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Physiotherapy

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/7190

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End date: 2019

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Now showing 1 - 10 of 28
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    FOOT DROP AND FATIGABILITY IN PEOPLE WITH MULTIPLE SCLEROSIS
    (Queen Margaret University, Edinburgh, 2019) Andreopoulou, Georgia
    People with Multiple Sclerosis (pwMS) often experience walking impairments such as foot drop which can lead to trip and falls. Foot drop can be either transient and is often induced by exercise (fatigability) in pwMS whose walking ability is not affected and can become more fixed with disease progression. The overall aim of this PhD was to explore foot drop, its presence in pwMS with different disability levels and the psychometric properties of outcomes used to evaluate walking impairments. The first study in this thesis was a systematic review into the level of evidence for the psychometric properties of walking measures that have been used to evaluate the effect of assistive technology such as FES for foot drop in MS. Moderate to strong psychometric evidence was found for the Multiple Sclerosis Walking Scale, Timed 25 Foot Walk, 6 minute and 10 meter walk tests. There were no psychometric studies for three-dimensional (3D) gait kinematics in pwMS even though it was one of the most frequently used outcome measures. The second study assessed the test-retest reliability of 3D ankle kinematics and spatiotemporal parameters in pwMS, with low Expanded Disability Status Scale (EDSS < 3.5) and in those with moderate to high EDSS (EDSS: 4-6). Reliability was excellent for ankle kinematics and spatiotemporal parameters in both groups, with lower minimal detectable change (MDC95%) values in the low EDSS group compared to the higher EDSS group. The third study investigated transient exercise induced foot drop in highly physically active pwMS (EDSS < 3.5) and health controls using 3D kinematics. It was found that 6 out of 15 pwMS and none of the healthy controls presented this phenomenon. The fourth study examined the direct orthotic effect of FES during dual-tasking (i.e. walking combined with a cognitive task) and after inducing fatigability. Low to moderate effect sizes indicated that the direct orthotic effect was higher under dual-task and fatiguing conditions but this needs to be confirmed in appropriately powered studies. In conclusion, the studies in this thesis have contributed to the psychometric evidence of gait kinematics in pwMS, have objectively documented the presence of transient foot drop in highly physically active pwMS and orthotic effect of FES under a variety of conditions simulating the perceived benefits in ‘real life’ reported by FES users. Key words: multiple sclerosis, foot drop, fatigability, FES, psychometric properties, 3D gait kinematics
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    FRAILTY, CARDIOVASCULAR FUNCTION AND RISK OF FALLING AMONGST PATIENTS WITH STAGE 5 CHRONIC KIDNEY DISEASE ON HAEMODIALYSIS
    (Queen Margaret University, Edinburgh, 2019) Zanotto, Tobia
    This PhD thesis explores the risk of falling of stage 5 chronic kidney disease (CKD-5) patients receiving haemodialysis (HD) therapy. Previous research has suggested that multiple risk factors such as older age, comorbidities, polypharmacy, and frailty contribute primarily to the increased risk of falling in this clinical population. However, HD patients are also characterised by severe cardiovascular disease burden that often manifests with symptoms of orthostatic intolerance, impaired blood pressure control and syncope, all of which may be implicated in the aetiology of falling. The aim of this thesis was to address important research questions, such as: Are frailty and its physical function/activity components associated with falling in CKD-5 patients on HD? Are baroreflex function and the cardiovascular responses to orthostasis also associated with falling? What is the relative importance of frailty and cardiovascular function as potential exercise-modifiable risk factors for falls in this patient group? A prospective observational study involving 76 prevalent HD patients (61.1±14 years) confirmed previous observations that CKD-5 patients on HD are at higher risk of falls compared to the non-uraemic population, as 37.7% of research participants experienced at least one fall during a 12-month follow-up, and the incidence of falls recorded was 1.16 falls/person-year. Although participants classified as fallers did not appear to differ from non-fallers in single physical function measures such as timed-up and go (TUG), 5 repetitions chair sit to stands (CSTS-5), or muscle strength, frailty and lower postural balance were associated with increased odds of falling. In addition, baroreflex function indices reflecting frequency of baroreflex activation, as well as the blood pressure response to a five-minute 60° head-up tilt test (HUT-60°) were associated with increased odds of falling and a greater number of falls. More importantly, we showed that modelling the risk of falling by adding a cardiovascular function variable to a frailty-only model improved significantly the prediction of number of falls experienced by CKD-5 patients on HD. Overall, this PhD thesis revealed that cardiovascular mechanisms implicated in the short-term regulation of blood pressure showed a greater relative importance than frailty in predicting falls in the study participants. These findings challenge the current assumption that frailty is the primary factor involved in the aetiology of falls in CKD-5 patients on HD. The clinical implications of this novel observation are also discussed from a preventive and rehabilitative perspective. Key words: Stage 5 chronic kidney disease, haemodialysis, falls, frailty, cardiovascular function.
