Physiotherapy

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An investigation of physical activity, influences on participation and psychological well-being in female undergraduates.
(Queen Margaret University, 2002) Bulley, C. J.
Recent health surveys have found that many young women do not participate in sufficient physical activity to produce health benefits. Consequently, they are at risk of developing cardiovascular disease, diabetes and osteoporosis in later life. The transition between secondary and higher education is associated with particular risks in relation to declining activity participation. There is clearly a need to explore the aetiology and impact of activity behaviour change in this context. A literature review identified several gaps relating to the validity of physical activity measurement, mental health benefits associated with participation and factors influencing changes in activity choices over time. Three studies were designed to address these issues in a female undergraduate population at Queen Margaret University College in Edinburgh. A theory is proposed to explain relationships between many of the variables explored. Study One aimed to validate the Scottish Physical Activity Questionnaire (SPAQ) against an estimate of time in moderate and vigorous activity derived from heart rate monitoring data. Women were monitored for three days of the seven-day recall period (N=23). Self-report and heart rate estimates of time in activity differed significantly (t test: p=0.008) and correlated poorly (r=0.03). The questionnaire was modified as a result of analysis and testing was repeated in a sample of 21 women. Modified SPAQ for students and heart rate estimates of time in activity did not differ significantly (p=0.119) and demonstrated improved correlations (r=0.59). Stage of Behaviour Change classifications also demonstrated hierarchical agreement with subjective and heart rate estimates of time in activity. Study Two aimed to establish baseline levels of exercise and moderate lifestyle physical activity in female undergraduates and to explore associations with psychological well-being over time. A large longitudinal survey was carried out using the modified SPAQ for students and psychometric measurement tools. The first survey time-point occurred at the start of the academic year and according to Stage of Behaviour Change classification 51% of participants were not active enough to achieve health benefits (n=425). The second survey was carried out two months later. Significant correlations were found between self-esteem scores and Stage of Behaviour Change classification in relation to moderate lifestyle PA (r=0.29), but not vigorous exercise. The low response to survey two (n=89) necessitated a change in methodology, implemented in the final study. Study Three aimed to explore changes in activity over the first academic year, influences on activity-related decisions and the effects of these choices on psychological well-being. Sixteen participants from the previous study sample were interviewed in a qualitative study design. Content analysis indicated that individuals frequently decreased their activity participation on entry to higher education, but some re-incorporated activity into their lifestyles over subsequent months. Many influences on activity patterns were discussed, including the negative impact of transition periods such as the summer vacation. Data analysis led to the development of the Narrative Integration Theory, which describes motivation to participate in physical activity as being influenced by the immediate affective reaction to the experience. This is reciprocally related to interacting personal, cultural, environmental and social influences and their integration into a sense of identity. Positive experiences are required to alter negative perceptions and to build feelings of competence in relation to activity participation. This thesis provides further understanding of the challenges to activity behaviour experienced by female students. Decisions relating to uptake of activity and continued participation are frequently made with conscious processing and reflect complex issues relating to personal identity and self-evaluations.
The pain of rheumatoid arthritis: the different perspectives of patient and rheumatologist.
(Queen Margaret University, 2005) Howden, Stella
The chronic pain associated with rheumatoid arthritis (RA) is identified by patients as a priority for treatment and is said to shape their illness experience. However, review of the literature reveals that little is known about patients' perspectives on pain in RA, with even less being known about how rheumatologists, the clinical experts in patient care, perceive this phenomenon. Increasing knowledge and understanding of patients' and rheumatologists' perspectives on pain can be used to try to influence their action/inactions as well as helping to identify patients' specific concerns and unmet needs. The aims of this study were: To describe patients' and rheumatologists' perspectives on the meaning of pain in RA; To explore how these pain meanings are constructed; and To consider the implications of these constructions for pain management. This interpretive, qualitative study used semi-structured interviews to generate accounts related to respondents' perspectives on pain in RA. Purposive sampling was used to select a heterogeneous group of patients with RA (n=29) and rheumatologists (n=16). Thematic analysis was used inductively to generate findings using a cumulative, constant comparative technique (Strauss and Corbin, 1998). Both patients and rheumatologists presented multiple pain meanings but generally viewed pain as an expected symptom of the disease, both being resigned to the belief that most patients would have some degree of daily pain. Additionally, both groups considered the pain experience to have a pervasive, negative impact on life, potentially threatening the patient's concept of 'self'. In contrast, patients' and rheumatologists' pain meanings regarding clinical topics were not similar. Patients' views of medical responsibility were narrowly difined, rooted in western biomedical conceptions of pain and were influenced by experiences of clinical interactions. Accordingly, patients viewed the rheumatologist to be responsible only for 'legitimate' pain i.e. pain associated with the body and disease processes. Rheumatologists, on the other hand, presented a more comprehensive understanding of pain by incorporating psychological and social theories along with an associated 'ideal' model of care (reflecting a biopsychosocial approach). Consequently, they identified eclectic roles/responsibilities for themselves in patient management. However, rheumatologists viewed this 'ideal' as difficult to attain in the context of their experiences of clinical work where multiple constraints were perceived to exist, such as difficulties in deciphering pain, the perception of limited resources (e.g. time) and organisational barriers. In light of this, their role was often reduced to focusing simply on disease management, thus displacing the 'ideals' of patient-centred care and perpetuating the dominant biomedical discourse of pain in the clinical context. This thesis adds to the body of knowledge about patients' perspectives on pain when they live with a chronically painful condition and patient barriers to reporting pain. New findings are presented regarding the medical experts' conceptions of pain; in particular, those related to complex clinical work. The findings also identify areas of unmet need regarding patients' knowledge of pain, pain management and of the roles and responsibilities of healthcare professionals. Suggestions are made for further work in the areas of investigating patient barriers to reporting pain; exploring patient perspectives on self-management and using alternative research methods to complement and develop the findings from this study.
