Melbourne School of Health Sciences Collected Works - Theses
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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.
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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.