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    ENHANCING KINEMATIC SHOULDER FUNCTION EVALUATION THROUGH A VALID, SIMPLE AND CLINICALLY APPLICABLE SCORE
    (Queen Margaret University, Edinburgh, 2019) Pichonnaz, Claude
    Introduction Controversies surrounding Patient-Reported Outcome Measures (PROMs) and the cumbersome-nature of movement analysis-based (MAB) methods for shoulder function evaluation make the exploration of alternatives needed. Research aimed at the simplification of MAB outcome measures had demonstrated previously that the B-B Score, which relies on two movements only, was valid for out-of-laboratory evaluations of shoulder function. Nevertheless, further investigations were needed to optimise testing procedures, test the B-B Score’s capability of acquisition using a user-friendly device, and critically evaluate its measurement properties in comparison to current methods. Objective The aim of this thesis was to develop and assess the simplest possible MAB shoulder function scoring procedure for clinical measurement. Methods The research included four steps: 1) Optimisation of the B-B Score testing procedure (Phase 1 study [data-driven]), 2) Comparison of measurements using a smartphone or an inertial sensor system (Phase 2 study [data-driven]), 3) Validation in frequentlyoccurring pathologies (rotator cuff conditions, instability, fracture, capsulitis) (Phase 3 study [data-driven]), 4) Benchmarking of the new approach with concurrent MAB outcome measures and PROMs (literature review). Results Amongst the tested methods, the B-B score was optimised by using the mean of three replicates in the computation of the range of accelerations by angular velocities. The comparison of easily-used smartphone and reference device showed non-significant differences and excellent relationships between measurements (Intraclass Correlation Coefficient [ICC=0.97]). The smartphone’s B-B Score intra-rater and inter-rater reliability was excellent (ICC=0.92), but limits of agreement could reach up to ±19.4%. The score was responsive (area under the curve [AUC≥0.70]) and demonstrated excellent discriminative power between patients and controls (AUC≥0.90), except for shoulder instability (AUC=0.67). The correlations with PROMs were moderate to high. The benchmarking established that the measurement properties of the B-B Score compared equivalently with those of PROMs and MAB outcome measures, except for shoulder instability. Conclusion Shoulder function can be efficiently evaluated using a simple scoring procedure performed with a smartphone, which facilitates its objective assessment. Further research is needed to understand how best to reduce the effects of variability associated with single measurements in order to optimise clinical applicability and to explore the B-B Score’s properties in other situations requiring functional assessments of the shoulder. . Keywords: shoulder, shoulder function; outcome assessment; validation studies, reliability and validity; inertial sensors; smartphone sensors; body-worn sensors; kinematics; sensitivity and specificity.
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    QUANTILE REGRESSION AS A METHODOLOGY FOR UNDERPINNING PROPORTIONATE UNIVERSALISM
    (Queen Margaret University, Edinburgh, 2019) Rush, Robert
    In the social sciences, and beyond, we are often interested in the impact of factors on some outcome. These research questions of interest are traditionally addressed with linear regression, which informs on those factors impacting on the average. Frequently though the interest is not in the ‘average’ but with those in the tails of the outcome distribution, where for example the low performing or high scoring are contained. This is particularly the case when these analyses are to inform policies to improve on those low performing and the identification and targeting of possible interventions for this. Focusing solely on the average and applying interventions across the board can only widen the gap between those low scoring and better performing. These traditional modelling methods will not provide information on differential impact of a factor across the distribution and indeed can fail to identify important factors. In addition to the analysis suitable to the research question there are inherent linear regression model assumptions which must be met. To try and address this using traditional techniques by segmenting the data to assess factor impact is inefficient and can have power implications. Also a logistic regression approach provides a cut-point with those on either side, regardless of their proximity to that cut-point being in one group or the other. Therefore to understand the effect of factors across the outcome distribution we must use different techniques and a quantile regression approach offers an assessment across the outcome distribution and can identify those factors which are influential at different locations on that distribution and is also robust to the assumptions which dog those other traditional methods. Thus with a principled method such as quantile regression analysis, there exists an enormous potential to inform not just basic policy questions, as to relationships amongst factors and outcome, but with the resulting more nuanced answers provide those key policymakers with a more complete evidence base with robust informative estimates on those mediating factors and on who to target.