Skill acquisition in people with chronic upper limb spasticity after stroke
(Queen Margaret University, 2006) Van Wijck, F M J.
Background After a stroke, a considerable proportion of people experience upper limb (UL) impairments, which may affect their activities of daily living. Focal spasticity is common, for which botulinum toxin-type A (BTX-A) is used increasingly. However, published randomised controlled trials have not used valid outcome measures to assess the effects of BTX-A on spasticity and have hardly explored its impact on UL function. The primary aim of this thesis was to investigate whether task-specific UL practice in the form of an evidence-based, functional skill acquisition programme, administered after BTX-A, would have any differential effects on upper limb spasticity or functional UL activity in people more than six months after stroke. The prerequisites were to: 1) clarify the definition of spasticity, 2) pilot a novel biomechanical spasticity measurement device, 3) standardise the assessment of arm function, 4) systematically review the literature on the effects of BTX-A and 5) compile an evidence- and theory-based skill acquisition programme. Methods Design: randomised controlled feasibility study with four repeated measures and a blinded assessor. Fourteen participants (time after stroke: range 1.4 -11.0 years) gave informed consent and were randomised into either the experimental group (EG: BTX-A plus skill acquisition) or the placebo control group (CG: BTX-A plus inflatable arm splint). Outcome measures were: Action Research Arm Test, Canadian Occupational Performance Measure, grip force of the affected hand, Stroke Impact Scale, EMG of the elbow flexors, biomechanically measured resistance to passive movement and Ashworth scale. Outcomes were assessed at baseline and weeks 4, 7 and 13 following BTX-A injection. Differences in change between the two groups were analysed using the Mann-Whitney U-test. Applying the Bonferroni correction for three repeated measures yielded a critical p-value of 0.017. Results At baseline, there were no significant differences between the two groups in any of the dependent variables. Compared to the CG, the EG improved in self-reported hand function between baseline and week 4 (median change 25%, range 0 to 30% vs. CG: median change 0%, range -10 to 0%; p=0.04). The EG also improved in arm function between baseline and week 7 (median ARA T change 4 points, range 1 to 8 points vs. CG: median change -1 point, range -3 to 0 points; p=0.003) as well as in self-reported ADL between baseline and week 13 (median change 11.3%, range 5 to 20% vs. CG: median change 0%, range -2.5 to 5%; p=0.02). Only the differential improvement in ARAT by the EG reached statistical significance. There were no significant differences between the two groups in any of the other outcome measures. Although the programme was perceived as intensive, most participants in the experimental group had found the intervention to be enjoyable. Conclusion The main finding of this study was that people with severe and chronic upper limb spasticity may still improve in functional activity involving their affected arm, using a combination of BTX-A and a functional skill acquisition programme - without exacerbating spasticity. BTX-A alone did not improve upper limb activity in this study. Implications for clinical practice and research were discussed.
Chronic Patellofemoral Pain Syndrome: A randomised controlled trial based on the international classification of functioning, disability and health
(Queen Margaret University Colege, 2006-08) Syme, Grant
Signal detection theory in the study of nociceptive and pain perception processes
(Queen Margaret University, 2008) Tan, Chee-Wee
Signal detection theory (SDT) measures (discriminability and response bias) have been proposed to be valid for determining pain perception changes. The construct validity of SDT measures applied to pain perception studies has been questioned on three grounds: interpretation, methodology and theory. Multiple interpretations are possible for the combinations of discriminability and response bias change when the magnitude-rating scale is used for pain perception studies. This is resolved by utilising the confidence-rating scale. The problem of comparability of results between the two scales is bridged by Irwin & Whitehead's (1991) common analytical framework. The results of this thesis supported the framework's prediction that both scales are comparable. Therefore, the confidencerating scale was used for all studies within this thesis for interpretational clarity. Response bias data were not analysed in this thesis due to data artefacts created by correction methods for zero proportions in response categories. Methodologically, the construct validity of discriminability is influenced by the research design and procedures. Therefore, the following procedures were adopted to address weaknesses in previous studies. The one-interval confidence-rating task was used with a six-category confidence-rating scale and post-trial feedback. Based on a methodological study conducted within this thesis, the trial number was pragmatically reduced from 40 trials to 17 trials per stimulus intensity. This trial number reduction would not alter the mean and variance of the data sufficiently to influence the outcome of inferential statistical testing performed. Due to the novel use of the Quantitative Sensory Testing machine for the signal detection study procedures, accuracy and precision study on the machine was performed. This thesis found that the accuracy, repeatability and reproducibility of the machine in generating noxious thermal stimuli is excellent for the purposes of this thesis. Machine error is eliminated as a major source of variance for the thesis results. Theoretically, critics have challenged the construct validity of discriminability as an indicator of pain perception alteration. This thesis examined this issue in two separate contexts: 1) discriminability change as a correlate of local anaesthesia and, 2) discriminability as a correlate of psychological factors (depression and anxiety) in chronic low back pain (CLBP) sufferers. The results failed to establish the construct validity of discriminability for both contexts. However, the higher discriminability in CLBP sufferers compared to healthy individuals is in contrast to past research and warrant further investigation. This thesis addressed the construct validity issues through theoretical, methodological and interpretational modifications. A more robust analysis of the construct validity issue was facilitated. Caution is recommended on the use of discriminability as a pain perception measure until the construct validity issue has been satisfactorily resolved.
