Physiotherapy
Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/7190
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Item 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.Item 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, GrantItem 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.Item Investigating the experiences of people with 'RSI: an internet based qualitative study(Queen Margaret University, 2009) Watson, MohinderThis 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.Item 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.Item 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.Item Signal detection theory in the study of nociceptive and pain perception processes(Queen Margaret University, 2008) Tan, Chee-WeeSignal 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.Item The pain of rheumatoid arthritis: the different perspectives of patient and rheumatologist.(Queen Margaret University, 2005) Howden, StellaThe 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.