non-pharmacological stroke recovery motor interventions and embedded them in an accompanying protocol for a systematic scoping review. Study 2 executed the systematic scoping review and demonstrated a lack of published and high-quality preclinical and clinical early-phase stroke recovery motor trials that explicitly aimed to investigate dose. Study 3 established a lack of Phase I stroke trials that were registered or funded. Collectively, these studies resulted in original contributions in the form of (a) a systematic discovery pipeline tool, (b) an Early Phase Research Quality Checklist, and (c) an understanding that systematic early-phase research is rarely completed. The above findings provided an essential basis for in-depth investigation of the adaption of early-phase trial designs for application to the domain of clinical non-pharmacological stroke recovery motor interventions. As a part of this investigation, Study 3 developed a decision support tool to guide the design of Phase I non-pharmacological trials that can escalate more than one dose dimension. Study 4 utilised the decision support tool to guide the design and implementation of a multidimensional Phase I dose-ranging trial of an upper limb motor intervention delivered early post-stroke. This trial is ongoing, with the current tolerable dose being three 15-minute upper limb sessions per day. Finally, Study 5 investigated the impact of target population selection on the generalisability of upper limb motor trials conducted early post-stroke. Participant sampling was found to be a complex process that needs to be adequately reported and systematically undertaken to ensure an appropriate balance between internal and external validity. Overall, these studies have resulted in the original contributions in the form of: (d) a Phase I decision support tool, (e) confirmation that a multidimensional Phase I dose-ranging trial is feasible to implement, (f) confirmation that the current tolerable dose range is higher than usual care upper limb therapy provided early post-stroke in Australia, (g) an understanding that a lack of reporting in trials is impacting generalisability, and (h) an understanding that broadening eligibility criteria alone is unlikely to improve generalisability. Collectively, these contributions have enriched early-phase stroke recovery research by identifying barriers to its completion and providing solutions to support its uptake and quality. The completed research provides a sound basis for ongoing work to demonstrate the benefits of embedding intervention development through a systematic discovery pipeline approach within the confines of intervention complexity and the heterogeneous context of stroke. Adopting a systematic approach to intervention development via early-phase trials is achievable and likely a crucial step in bringing the field closer to identifying practice-changing interventions.
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ItemDetermining discharge destination in acute general medicine( 2022)The field of general medicine (also known as internal medicine) utilises a patient-centred, multidisciplinary approach to manage acutely unwell, complex patients. This heterogeneous medical discipline is known for its increased hospital admissions (500,000 admissions per year in Australia), longer length of hospital stays (1.83 million days per year in Australia), and high 28-day readmission rates (up to 21% globally). Notably, up to a third of general medical bed days consist of patients who are “medically ready for discharge”, but remain in hospital for non-medical reasons, such as waiting for post-acute facilities, clinician indecision and co-ordination of services. Thus, early, and accurate identification of such patient needs may allow for timelier discharge. The primary aim of this thesis was to identify predictors of discharge destination from acute general medical units and the secondary aim was to explore physical activity in the context of a general medicine hospital admission. In the first section of this thesis (Determining Discharge Destination), two systematic reviews were undertaken. The first systematic review identified 23 assessment tools and 44 patient factors associated with discharge destination in acute general medicine. The second systematic review evaluated the psychometric properties of these assessment tools and identified that the de Morton Mobility Index (DEMMI), Alpha Functional Independence Measure (AlphaFIM), the Barthel Index and the Mini Mental State Examination (MMSE) had the strongest psychometric properties. This section of the thesis identified a paucity in recent literature in an Australian context. Thus, the third study in this section of the thesis was a prospective observational study involving 417 acute general medical patients from a large tertiary hospital in Australia. This study found 54 factors associated with discharge destination and created two models to predict patients who were discharged home or “not home”. The models included the “DEMMI and toilet transfers” and the “AlphaFIM and walking independence”. The second section of this thesis (Physical Activity in General Medicine) consists of a prospective observational study involving 50 acute general medical inpatients. Physical activity was found to be low prior to and during an acute general medical admission. The tool used to measure pre-hospitalisation physical activity demonstrated a floor effect and indicates the need for a valid and reliable assessment tool that is appropriate for frail older people. No relationship was found between pre-hospital and in-hospital physical activity levels. A fair and significant association was found between both pre-hospital and in-hospital physical activity and mobility performance meaning that patients who had better mobility scores on admission had higher physical activity levels prior to and during their hospital admission. The findings of this thesis provide a comprehensive examination of tools to assist early identification of discharge destination, supplemented by an exploration of physical activity prior to and during an acute general medical hospital admission. This may facilitate a timelier discharge which has potential to improve both patient and hospital outcomes. Areas for translation of known research into clinical practice include a development of a core acute assessment tool set and promotion of physical activity. This thesis also highlights future directions for research, especially regarding further analysis of psychometric properties of known assessment tools associated with discharge (including validation of the two created models), and the creation of a valid and reliable assessment tool for physical activity in frail older people.