An assessment of neuromuscular performance, functional range of motion and quality of life characteristics in children diagnosed with hypermobility syndrome
(Queen Margaret University, 2008-06) Fatoye, Francis A.
Introduction: Hypermobility syndrome (HMS) is a common cause of morbidity in children, with the knee most frequently affected by its symptoms. Impaired joint proprioception has been reported in adults with HMS. Muscle weakness, problems with school activities and abnormal gait patterns have been observed in children with this condition. It has also been suggested that activities of daily living and physical and sporting activities may be limited in children with HMS due to pain. To date, the factors associated with HMS in children have not been well reported. The relationships between impairments, function and quality of life (QoL) have not been investigated in children with this condition. The purpose of this study was to identify the range of neuromuscular performance, functional range of motion (ROM) and QoL indices, and investigate the relationships between these features in children with HMS. A purpose-built motorised device was developed and validated for the assessment of knee joint proprioception as an integral part of the research programme. The test-retest repeatability of various outcome measures used for the present study was also investigated in healthy children and those with HMS. Methods: A cross-sectional study was conducted. Twenty nine children with HMS and 37 healthy children (aged 8 – 15 years) were investigated for neuromuscular indices, functional ROM and QoL. Knee joint kinaesthesia (JK) and position sense (JPS) were examined using a motorised device, muscle torque was tested with a digital myometer, passive ROM was measured with a universal goniometer and functional ROM was assessed using the VICON camera system. Pain intensity and QoL were measured using the Coloured Analogue Scale and the Paediatric Quality of life Inventory respectively. Mann-Whitney U tests and independent t-tests were performed to determine the differences between the two groups. The relationships between pain and each of the following: neuromuscular impairments, functional ROM and QoL were examined in children with HMS. The correlation between Beighton scores and each outcome was also evaluated in children with HMS. Results: Knee JK and JPS were significantly poorer (both p < 0.001) in children with HMS compared with the controls. Significantly reduced (p < 0.001) knee muscle torque was also observed in children with HMS. Pain intensity and passive knee ROM were significantly higher (both p < 0.001) in children with HMS. They also demonstrated significantly increased knee extension, reduced knee flexion in loading response and during maximal knee flexion of walking (all p <0.001). Moreover, the overall QoL perception and all the domains were significantly poorer (p range < 0.001 to 0.008) in children with HMS than the controls. No relationship (r range = -0.065 to 0.271; p range = 0.106 to 0.985) was found between pain, neuromuscular impairments and functional ROM in children with HMS. However, a significantly strong negative relationship (r = -0.65; p = <0.001) was established between pain and QoL in children with HMS. In addition, no relationship (r range = -0.014 to 0.315; p range = 0.112 to 0.895) was observed between Beighton scores and neuromuscular impairments, functional ROM and QoL in children with HMS. Conclusions: Children with HMS, compared with their healthy counterparts had knee joint proprioception and knee muscle torque deficits, increased passive knee ROM and pain intensity. Abnormal walking patterns (increased knee extension, reduced knee flexion in both mid stance and maximum knee flexion in swing phase during walking) were also found in children with HMS. They also presented with poorer QoL in comparison with the controls. Clinicians are to be aware of these identified features and should develop appropriate treatment intervention programmes for children with this condition.
Investigating the experiences of people with 'RSI: an internet based qualitative study
(Queen Margaret University, 2009) Watson, Mohinder
This internet-based qualitative study aimed to explore the subjective experience of having Repetitive Strain Injury (RSI) using an 'insider's perspective' (Schneider and Conrad, 1983). A purposive sample of RSI sufferers was recruited from an online support group covering diverse experiences across different age groups, gender, occupations, health care use and both clinically recognised RSI conditions and diffuse nonspecific RSI. Data triangulation involving documentary analysis of 468 archived email postings and 5 asynchronous online focus groups (n=57) was used to illuminate different aspects of RSI sufferers' experiences. Data from each method was thematically analysed and the findings integrated. Firstly, methodologically the internet medium was found to be a valuable additional tool for accessing illness experiences. Further, the essence of the RSI experience was conceptualised as a major life change and uncertainty affecting people's employment, social participation and ability to perform routine daily activities such as caring for themselves, family members and the home. Also changed were their identities, financial circumstances and relationships both in and outside of work. RSI was found in the study to bear the hallmarks of a chronic pain condition with attendant implications for management and diagnosis. The significance and meaning of a medical diagnosis was found to extend far beyond establishing 'what was wrong'; it became a quest for evidence to support the reality of their suffering and a means of defending threats to their integrity and identity. The implications of these findings are discussed in the context of current chronic pain management which places less emphasis on finding a diagnosis on the premise that regardless of aetiology, the problems encountered are similar across different chronic pain conditions, and it is more useful to restore functioning and reduce disability. However, this study shows that the significance of a diagnosis should not be under- estimated since for the individual with RSI, it carries multiple meanings and profound consequences for their daily lives.
The upper limbs after stroke: exploring effects of bilateral training and determinants of recovery
(Queen Margaret University, 2009) Morris, Jacqueline H.