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    Pre-surgery exercise-conditioning (P–SEC) in patients waiting for Total Knee Arthroplasty
    (2018) Risso, Anna Maria
    Using a randomised controlled trial to assess efficacy, a ‘novel’ pre-surgical exerciseconditioning (P–SEC) programme was investigated in this thesis addressing the knowledge gap in the literature regarding pre-surgical conditioning for improving objective measures of physical performance (neuromuscular and sensorimotor) and self-reported outcomes in patients waiting to undergo total knee arthroplasty (TKA) surgery. Crosseducation (CE) effects measured in the untrained limb following the P–SEC intervention were also investigated.A single-centre, assessor-blinded randomised controlled study was conducted over an 11-month period. Forty-six participants waiting to undergo TKA surgery were enrolled and randomised into one of three groups (two intervention groups (P–SECIPSI (n = 15) and P–SECCONTRA (n = 17), in which the knee extensors of the leg awaiting surgery and the non-surgical leg, respectively, were trained) and one control group (n = 14), which received usual care practice of no training). Seventeen participants (out of 46) had been lost-to-follow-up. Participants underwent evaluation at four pre-surgery assessments: 12 weeks (T1), 2 weeks (T2), 1 week (T3) pre-surgery, week of surgery (T4) and at 6 weeks post surgery (T5). Objective measures of neuromuscular (electromechanical delay (EMD), rate of force development (RFD), peak force (PF)) and sensorimotor (force error (FE)) performance outcomes revealed statistically significant group x time x leg interactions with moderate to large gains (12% – 37%; ES = 2.0; p < 0.05) in the respective outcomes. No statistically significant (p > 0.05) group x time interactions were found for the patient reported outcomes as measured by the Oxford Knee Score (OKS), Knee injure and Osteoarthritis Score (KOOS), 36-Item Short Form Health Survey (SF-36v2TM), Pain Self Efficacy Questionnaire (PSEQ), Performance Profile (PP) and International Physical Activity Questionnaire (IPAQ). Small but approaching moderate (4% – 11%; ES = 0.1 – 0.4; p < 0.05) CE-related improvements in the physical performance outcomes (EMD, RFD, PF and FE) were also reported in the untrained limb. This thesis provides evidence that a novel approach to P–SEC which elicited statistically significant improvements in physical performance outcomes (neuromuscular and sensorimotor) in patients waiting for TKA surgery compared to a usual care control group. Furthermore, this study is the first of its kind to evaluate and confirm the presence of CE in this cohort of patients. The novel characteristics of P–SEC highlight the importance for revisiting contemporary pre-surgical conditioning. Limitations to the study included sample’ size attrition, with the potential for bias and inflated rates of Type II error. The thesis presents possible directions into the use of this ‘novel’ intervention in clinical practices and in other joint related conditions. Keywords: arthroplasty, sensorimotor, knee osteoarthritis, pre-surgical, neuromuscular, cross-education
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    THE EFFECTS OF ENHANCED SENSORI-MOTOR REHABILITATION ON INDICES OF FUNCTIONAL PERFORMANCE IN PATIENTS UNDERGOING TOTAL KNEE REPLACEMENT
    (2019) Moutzouri, Maria
    The primary aim of this thesis addressed a knowledge gap regarding whether sensori-motor training (SMT) stimuli implemented early post-surgery are capable of targeting persisting sensori-motor and neuromuscular deficits in TKR patients’ performance. Therefore, the effects of early enhanced sensori-motor training (ESMET) on self-reported and objective measures of physical function, sensori-motor, neuromuscular, and musculoskeletal performance capabilities of patients undergoing total knee replacement (TKR) were investigated. In order to assess the effects of SMT on patients’ functional mobility and sensori-motor function, as well as indirectly investigating the mechanism underpinning any observed effects, relevant outcome measures used in the literature were reviewed for their clinimetric properties. Indices of functional performance, as reflected by the Timed Up and Go Test (as primary outcome), balance-related performance, sensori-motor performance, neuromuscular performance, muscle size and knee ROM, as well as patient-reported measures (PROMs), were selected on the basis of their clinimetric utility to best reflect the outcome of the SMT intervention. A clinical survey of Greek physiotherapists’ perspectives revealed that contemporary usual care management of TKR-related rehabilitation incorporated in the majority of cases home-based exercises with emphasis on knee ROM and muscle strengthening (Moutzouri et al, 2016b). A