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ItemEvaluating the effect of self-management interventions on medial tibiofemoral contact force using electromyogram-informed neuromusculoskeletal modelling in people at risk of, and with, established knee osteoarthritis( 2022)Knee osteoarthritis (OA) predominantly involving the medial tibiofemoral compartment is a major public health problem worldwide causing pain, disability, and reduced quality of life. Longitudinal data suggest that higher knee loads during walking are associated with structural disease progression in people with medial knee OA. Higher knee loads during walking are also associated with structural disease onset in high-risk groups such as people who have undergone arthroscopic partial meniscectomy (APM). As there is no cure for OA, conservative interventions such as strengthening exercise and “appropriate” footwear are recommended throughout the OA disease continuum. However, no studies have been able to demonstrate that exercise can reduce knee loads in those at risk of, and with, established knee OA and belief that exercise could generate harmful knee loads continues to exist among patients and clinicians. This ambiguity also extends to footwear interventions, where stable supportive shoe types are recommended in most clinical guidelines despite conflicting biomechanical evidence that suggests flat flexible shoe types may reduce knee loads. A critical limitation of the current body of evidence is the use of the external knee adduction moment (KAM) as a surrogate measure of internal medial tibiofemoral contact force (MTCF). Change in the MTCF does not necessarily correspond directly with change in the KAM, predominantly due to the role internal muscle forces play in stabilizing the knee against these external loads. The use of electromyogram (EMG)-informed neuromusculoskeletal modelling is a promising means to consider the influence of muscle in estimates of internal contact force. However, it has not yet been implemented to estimate loads in knee OA intervention studies. The overarching aim of this thesis is to implement EMG-informed neuromusculoskeletal modelling to estimate MTCF during exercise and footwear interventions in people following APM (high-risk for developing knee OA), and those with established medial knee OA. This thesis first describes secondary analyses from two randomised controlled trials. In Study 1 (Chapter 4), which involved 41 participants aged between 30-50 years with medial APM in the prior 3-12 months, no significant difference in MTCF (peak and impulse) was found following a 12-week functional weightbearing exercise program compared to no intervention. In Study 2 (Chapter 5), which involved 62 participants aged over 50 with medial knee OA and varus malalignment, no significant difference in MTCF (peak or impulse) was found between a 12-week functional weightbearing (WB) and a 12-week non-weightbearing (NWB) quadriceps strengthening exercise program. Interestingly, the functional WB exercise program reduced the external contribution to MTCF, while the NWB quadriceps strengthening program reduced the muscle contribution to MTCF. This thesis then describes two cross-sectional studies, both utilising the same cohort of 28 people over the age of 50 with medial knee OA and varus malalignment. The first (Study 3, Chapter 6) compared the immediate effect of stable supportive and flat flexible shoes on continuous and discrete measures of MTCF during walking. Statistical parametric mapping (SPM) showed lower MTCF in the stable supportive compared to flat flexible shoes during 5-18% of stance phase. For the discrete outcomes, loading impulse, mean loading rate, and max loading rate were lower in stable supportive shoes compared to flat flexible shoes. The second cross-sectional study (Study 4, Chapter 7) evaluated the MTCF and muscle forces during each of three weightbearing exercises (double leg squat, forward lunge, and single-leg heel raise), relative to walking. Results showed that knee extensor and flexor force was higher during squatting and lunging compared to walking, while the MTCF was lower during squatting and heel raises compared to walking. Collectively, this thesis does not provide any evidence that 12-week functional weightbearing exercise programs can change MTCF in people following APM and with medial knee OA and varus malalignment. However, novel findings suggest that stable supportive shoes can reduce aspects of the MTCF compared to flat flexible shoes, suggesting that this shoe type may be most suitable for people with knee OA and varus malalignment. This thesis also provides evidence that common weightbearing exercises (squatting, lunging and heel raises) do not result in harmful increases in MTCF. These exercises may therefore be used safely in clinical settings for people with knee OA and varus malalignment.