Background: Bilateral task training (BT) may improve upper limb (UL) recovery on the affected as well as non-affected side in longstanding stroke however for acute stroke its effects on physical and psychosocial outcomes compared to unilateral training (UT) has not been clearly established. Furthermore, clinical and demographic factors that influence UL training responses and predict UL recovery are also unclear for acute stroke. PrimaryAims: To compare effects of BT and UT on: • ipsilesional and contralesional UL outcomes • anxiety, depression and health related quality of life (HRQOL) Secondary Aims: To investigate: • which clinical and demographic factors influence contralesional training responses • predictors of UL activity limitation over time for the sample as a whole • UL dysfunction as a predictor of HRQOL six months after stroke for the sample as a whole Design: Single-blinded randomised controlled trial, with outcome assessment at baseline (T1), after 6 weeks training (T2), and 18 week follow-up (T3). Participants: 106 in-patients randomised to receive BT (n=56) or UT (n=50) 2 to 4 weeks after stroke onset. Intervention: Supervised BT or UT for 20 minutes on 5 weekdays, over 6 weeks, using a standardised programme developed for the study. Outcome Measures: UL outcomes: Action Research Arm Test (ARAT), Rivermead Motor Assessment (UL scale), Nine-Hole Peg Test (9HPT). Secondary measures: Modified Barthel Index, Hospital Anxiety and Depression Scale, and Nottingham Health Profile. Assessment was conducted by a blinded assessor. Results: Between the two groups, there were no significant differences at T1 or T2 on any contralesional UL measure or on any psychosocial measure (p>0.05). At T3, 9HPT (p=0.03) and ARAT pinch section scores (p=0.04) in the UT group were significantly higher. None of the selected clinical or demographic factors significantly influenced training responses. BT significantly improved ipsilesional dexterity between T1 and T2 (p=0.04). For the sample as a whole, early ARAT and MBI scores significantly predicted contralesional ARAT scores at T2 and T3. Anxiety, depression and UL impairment significantly predicted overall HRQOL at T3. Conclusions: BT was no more effective than UT for the affected arm – in fact UT was more effective for dexterity. BT was more effective than UT, however, for short-term recovery of ipsilesional dexterity. Future studies should determine optimal BT characteristics for contraand ipsilesional recovery in stroke populations with differing levels of severity. Knowledge of predictors of UL activity limitation and HRQOL will enable therapists to target rehabilitation at factors that most influence these important outcomes.
The biomechanical optimisation (tuning) of the Ankle Foot Orthosis - Footwear Combination (AFO-FC) of children with Cerebral Palsy - the effects on sagittal gait characteristics, muscle and joint characteristics and quality of life.
(Queen Margaret University, 2010) Jagadamma, Kavi
The current study aimed to investigate influences of rigid Ankle Foot Orthoses (AFOs) on gait in children with Cerebral Palsy (CP), immediate effects of tuning of AFO-FC (AFO-Footwear Combination) on gait of children with CP, short-term effects of tuning of AFO-FC on gait, muscle and joint characteristics and quality of life in children with CP, and the feasibility of conducting a larger trial. The study included 11 healthy children and 8 children with CP. Outcome measurements included sagittal plane kinematics and kinetics derived using 3D motion analysis, Gait Deviation Index (GDI), physical examination, and quality of life using the PedsQL™ questionnaire. Data from healthy children demonstrated influences of shoes on gait parameters and the role of the ankle joint in adapting to various wedges and rockers during gait. When studying children with CP, beneficial effects of rigid AFO-FC on gait parameters were evident; these were thought to relate to the appropriateness of the AFO-FC and familiarisation with the prescription. Immediate effects of tuning varied according to gait patterns previously demonstrated with non-tuned AFO-FC; benefits to knee kinematics and kinetics were largely seen in legs with extended knee gait, followed by jump knee gait, and with poorest responses in legs with crouch knee gait. Short-term effects of tuning were evident when comparing measurements taken before and after two-to-four months of wearing the tuned AFO-FC. Barefoot walking demonstrated significantly improved walking speed. Stride-length improved when comparing tuned AFO-FC at baseline with the tuned AFO-FC following the intervention period. No short-term changes were seen in PedsQL™ scores, muscle and joint characteristics, and GDI. Feasibility issues were also identified. It was concluded from this exploratory trial that tuning of AFO-FC improved gait for children with CP, although initial gait pattern affected the amount of benefit. This was evident immediately after tuning and some parameters improved further after short-term intervention. A randomised controlled trial is required; power analysis indicates the need for a larger sample of 18 in each group to detect change in GDI with a medium effect size and at a power of 0.8 and p <0.05.
The influence of Obesity on outcomes following Total Knee Arthroplasty
(Queen Margaret University, 2012) Ayyar, Vandana
With the rising obesity and the increasing age of the population, a large proportion of patients who undergo Total Knee Arthroplasty (TKA) are obese. Knowing the health risks associated with obesity, it is important to determine if the outcomes of a TKA is compromised in obese patients. Significant discrepancies in the findings of previous studies assessing the effect of body mass index (BMI) on TKA outcomes were observed in a literature review, thus making it difficult to confirm an effect of obesity measured as BMI on the outcomes after TKA. This thesis comprises two studies which further explored the effects of BMI and other body composition measures on the outcome of TKA. 1. The aim of a retrospective epidemiological study was to assess the effect of BMI on patient reported outcomes after TKA. 2. The aim of the prospective cohort study was to assess the effect of body composition, measured by waist circumference (WC), waist to hip ratio (WHR), bioelectrical impedance analysis (BIA), ultrasonography (US) and BMI, on patient reported outcomes after TKA. It was concluded from these two studies that group division of obesity based on the classification of BMI greater or less than 30 kg/m2 could not identify an effect of obesity on outcomes. However, on using BMI as a continuous variable, an adverse effect of BMI on knee function and overall physical health was evident for higher BMI ranges. Body composition measures of BIA and US did not detect an effect of obesity for any outcomes. Effect of obesity detected by BMI and WC was similar. The negative association of BMI and outcomes observed was very weak across BMI ranges of 25-30 kg/m2and a significant association was achieved due to poorer patient reported physical function (indicated by Short Form 12 and Oxford Knee Score questionnaires) in some cases with very high BMI values (> 40 kg/m2). In addition to this finding, the lack of group difference when outcomes were evaluated across a BMI of 30 kg/m2in the two studies and the disparity between studies in the results when using a BMI classification of 30 kg/m2 supported the conclusion that a BMI classification across a cut-off value of 30 kg/m2 does not predict a poor result in obese after TKA. However, because of the limited number of highly obese (> 35kg/m2) participants in both studies of the thesis and often in previous studies, no definite conclusions regarding the effect of higher obesity levels on the outcome of TKR can be drawn from the studies in this thesis. Adequately powered future studies with more morbidly obese participants could give more definitive answers to the effect of BMI and other measures of body composition on outcomes following TKA.