first systematic review including studies with IIc-IV level of evidence (Moutzouri et al, 2016c), revealed that patients undergoing TKR surgery experience persisting deficits in static and dynamic balance and incidence of falls remain within the pre-surgery levels. In parallel, a second systematic review evaluating preliminary effects of contemporary functional physiotherapy programmes being augmented by SMT in TKR clinical population, revealed statistically significant greater effects for balance performance but not for functional capabilities. However, the number of studies that had met inclusion criteria was small (n = 5) and the nature of their designs, which had been as pilot studies in the majority of cases, precluded conclusive findings. Following preliminary investigations of reproducibility of measurement and related clinimetric characteristics of outcomes, the main aspect of the thesis reported on the findings of a novel randomised control trial (Moutzouri et al,2017), in which the effects of a newly formulated time-matched sensori-motor exercise training programme [ESMET] was compared with those from a functional exercise training programme [FET] (representing the control condition and usual care practice, and which have been characterised by the findings of the aforementioned clinical survey) during rehabilitation following TKR. Participants (n= 52) were allocated to 12-week programmes of rehabilitation, initiated in the second week post-surgery, and assessed at pre-surgery (0 weeks), 8 weeks post-surgery, and at 14 weeks post-surgery on outcomes which included indices of self-reported and objective measures of physical function, sensori-motor, neuromuscular, and musculoskeletal performance capabilities. The findings revealed significant advantages for the new sensori-motor focused rehabilitation on several outcomes (relative effect size range at 14 weeks post-surgery ~ 0.5 to 2.1), including a significant group by time interaction (F(1.7,82.5)GG = 11.0; p <0.005) for the study’s primary outcome (Timed Up and Go Test), favouring ESMET over FET by ~ 35 %. However, the study’ findings need to be interpreted with caution due to the single-blind nature of the study. Key words: total knee replacement; knee osteoarthritis, Rehabilitation; Balance; sensori-motor training
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    DETERMINING SELECTIVE VOLUNTARY MOTOR CONTROL OF THE LOWER EXTREMITY IN CHILDREN WITH CEREBRAL PALSY
    (2018) Balzer, Julia
    For physiotherapists working in neuro-paediatric gait-rehabilitation, improving motor control of the lower extremity is a major focus. Nevertheless, our understanding of selective voluntary motor control (SVMC) is in its infancy. This PhD project aimed to contribute to close this gap by investigating the nature of SVMC of the lower extremity in children with cerebral palsy (CP) and providing a psychometric robust yet sensitive measurement instrument for quantifying SVMC. The first study investigated the influence of SVMC and other lower extremity and trunk motor impairments on gait capacity using multiple regression-analyses. Although SVMC was not kept within the final model, these study results revealed the importance of SVMC in relation to muscle strength, trunk control and gait capacity. The aim of the second study was to establish validity and reliability of the German version of the ‘Selective Control Assessment of the Lower Extremity’ (SCALE). Although the psychometric properties of the German SCALE were good, information about its responsiveness is lacking. Accordingly, a systematic review was carried out to identify a SVMC measurement instrument with the highest level of evidence for its psychometric properties and best clinical utility. As the findings showed the absence of appropriate, responsive SVMC measures, the aim of the last study was to modify the existing SCALE to make it more sensitive. Due to the positive findings in relation to the psychometric properties of the SCALE, its procedure was combined with a surface electromyography Similarity Index (SI). The first validity and reliability results of the SCALE-SI are promising and serve as benchmarks when applying the SCALE-SI in future clinical and scientific practice. However, to use the SCALE-SI as an outcome measure for detecting therapy-induced changes of SVMC in children with CP, its responsiveness needs to be evaluated in future studies. Key Words: cerebral palsy, selective voluntary motor control, psychometric properties, lower extremity, gait rehabilitation
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    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.
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    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.
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