Physiotherapy
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Item ASSESSING LOWER LIMB SOMATOSENSORY FUNCTION OF CHILDREN WITH UPPER MOTOR NEURON LESIONS(2024-12-11) Marsico, PetraThrough the somatosensory system, we receive information about the external and internal state of our body as the foundation of our feedback-control system for all motor activities. Therefore, somatosensory function is essential for motor control, and motor learning. Lower limb somatosensory function is particularly important for balance, gait and mobility. Different modalities of the somatosensory system can be impaired in children with Upper Motor Neuron (UMN) lesions. Therefore, we require child-friendly outcome measures to assess somatosensory function of the lower limbs that can be included in a toolbox for clinicians and researchers. Methods: An overview of the current state of knowledge was compiled on the basis of a systematic review. The systematic review analysed the psychometric properties of the available measures for assessing lower limb somatosensory function. Subsequently, an expert panel participated in a Delphi study to identify the most important modalities of lower limb somatosensory function in relation to motor outcomes. We developed standardised protocols to assess various somatosensory modalities and investigated validity, reliability, and feasibility in children with UMN lesions. We investigated the relationships between tactile function, body awareness, and motor outcomes. Finally, we developed a sensor-based tool to assess lower limb proprioception and assessed its validity, reliability, and feasibility. Results and conclusions: The toolbox provides outcome measures to assess six modalities of lower limb exteroception, proprioception, and body awareness in children with UMN lesions. The feasibility and psychometric properties of the investigated outcome measures are confirmed as good. The correlations between the individual somatosensory and motor function assessments vary greatly. Structural body awareness and joint position sense showed the highest relationship to motor activity and are included into the core toolbox. Further studies should investigate the validity, reliability, and feasibility of a tactile localisation tasks of the whole lower limb to assess body awareness.Item PLAYING-RELATED MUSCULOSKELETAL DISORDERS AMONG MUSIC STUDENTS IN EUROPE(2023) Cruder, CinziaBackground and aims: The achievement and improvement of musical competences and technical abilities to reach the highest levels of performance may expose music students to a wide range of playing-related musculoskeletal disorders (PRMDs). The main aim of the present thesis was to longitudinally identify the factors associated with increased risk of PRMD onset among music students enrolled in different pan-European music institutions. Further goals were to determine the prevalence and incidence of PRMDs amongst music students during their training, as well as to describe and characterise the study population. Methods: 850 students from 56 European conservatories and music universities completed a web-based questionnaire on lifestyle and physical activity participation levels, musical practice habits, behaviours toward prevention, health history and PRMDs, as well as psychological distress, perfectionism and fatigue. The onset of PRMDs was assessed prospectively at 6 and 12 months. Results: At baseline, 560 participants (65.0%) self-reported a positive history of MSK complaints in the previous 12 months, 408 (48.0%) of whom self-reported PRMDs. Self-reported PRMDs were significantly associated with coming from West Europe (RRR=4.524; RRR>1), being a first- or a second-year Masters student (RRR=2.747; RRR>1), having more years of experience (RRR=1.040; RRR>1) and higher rates of perceived exertion after 45 minutes of practice without breaks (RRR=1.044; RRR>1). The incidences of PRMD onset at 6 and 12 months were 28.8% and 49.0%, respectively. Longitudinally, changes in physical activity level (both increase and decrease; 6-month AOR=2.343, 12-month-AOR=2.346; AOR>1), increased levels of fatigue (6-month AOR=1.084, 12-month-AOR=1.081; AOR>1) and increased level of socially-prescribed perfectionism (6-month AOR=1.102; AOR>1) were significantly associated with PRMD onset. The presence of MSK complaints at baseline (6-month AOR=0.145, 12-month-AOR=0.441; AOR<1), as well as changes to BMI and to levels of psychological distress (12-month AOR=0.663 and 0.914, respectively; AOR<1) retarded the onset of PRMDs. Conclusions: Cross-sectional and longitudinal findings showing high prevalence and incidence of PRMDs amongst music students, have been critically appraised as potential correlates, determinants and factors in the development of PRMDs. The findings offer contextualisation for revisiting contemporary evidence-based preventive strategies and optimisation of tailor-made interventions aimed at minimising the impact of PRMDs.Item Development Of A Balance Recovery Confidence Scale For Community-Dwelling Older Adults(2022) Soh, Shawn Leng-HsienFalls are concerning issues for older people. There is a lack of instruments that measure balance recovery confidence. Balance recovery confidence refers to the perceived ability to arrest falls. Patient-reported outcome measures (PROMs) are used to obtain information directly from the person being cared for. The overall aim of this thesis is to present the development of a PROM that measures balance recovery confidence in community-dwelling older adults. Methods: A sequential series of steps was taken to develop the PROM. First, a literature review was done to understand the self-efficacy theory, types of falls-related psychological concerns, PROMs used, the role of balance recovery control and the development of a PROM for the construct of interest. Four studies were then implemented. The first study systematically reviewed existing falls efficacy-related PROMs for their development, content validity and structural validity. The second study assessed the feasibility of studying near-falls and balance recovery among community-dwelling older adults. The third study constructed and validated the content of the balance recovery confidence scale with 22 community-dwelling older adults and 28 healthcare professionals. The final study assessed the psychometric