Laboratory and Clinical Investigation into Lower Limb Ischaemic Pain, and the Effect of Transcutaneous Electrical Nerve Stimulation (Tens) on Measures of Pain and Walking Performance
(Queen Margaret University, Edinburgh, 2013) Seenan, Christopher
Aims: The aims of this programme of research are to investigate the subjective description of ischaemic pain and to investigate the effects of TENS on lower limb ischaemic pain and walking performance in patients with Intermittent Claudication (IC). Methods: Four studies were conducted: two in the laboratory and two clinical trials. Laboratory- The first study investigated the reliability of a method of inducing lower limb ischaemic pain in healthy volunteers, the modified Submaximal Effort Tourniquet Test (mSETT). The second investigated the effects of High Frequency TENS (HF-TENS) and Placebo TENS (P-TENS) on lower limb ischaemic pain induced using the mSETT in healthy volunteers. Clinical- The first clinical study investigated the effects of HF-TENS and Low Frequency TENS (LF-TENS) on measures of pain and treadmill walking performance in patients with Peripheral Arterial Disease (PAD) and IC. The second examined patients' experiences of using TENS at home for PAD and IC. Results: The mSETT was found to have good test-retest reliability and induce pain similar in quality to that experienced by patients with IC. The pain experience induced with the mSETT was reduced by both HF- and P-TENS compared to baseline. HF-TENS however was more effective compared to P-TENS in this regard, prolonging time to pain threshold and tolerance whilst reducing the levels of pain reported throughout. In patients with PAD and IC, HF and LF-TENS interventions were found to increase maximum walking distance on a treadmill compared to P-TENS. HF-TENS was also found to increase pain-free walking distance. The experience of using TENS in daily life was characterised by feelings of both benefit and disappointment. This was interpreted through the following themes: (i) 'masking, but not taking the pain away' and (ii) 'walking further, but not far enough'. Conclusions: The mSETT is a reliable method of inducing lower limb, ischaemic pain in healthy volunteers and could be useful for the purposes of pre-clinical analgesic trials and investigation of the ischaemic pain experience. HF-TENS was found to reduce mSETT pain indicating hypoalgesic effects of TENS in experimentally induced, lower limb ischaemic pain. HF and LF-TENS have potential as interventions that increase walking performance for patients with IC. If using TENS at home for IC, expectations of treatment effect need to be managed to avoid disappointment and feelings of frustration.
Accelerometry measurement of physical activity and sedentary behaviour in pre-school children
(Queen MArgaret Univrsity, 2013) Hislop, Jane
This thesis is based on six studies which address questions around the use of accelerometers to measure physical activity and sedentary behaviour of pre-school children: are shorter epochs more accurate? Which epochs are most accurate? Are there advantages to using triaxial accelerometers? Which cut-points are most accurate? Are different generations of Actigraph accelerometers comparable? What is the recommended wear time to provide a reliable estimate of habitual physical activity and sedentary behaviour? Analysis of 7-10 day accelerometry data, collected from 31 pre-school children (mean (SD) age 5.9 (0.7) y), suggests that shorter epochs (15 s) result in significantly greater estimates of time spent in moderate-to-vigorous physical activity (MVPA) in comparison to 60-s epochs (p <0.05). When compared against a direct observation method, Children's Activity Rating Scale (CARS), with 32 pre-school children (4.4 (0.8) y) during 1 hour of free-play, 15-s epochs were more accurate than 60-s epochs. Comparison of the triaxial RT3 against a uniaxial accelerometer, suggests no advantage of the RT3 accelerometer. The Puyau et al. (2002) cut-points had the 'best' agreement with estimates of sedentary behaviour, light intensity and MVPA against the CARS. Different generations of accelerometers were not comparable, however, application of a correction factor to the GT1M data (7164 = GT1M/0.91) may improve comparability of total physical activity. Finally, analysis of 7 day accelerometry data from 112 pre-school children (3.7 (0.7) y) suggests that 3 days of 7 hours provides a reliable estimate of habitual physical activity and that inclusion of weekend days is not necessary. This thesis highlights the implications that methodological decisions can have over apparent estimates of physical activity and sedentary behaviour and has made recommendations for accelerometry use. Ideally, there needs to be a move towards consensus, as, only by adopting standardised approaches to accelerometry use, will comparison between study outcomes become meaningful.
