Physiotherapy - Theses
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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.
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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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ItemExploring opportunities to improve the health literacy responsiveness of hospital outpatient waiting areas( 2022)Creating health services which are responsive to the health literacy needs of consumers has potential to improve health outcomes and reduce healthcare costs. ‘Responsive’ health services provide appropriate and accessible health information, resources, supports and care environments for consumers. Providing health information, resources and supports in waiting areas is common practice; however, there is limited evidence as to whether this practice is meeting the health literacy needs of adult consumers in hospital outpatient settings. The purpose of this thesis was to explore consumer perspectives on the health literacy responsiveness of hospital outpatient rehabilitation waiting areas. A scoping review of the literature explored what was known from published and grey literature about the use of outpatient waiting areas to contribute to health literacy. The review found limited studies in hospital outpatient waiting areas. Studies in primary care and community waiting areas suggested that targeted interventions may improve health literacy and related outcomes such as behaviours, and clinical outcomes. An observational study in two hospital outpatient waiting areas investigated the number and types of health information, resources and supports available for consumers as well as how often and for how long consumers accessed these whilst waiting for their appointments. In-person and video recorded observations revealed that a range of items were available for consumers in the waiting area, however, these were rarely used. A constructivist grounded theory study explored and theorised opportunities for hospital outpatient waiting areas to contribute to health literacy. Participant observation and semi-structured interviews were conducted with 33 adult consumers attending outpatient rehabilitation at two hospitals. The substantive theory of ‘seeking choice to fulfill health literacy needs’ and related categories indicated that consumers sought choice reflective of their needs; however, the waiting area offered limited choice. Consumers shared ideas to address the lack of choice. A cross-cultural qualitative in-depth case study explored the perceptions and experiences of CALD consumers accessing health information and resources in hospitals including in an outpatient waiting area. Four adult consumers (two patients, two caregivers) from CALD backgrounds participated in semi-structured interviews with bilingual researchers. Data were analysed using reflexive thematic analysis. Five themes indicated that available health information is not responsive to the language, literacy, or cultural needs of CALD consumers. A secondary analysis of qualitative interview data using the Framework Method investigated the barriers and enablers experienced by consumers when accessing and engaging with health information, resources and supports in hospital outpatient waiting areas. Consumers’ ideas for designing a health literacy responsive waiting area were also evaluated. Themes and design typologies developed offered practical solutions which could be applied to future waiting area design. Overall, this thesis found that hospital outpatient waiting areas have potential to contribute to health literacy from the perspectives of consumers. However, in their current state, hospital outpatient waiting areas are not responsive to consumers’ diverse health literacy needs. The findings from this PhD research highlight future avenues for redesigning and coproducing health information, resources, supports and waiting area environments which are responsive to and inclusive of diverse health literacy needs.
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ItemGait Outcomes in Preschool-aged Children Born Very Preterm( 2021)Children born very preterm (VP; less than 32 weeks’ gestation) have a higher risk of motor impairment and poorer motor outcomes than their term-born peers. The underlying mechanisms of motor impairment and the motor developmental trajectory for infants born preterm are unclear, and the evidence investigating gait characteristics in children born VP is sparse. Four studies were designed to fill this knowledge gap by comprehensively investigating the gait of children born VP in various walking conditions at preschool age: preferred speed, cognitive dual-task, motor dual-task and tandem walking. Study 1 is a systematic review of the evidence on walking onset and gait characteristics in children born preterm (less than 37 weeks’ gestation) compared with term-born peers. The walking onset of infants born VP is delayed by over two months compared with term-born peers. Limited evidence is available about their subsequent gait development and whether these children ‘catch up’ to the typical gait patterns of their peers. The systematic review revealed that the gait of preschool-age children born VP had not yet been investigated. Study 2 is a cross-sectional study which compared the gait variables and step to step gait variability of children born VP with their term-born peers at 4–5 years of age. While the gait of preschool-age children born VP did not differ from their term-born peers when they walked at their preferred speed, differences occurred when walking complexity increased. Key differences included a wider base of support (BOS) in cognitive dual-task, motor dual-task and tandem walking, and higher BOS variability in preferred speed and tandem walking. The wider BOS might indicate an adaptation to maintain balance while walking. Study 3 is a cross-sectional study which examined the gait of preschool-age children born VP at risk for developmental coordination disorder (DCD) compared with their VP peers not at risk. Children at risk for DCD walked with minimal gait differences from those not at risk in preferred