properties of the newly developed PROM with 84 community-dwelling older adults in Singapore. Results and conclusions: Existing falls efficacy-related PROMs lack high-quality evidence in their development and content validity. The systematic review affirmed an absence of a suitable PROM of balance recovery confidence for community-dwelling older adults. The feasibility study demonstrated that balance recovery was a relatable concept for older adults. A 19-item balance recovery confidence scale was constructed and validated with experts’ consensus. Field testing showed that the scale has excellent psychometric properties, having moderate correlations with the Activities-specific Balance Confidence Scale, Falls Efficacy Scale-International, Late Life Function and Disability Instrument-Function and strong correlation with reactive postural control performance. Keywords: Patient-reported outcome measures, falls efficacy, balance recovery confidence, psychometric propertiesItem Sensorimotor and neuromuscular performance capabilities in elite young soccer players(2021) Clancy, ColinFollowing a review of the literature and using a prospective observational design delivered in an ecologically valid setting, this thesis enhances knowledge of sensorimotor (SM) and neuromuscular (NM) performance capabilities in elite young soccer players, culminating with a controlled cohort study to further investigate the influence of high intensity exercise stress on performance capabilities. Alterations in player perceived capabilities using the Borg Category-Ratio Scale (CR-10) and Perceived percentage of completed task duration (PTD), were also investigated. Impaired NM performance as a symptom of fatigue has previously been demonstrated in elite soccer players. However, the results from outcome measures offering such detailed and granular biological insights have not been documented previously. In addition, this research project aimed to observe (Chapter 6) and then provoke (Chapter 7) turbulence, physiologically, to examine whether the SM system is similarly affected, thereby verifying this mechanism as operational for soccer players. To objectify the conditioning dosage to which elite young soccer players are typically exposed to, Chapter 3 offered a season-long patterning of training and match-workload. To further contextualise the backdrop of this research project, NM performance capabilities were benchmarked by comparison with senior professional players in Chapter 4. Performance capabilities of sixteen elite male soccer players (age: 19.2 ± 1.1 years; height: 183.3 ± 6.1 cm; body mass: 76.1 ± 7.8 kg) were evaluated at weekly intervals over a 6-week in-season mesocycle (Chapter 5), and daily during a weekly competitive microcycle (Chapter 6). Assessments of peak twitch force (PTFe) and electromechanical delay (EMD) demonstrated significant changes in NM performance capability (p < 0.05; 13.6% and 15.1% impairments, respectively) whereas SM performance capability was preserved (p > 0.05). Congruence amongst fluctuating patterns of intra-mesocycle training workloads and concomitant neuromuscular performance responses was noted over time for Acute Training Load (ATL) with PF (r = -0.59; p < 0.05) (Chapter 5). Corresponding analysis of training workloads and conditioning status as influencers of post-match strength resilience and recovery identified potential for aspects of NM performance to be altered by careful manipulation of antecedent training workloads (r = 0.59-0.62; p < 0.05) (Chapter 6). Within routine aspects of the competitive season, greatest deficits in NM performance were observed immediately following match-play (p < 0.05; Cohen’s d: 0.32 [PF] and 0.89 [EMD]). Subsequently, using a potent, controlled exposure to exercise stress, an intermittent isometric fatigue trial (IIFT) was deployed to examine concurrent SM and NM performance responses while exploring alterations in player perceived capabilities. Declines in PF, rate of force development (RFD) and EMD performance following the IIFT reached statistical significance with effect magnitudes larger than observed within the ecologically relevant settings (p < 0.001; Cohen’s d: 0.58 [PF], 0.52 [RFD] and 2.34 [EMD]). Interestingly, SM performance capabilities remained intact following the IIFT (p > 0.05). Additionally, although both CR-10 and PTD ultimately demonstrated efficacy in predicting exercise cessation, a significant interaction effect (p < 0.01) was observed indicating a divergence between candidate explanatory paradigms of self-perception of capabilities for players within the task. This thesis has increased current knowledge and understanding by providing a novel exploratory evaluation of sensorimotor and neuromuscular performance capabilities in early career professional soccer players. The findings presented in this thesis will better inform future studies on conditioning soccer players and allow more targeted prophylactic strategies to be implemented by performance support staff. Key words: Sensorimotor, neuromuscular, soccerItem FOOT DROP AND FATIGABILITY IN PEOPLE WITH MULTIPLE SCLEROSIS(Queen Margaret University, Edinburgh, 2019) Andreopoulou, GeorgiaPeople 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 kinematicsItem FRAILTY, CARDIOVASCULAR FUNCTION AND RISK OF FALLING AMONGST PATIENTS WITH STAGE 5 CHRONIC KIDNEY DISEASE ON HAEMODIALYSIS(Queen Margaret University, Edinburgh, 2019) Zanotto, TobiaThis 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.Item ENHANCING KINEMATIC SHOULDER FUNCTION EVALUATION THROUGH A VALID, SIMPLE AND CLINICALLY APPLICABLE SCORE(Queen Margaret University, Edinburgh, 2019) Pichonnaz, ClaudeIntroduction 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.Item QUANTILE REGRESSION AS A METHODOLOGY FOR UNDERPINNING PROPORTIONATE UNIVERSALISM(Queen Margaret University, Edinburgh, 2019) Rush, RobertIn 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.Item Pre-surgery exercise-conditioning (P–SEC) in patients waiting for Total Knee Arthroplasty(2018) Risso, Anna MariaUsing 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-educationItem THE EFFECTS OF ENHANCED SENSORI-MOTOR REHABILITATION ON INDICES OF FUNCTIONAL PERFORMANCE IN PATIENTS UNDERGOING TOTAL KNEE REPLACEMENT(2019) Moutzouri, MariaThe 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