The role of the external factors on anterior cruciate ligament rehabilitation
(Queen Margaret University, Edinburgh, 2014) Darain, Haidar
Rehabilitation programme following anterior cruciate ligament (ACL) reconstruction is multifaceted and may be influenced by a variety of factors. The role of the environment for care and the levels of supervision from physiotherapists on the outcomes of ACL rehabilitation, have not received robust attention in the literature. In this thesis, two trials were carried out to investigate the role of these factors on the outcomes of ACL rehabilitation. In the first trial, a total of 76 patients [hospital-based rehabilitation group, n = 48 (age: mean ± sd: 31.5 ± 12.1 yr, height: 1.74 ± 0.06 m, body mass: 78.2 ± 10.8 kg, waiting time: 37.3 ± 33.7 months) and community-based rehabilitation group, n = 28 (age: mean ± sd: 34.5 ± 9.9 yr, height: 1.71 ± 0.07 m, body mass: 75.2 ± 12.4 kg, waiting time: 31.1 ± 26.7 months)] self-selected themselves into the hospital- and the community-based rehabilitation programmes. The patients in both the hospital- and the community-based rehabilitation programmes were assessed by selected patient-reported outcome measures (PROMs) included IKDC, KOOS, K-SES, VAS and Lysholm at four different occasions (pre-surgery and at the 6th, 12th and 24th weeks post-surgically). Significant differences at early phase of rehabilitation (up to 12th week post-surgery) on PROMs of function, favouring the outcomes of the hospital-based rehabilitation programme compared to the community-based rehabilitation programme, were observed. However, no differences between the outcomes of the latter two programmes were observed across 24 weeks rehabilitation programme following ACL reconstruction. This suggested that community-care had offered a similar environment to the hospital for achieving the outcomes of rehabilitation. In the second trial, the patients in the hospital-based rehabilitation programme (n=48) were iii further randomly allocated to the fully-supervised and the minimally-supervised rehabilitation groups [ fully-supervised rehabilitation group, n=24 (age: mean ± sd: 32.2 ± 11.1 yr, height: 1.73 ± 0.07 m, body mass: 75.8 ± 10.7 kg, waiting time: 35.8 ± 29.4 months), minimally-supervised rehabilitation group, n=24 (age: mean ± sd: 31.0 ± 13.2 yr, height: 1.75 ± 0.06 m, body mass: 80.6 ± 10.7 kg, waiting time: 28.8 ± 25.1 months)]. The patients in both the fully-supervised and the minimally-supervised rehabilitation groups were assessed on four different occasions (pre-surgery and at the 6th, 12th and 24th week post-surgery) on estimates of function (single-leg hop), physical performance (peak force, rate of force development, sensorimotor performance and electromechanical delay) and musculoskeletal performance (anterior tibio-femoral displacement) alongside the selected PROMs. Significant differences during the early phase of rehabilitation (up to 12th week post-surgery), favouring outcomes of the fully-supervised rehabilitation programme on some aspects and the outcomes of the minimally-supervised rehabilitation programme on other aspects, were observed. However, similar knee function across 24 weeks rehabilitation was observed on the selected objective measures and PROMs amongst the outcomes of the latter two rehabilitation programmes. This indicated that the outcomes of ACL rehabilitation had not influenced by the levels of supervision from the physiotherapists. In short, the environment and the levels of supervision from rehabilitation team were less likely to influence the final outcomes of ACL rehabilitation.
Interrelationships and Effects of Accelerated Rehabilitation Conditioning and Gene Polymorphism on Functional and Physical Responsiveness of People Recovering from Anterior Cruciate Ligament Reconstruction Surgery
(Queen Margaret University, Edinburgh, 2014) Alkitani, Abdulhameed
Chapter one of this thesis offered a general insight on the anterior cruciate ligament (ACL) injury and the outcome measures of ACL rehabilitation while chapter two was a systematic review on the effects of “accelerated rehabilitation” after ACL reconstruction surgery. The review concluded that 5 out of 10 randomised control trial studies had demonstrated moderate relative effect sizes in terms of improved knee laxity, neuromuscular performance, range of motion and some patient-reported outcome measures following accelerated rehabilitation for patients with ACL reconstruction. Chapter three was a systematic review in which the genetic influence on responsiveness to strength conditioning and the outcomes of knee after ACL reconstruction were investigated. The findings revealed that intra-genotypic responses to strength conditioning were heterogeneous and that duration, intensity and frequency of strength conditioning were factors that contributed to the differential responses of genotypes in regulating gains in strength.
Resistance (exercise) training in non-dialysis dependent chronic kidney disease (ckd stage 3) and validation of ultrasound in the measurement of muscle size and structure in haemodialysis patients (ckd stage 5)
(Queen Margaret University, Edinburgh, 2014) Geneen, Louise
AIM: This thesis set out to make an original contribution to knowledge with regard to methods of assessing muscle size and architecture in the CKD and ESRD population, and to assess the ability to improve the muscle size and architecture, and symptoms of uraemia, by implementing an anabolic intervention (resistance exercise training) in the CKD population. OUTCOME MEASURES: Ultrasound was shown to have high validity (against gold standard MRI measures; ICCs: VLACSA 0.96, VL depth 0.99, fat depth 0.98) and intra-rater reliability (ICCs: VL depth 0.98, total muscle depth 0.97, fat depth 0.99; MDC: VL depth 0.14cm, total muscle depth 0.19cm, fat depth 0.22cm) in measuring regional body composition at the mid-VL site in the CKD population. There were significant (p<0.01) correlations between US-derived measures of (mid-VL) muscle size and architecture with strength and function (larger muscle mass and/or pennation angle positively correlated with higher strength and/or functional performance). Patient-reported uraemic symptoms were worse (p<0.01) in those with reduced strength and/or function. INTERVENTION RESULTS: An anabolic (resistance training) intervention (12-weeks, randomized to once [RT1 n=7] or three times [RT3 n=10] per week, 80%1RM) brought about significant improvements over time (p<0.01) in all measures of muscle size and architecture (VL depth, total muscle depth, VLACSA, pennation angle). Interaction effects (group*time) were only seen in pennation angle (p<0.05) and VLACSA (p<0.01) where RT3 gains were greater than RT1 from week 8 onwards. All measures of strength, function, and uraemic symptoms improved over time (p<0.01) with no interaction effects (no difference from greater training frequency/ volume). CLINICAL AND RESEARCH IMPLICATIONS: The intervention results suggest implementing a RT form of “prehabilitation” in early stage (CKD3) patients just once per week is sufficient to bring about statistically and clinically important changes in strength and function that benefit the patient through reduced frequency and/or intrusiveness of uraemic symptoms (improved health-related quality of life), with minimal time-commitment. Further research should examine if there is additional benefit to the significantly greater increases in VLACSA and pennation angle observed in RT3, with regards to long-term maintenance of functional improvements, and whether an RT1 or RT3 programme delays the progression of CKD, the need for RRT, and patient mortality.