speed walking; however, differences emerged when walking demands increased in the other three more challenging walking conditions. This study also found that children at risk for DCD walk with higher gait variability in all four conditions. Similarly to Study 2, one of the key differences included wider BOS in motor dual-task and tandem walking and higher BOS variability in preferred speed, cognitive dual-task and tandem walking, which might reflect greater balance challenges. Finally, a longitudinal study, Study 4, examined the associations between the Alberta Infant Motor Scale (AIMS) and walking ability at 12 months, and motor and gait outcomes at 4–5 years in children born VP. The AIMS total score was associated with poorer balance, wider tandem BOS and higher rates of preschool-age motor impairment. Children with a motor delay at 12 months had lower balance skills and longer double-limb support, but not higher odds of non-cerebral palsy motor impairment at preschool age. Furthermore, this study reveals that early independent walking at 12 months is associated with better balance skills but not gait characteristics at preschool age in children born VP. Overall, the studies undertaken in this thesis demonstrate that preschool-age children born VP are at risk of greater walking impairments than term-born children when walking demand increases. This thesis makes a novel contribution to the understanding of gait development, identifying a high-risk subgroup and predictors of neurodevelopmental outcomes at preschool age in the VP population. Understanding the gait of children born VP is essential to minimising the negative impact on motor development and potential secondary impacts on physical activity, participation, academic achievement and self-esteem. The studies in this thesis establish a foundation for future research exploring walking performance in preschool-age children born VP.
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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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ItemDigitally-delivered exercise for people with knee osteoarthritis( 2021)Knee osteoarthritis (OA) is one of the most common musculoskeletal conditions. Knee OA imposes a substantial individual and societal burden. This burden is projected to increase due to rising obesity rates and an ageing population and become unsustainable for healthcare systems within the next 15 years. In light of this, it is unacceptable that many people with knee OA are not participating in evidence-based and recommended treatments, such as strengthening exercise and physical activity. This is in part due to issues of access to suitably trained health professionals to prescribe and support recommended exercise as well as the challenges people with knee OA experience adhering to regular exercise. This thesis will explore a novel and scalable method of delivering and supporting evidence-based exercise management to people with knee OA. Specifically, this thesis will develop and rigorously evaluate a self-directed digitally-delivered exercise intervention for people with knee OA. Study One involved the development of a 24-week automated mobile phone text message intervention to support exercise adherence for people with knee OA. This study used the Behaviour Change Wheel framework which guided the application of evidence and behaviour change theory. The intervention was designed to promote participation in weekly knee strengthening exercise by targeting common exercise facilitators and barriers experienced by people with knee OA. Study Two reports the methodology of a two-arm parallel-design, assessor- and participant-blinded randomised controlled trial. This study was designed to evaluate a digitally-delivered intervention combining web-based OA and exercise information, physical activity guidance and prescription of a 24-week self-directed knee strengthening regimen (the My Knee Exercise website) supported by the mobile phone intervention designed in Study One, compared to web-based OA and exercise information only (control), in people with knee OA. Primary outcomes were overall knee pain and physical function (WOMAC function), at 24-weeks. Study Three presents the results of the RCT described in Study Two. In this study 206 people with clinically diagnosed knee OA were recruited from the community across Australia and randomised into one of the two groups. Study findings demonstrate that the self-directed, digitally-delivered exercise intervention resulted in greater improvements in pain and function at 24 weeks, compared to internet-delivered education alone in people with knee OA. These findings may be clinically relevant on a population level. Study Four qualitatively explored participants’ experience and perceptions of using the self-directed digitally-delivered exercise intervention (n=16). Participants had overall positive experiences with the intervention, valuing its simplicity and comprehensiveness, and most appreciated the regular text message contact as an exercise prompt. However, the messages evoked feelings of guilt for some if weekly exercise was not possible. Additionally, a human presence associated with the intervention appeared important. Study Five involved a secondary analysis of data from Study Four and explored if certain baseline participant characteristics were potential moderators of the effect of the self-directed digitally-delivered exercise intervention on changes in pain and function at 24 weeks, compared to the control. Except for pain self-efficacy, which moderated change in function but not pain, only weak evidence was found that the selected baseline patient characteristics moderated intervention outcomes. Collectively, findings of this thesis demonstrate the unsupervised, free-access intervention is an acceptable and efficacious method of providing recommended evidence-based exercise to people with knee OA. Findings of this thesis will inform intervention modifications and can be used to guide the design of future digitally-delivered exercise interventions in people with knee OA or other chronic conditions where exercise is a core treatment.