Physical activity, physical function and arterial stiffness of people undergoing maintenance haemodialysis for stage 5 chronic kidney disease
(Queen Margaret University, Edinburgh, 2015) Prescott, Sean
This thesis addresses current issues regarding assessment of physical activity (PA) and physical function (PF) status of haemodialysis (HD) patients, specifically: What is the recommended wear time to provide a reliable accelerometer estimate of habitual PA and sedentary behaviour? Can similar outcomes from different accelerometers be used interchangeably? Do subjectively and objectively estimated PA outcomes agree closely enough to be pooled? Which PF assessments are potentially most ‘useful’? This thesis also explores potential risk factors of arterial stiffness, a strong predictor of mortality in this population. A PA reliability study involving 70 maintenance HD patients (55.9 ± 15.7 years) over a seven-day monitoring period indicated one dialysis day and two non-diaysis days with a minimum of eight hours wear per day would provide reliable estimates of PA and sedentary behaviour regardless of accelerometer employed, and allowed 90% sample retention. Concordance studies indicated broad agreement for similar outcomes obtained via ActivPAL and Actigraph GT3X accelerometers but they were not interchangeable. ActivPAL is recommended for monitoring steps taken and time seated, Actigraph activity count output for total/overall PA. Questionnaire and accelerometer estimated PA outcomes may not be used interchangeably or pooled. More of the shared variance of physical performance was explained by clinical, demographic and habitual PA factors than for self-reported functional status thus recommending the former. Age, blood pressure and HD vintage were determinants of arterial stiffness, however PA and cardiorespiratory fitness did not appear to be risk factors in this sample. This thesis makes clear recommendations regarding implementation of PA and PF assessment methods, and illustrates their application on sample retention, as well as characterising and potentially identifying individuals at risk of poor outcomes. Emergence of HD vintage as a risk factor for arterial stiffness underscores the need for further research into adjunctive lifestyle interventions to manage health threats in this population.
Myofascial trigger points and innervation zone locations in upper trapezius muscles
(Queen Margaret University, Edinburgh, 2016) Barbero, Marco
Myofascial pain syndrome is characterized by sensory, motor and autonomic symptoms, and a myofascial trigger point (MTrP) is considered the principal clinical feature. Clinicians recognise myofascial pain syndrome as an important clinical entity but many basic and clinical issues need further research. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Authors also suggest that MTrPs are located in the innervation zone (IZ) of muscles. The aim of this thesis was to describe both the location of MTrP and the IZ’ locations in the upper trapezius muscle. The hypothesis was that distance between the IZ and the MTrP in upper trapezius muscle is equal to zero. This thesis includes two preliminary studies. The first one address the reliability of surface electromyography (EMG) in locating the IZ in upper trapezius muscle, and the second one address the reliability of a manual palpation protocol in locating the MTrP in upper trapezius muscle. The intrarater reliability of surface EMG in locating the IZ was almost perfect; with Kappa = 0.90 for operator A and Kappa = 0.92 for operator B. Also the interrater reliability showed an almost perfect agreement, with Kappa = 0.82. Both the operators conducted 900 estimations of IZ’ location through visual analysis of the EMG signals. The reliability of an experienced physiotherapist using a manual palpation protocol in locating the MTrP in the upper trapezius was established. An anatomical landmark system was defined and MTrP’ location established using X and Y values. The ICC values were 0.62 for X and 0.81 for Y. Twenty-four subjects with MTrP in upper trapezius were enrolled for this latter study. MTrP’ and IZ’ locations were described in 48 subjects. MTrPs were located in well-defined areas of the upper trapezius, showing a typical location with a mean distance from the IZ of 10.4 ± 5.8 mm. MTrPs in the upper trapezius are proximally located to the IZ but not overlapped by it (p = 0.6). These results extend the body of knowledge regarding the phenomenon of MTrP iperalgesia.