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ItemMuscle strengthening and neuromuscular control retraining for the treatment of chronic low back pain( 2021)Chronic low back pain (CLBP) is a complex multifactorial condition. There are multiple factors associated with CLBP-related disability, including neuromuscular, behavioural and psychological factors. Traditional assessments of neuromuscular impairments (e.g., lumbar extension strength, lumbar range of motion, the ability to contract lumbar multifidus (LM) and transversus abdominus in isolation) have been shown to be weakly associated with CLBP-related disability. Despite this, exercise interventions, such as strengthening exercises, are efficacious and recommended by clinical practice guidelines for reducing disability in people with CLBP; however, there is presently no indication as to which form of exercise is optimal. A recent study identified a relationship between CLBP-related disability and reduced neuromuscular control of the lumbar extensors. These findings suggest that exercises based on retraining neuromuscular control of these muscles may be efficacious for CLBP patients; however, this has not been subject to experimental investigation. Considering the already determined positive effect of strengthening exercises on disability in this population, a combination of strengthening and novel neuromuscular exercises may yield meaningful clinical changes in CLBP-related disability. Thus, the main aims of this thesis are to i) determine whether the addition of neuromuscular retraining of lumbar extension to a program of general muscle strengthening reduces CLBP-related disability compared to a muscle strengthening program in isolation, and ii) investigate the neuromuscular, biomechanical and psychosocial mechanisms in which neuromuscular control retraining and muscle strengthening may influence CLBP-related disability. Muscles in the lumbar spine work synergistically during movement and functional tasks (e.g., lifting). Specifically, iliocostalis lumborum (IL) plays an important role in movements and stabilisation of the lumbar spine. However, structural changes of the IL are not well understood in people with CLBP. There is also limited understanding of the relationships between changes to lumbar muscle and outcomes such as pain and strength. Therefore, this thesis also aims to iii) establish the reliability of novel muscle morphological and compositional measures of the lumbar extensors via ultrasound imaging; iv) compare CLBP participants with healthy matched controls using novel assessments of lumbar extensor morphology and composition; and v) investigate the relationship and predictive ability of morphological and compositional measures of the lumbar musculature and pain intensity and strength. To address these aims, a randomised controlled trial (RCT; aims i and ii), a reliability study (aim iii) and a cross-sectional study (aims iv and v) were conducted. The RCT investigates the effects of neuromuscular control retraining and strengthening exercises on CLBP-related disability. Details regarding the specific training parameters (i.e., repetitions, sets, time etc.) for the interventions and outcome measures utilised in the RCT are reported in a protocol study (Chapter 4). The RCT (Chapter 5) found that lumbar extensor neuromuscular control retraining in conjunction with strength training conferred no benefit over strength training alone in people with CLBP. However, it established that both interventions resulted in clinically important reductions in disability, pain intensity, and kinesiophobia. The reliability study (Chapter 6) revealed that LM morphology and composition can be assessed reliably by different assessors using ultrasound imaging. Similarly, measures of IL possess excellent test-retest reliability but poor-fair inter-rater reliability. The cross-sectional study (Chapter 7) found CLBP-related changes in lumbar multifidus morphology and IL composition compared with healthy individuals. Furthermore, it was identified that pain-inhibition contributes to decreases in size and contractility of the LM of people with CLBP.