Outcome measures of physical function in adult unilateral lower limb amputees during prosthetic rehabilitation: use in clinical practice and psychometric properties
(Queen Margaret University, Edinburgh, 2016) Scopes, Judy
The aim of this thesis is to inform clinicians and researchers of the reliability and responsiveness of the most commonly used outcome measures in prosthetic rehabilitation in the UK. In addition, this thesis supports the call for more studies of high methodological quality to provide evidence of the psychometric properties of outcome measures of physical function in lower limb amputees. A survey (study I) of Allied Health Professionals established that the outcome measures used most often during prosthetic rehabilitation in the UK were: the Timed Up and Go (TUG), a timed walk test, the Locomotor Capability Index (LCI) and its modified version (LCI-5), the Socket Comfort Score (SCS) and the Special Interest Group in Amputee Medicine (SIGAM) Mobility Grades. A standardised quality checklist (COSMIN) was used in a systematic review (study II) to measure the methodological quality and strength of evidence of the published literature that reported on the psychometric properties of outcome measures used to measure physical function during prosthetic rehabilitation. The review found mixed methodological quality ratings and many studies with small sample sizes rendering the strength of the evidence indeterminate. A limited number of studies commented on limits of agreement and measurement error when reporting on reliability. Even fewer studies reported on responsiveness with only one reporting minimally clinically important difference (MCID) values. Values for consistency, agreement and measurement error, were calculated for the top five commonly used outcome measures as identified from the survey, using a test-retest study design with a period of 7 days between tests (study III). Minimum detectable change (MDC) values were calculated for the SIGAM, LCI-5, TUG and 2MWT. The EQ-5D-5LTM, a measure of the global health of the respondent, was also included as knowledge of its psychometric properties in a population of pwLLA is unknown. However, reliability could not be confirmed for the EQ-5D-5L or the SCS in this population. A longitudinal study (study IV), based during the early rehabilitation period (mean 84 days) following provision of a primary prosthesis, gathered data to calculate indices of responsiveness for the same six outcome measures. Effect sizes were presented for five measures: SIGAM, LCI-5, TUG, 2MWT, SCS and EQ-5D-5L. Minimal clinically important difference values were also presented for the first time for all the outcome measures in this population. A patient reported change questionnaire was used as the anchor in a Receiver Operator Characteristic (ROC) curve analysis to establish the MCID values.
Effects of reconstruction surgery and individualised rehabilitation on neuromuscular, sensorimotor and musculoskeletal performance in patients with anterior cruciate ligament deficiency
(Queen Margaret University, Edinmburgh, 2016) Yates, Christopher
CONTEXT: Rehabilitation following Anterior Cruciate Ligament (ACL) Reconstruction (ACLR) benefits most patients electing ACLR surgery. Contemporary practice offers limited adaptation of the service to the needs of individual patients. This thesis focuses on a Randomised Control Trial (RCT) that evaluated the effects of a novel formulation of patient-centred musculoskeletal rehabilitation involving the Performance Profiling Technique (Butler and Hardy, 1992). Performance Profile Management (PPM), a programme of rehabilitation, was adapted to incorporate patient-physiotherapist negotiation and agreement on decisions for subsequent rehabilitation and treatment strategies. Therefore, the primary aim of the research was primarily to assess the efficacy of individually-tailored, self-managed rehabilitative care (PPM) in comparison to contemporary (CON) clinical practice. The latter would facilitate an understanding of patient needs and verify the circumstances in which rehabilitation might be enhanced by allowing individuals to play a key role in designing their treatment and recovery. A secondary clinical aim was to evaluate the strength of relationships amongst Patient-Based Outcome Measures (P-BOMs) and Clinician-Based Outcome Measures (C-BOMs). Currently, it is unknown which combination of outcome measures (P-BOMs or C-BOMs) delivers an optimum global assessment of functional and physical performance capabilities during patients' post-surgical rehabilitation. A clinically-relevant and significant association amongst P-BOMs and C-BOMs might indicate correct scaling of patients' own capability perceptions with those measured using objective assessment methods (C-BOMs) and endorse the utility for the clinical use of P-BOMs.
Peri-surgical changes in functional capabilities associated with reconstructive knee surgery
(2017) Peer, Maria
This thesis, using a meta-analytical review of the literature and a controlled longitudinal cohort trial, addresses a knowledge gap regarding peri-surgical changes in self-reported and objective measures of physical function, neuromuscular and sensorimotor performance capabilities of patients undergoing total knee arthroplasty (TKA). Responsiveness and patterns of change in perceived exertion (Borg Category-Ratio Scale [CR-10]), perceived task duration (PTD) and neuromuscular performance during an intermittent isometric fatigue task (IIF) were also investigated. Twenty-six individuals (50 % female, 66.8 ± 1.4 years) underwent evaluation at 3 and ~12 weeks pre-surgery, and again at 6 and 12 weeks post-operatively. Patient-reported outcomes including the Knee injury and Osteoarthritis Outcome Score (KOOS), Oxford Knee Score (OKS), 36-Item Short Form Health Survey (SF-36), Performance Profile and International Physical Activity Questionnaire demonstrated significant changes in peri-surgical functional status. Significant time related interactions between operated and control legs were observed for range of movement, knee circumference and neuromuscular performance indices of volitional peak force (PFV), rate of force development, rate of force relaxation, electromechanical delay activation and relaxation (vastus medialis). Items of the KOOS (pain and activities of daily living), OKS and SF-36 (role emotional) and PFV demonstrated significant differences at three weeks pre-surgery compared to baseline. Differences in the rate of change of performance at week 6 and week 12 post-surgery contributed most to the overall interactive- and main effect-related changes in the selected outcome measures. In estimating patient perceptions of exercise stress in an environment mimicking aspects of self-managed rehabilitative conditioning, the Borg Category-Ratio Scale and PTD showed a differential pattern of change during a novel IIF, with the latter perceptual tool showing congruency with patterns of objective fatigue-related loss of performance. This thesis provides the most comprehensive evaluation of peri-surgical physical function using patient-reported and objective (physical and physiological performance) outcomes. Further, this study is the first to contribute insight into how people undergoing TKA perceive exercise exertion and task duration. The research presents possible directions of future research to optimise physical function of TKA recipients.