Doctor of Philosophy / The aim of the studies reported in this project was to examine factors associated with the prevention and management of trapeziometacarpal osteoarthritis, both in musculoskeletal physiotherapists and the general patient population. Two studies were undertaken to investigate factors associated with the aggravation of thumb pain in musculoskeletal physiotherapists. Study 1 was a survey of the prevalence of thumb pain, and allowed determination of the most aggravating spinal manipulative therapy technique. It identified that 83% of respondents complained of an aggravation of thumb pain due to the performance of spinal manipulative therapy techniques, with 85-87% of the painful respondents complaining of thumb pain aggravated by unilateral and central PA glides. Study 2 was conducted to determine whether the alignment of the joints of the thumb during performance of these glides was associated with thumb pain. This observational study of 129 musculoskeletal physiotherapists performing a PA glide identified that aligning the metacarpophalangeal and interphalangeal joints in extension was associated with a lower prevalence of work-related thumb pain. Therefore, it is suggested that musculoskeletal physiotherapists be taught to perform these techniques with the joints of their thumb in extension in an effort to reduce the development of work-related thumb pain. Furthermore, it is suggested that those who are unable to maintain this alignment voluntarily be provided with a thermoplastic thumb splint to maintain the extended alignment. Two studies were undertaken to investigate the conservative and surgical management of patients with trapeziometacarpal osteoarthritis. Study 3 was a randomised controlled trial conducted to compare the efficacy of a new thumb strap splint and an abduction exercise regimen against the standard approach to conservative management of trapeziometacarpal osteoarthritis, namely a short opponens splint and pinch exercise regimen. While there was no additional benefit of one approach over the other, all participants improved in the outcomes of pain, strength and hand function over the six-week period of intervention. Nevertheless, some people find that symptom relief from conservative intervention is inadequate and short-lived, requesting surgery for the treatment of disabling and persistent pain from trapeziometacarpal osteoarthritis. Study 4 was a systematic review, conducted to determine evidence of efficacy of one surgical procedure over another. This review identified six randomised controlled trials of surgery for trapeziometacarpal osteoarthritis. While there was evidence of no difference in the reduction in weakness between the procedures, there was insufficient evidence to confirm that there was no difference in the outcomes of pain, contracture, hand function, or patient global assessment. Furthermore, there was sufficient evidence to conclude that trapeziectomy had significantly fewer adverse effects, and trapeziectomy with ligament reconstruction and tendon interposition (LRTI) had significantly more, when compared with the other procedures analysed in this review. It is suggested that the decision as to which intervention is most appropriate for a given patient be based upon the individual patient’s requirements, the extent of disease, and the demands placed upon the joint by domestic duties, work, leisure and recreational activities. The studies presented in this project assist in formulating preventative and management strategies for people with trapeziometacarpal osteoarthritis.

<p>The aim of this investigation was to elucidate and describe those patients who had discontinued their participation and/or paticipated infrequently in physiotherapy treatment based on their own activity and responsibility. The ambition was to understand the phenomenon of compliance/adherence from various perspectives in behavioural as well as social science.</p><p>In study I the phenomenon compliance/adherence was studied in relation to Health Locus of Control and Health Belief variables. This study was based on a questionnaire that was answered by all patients before beginning of treatment. Questions concerning the patients´conceptions about both health locus of control and health beliefs were the focus.The definitions of compliance/adherence were completed treatment period and exercise frequency, respectively. Those patients who completed the treatment were also studied regarded exercise frequency.</p><p>The results of study I showed that those who discontinued their treatment reported a higher perceived threat from their health condition (higher level of dysfunction (higher pain intensity) and a higher perceived severity of their health condition (higher level of dysfunction, worse general health) than those who completed treatment. The results also showed that those who exercised once a week or less often valued the significance of the caring situation as lower (HLC), perceived a higher threat from their health condition (higher pain intensity), a higher severity of their health condition (higher level of dysfunction, worse general health, greater distrution of impairment), more barriers to treatment (lower expectations), and had certain differences in demographic variables (younger individuals, more women) than those who exercised more often (HB).</p><p>Study II investigated patients´descriptions of their reasons for discontinuing the treatment, whether those reasons varied, and if so how they varied. Sixteen patients who had discontinued their treatment were interviewed with open-ended questions. The inteviews began with a question about the background to the physiotherapy treatment. There were questions concerning carrying out the treatment as well as concerning what they thought about their impairment. The patients were also asked about their priotities in daily life, as these wre presumed to be anobstacle to the treatment over a shorter or longer period of time. The third domain concerned how they experiebced the patient/physiotherapist relationship. The interviews were anlysed qualitatively.</p><p>Analysis of study II resulted in four different descriptions of reasons for treatment discontinuation. A) It was about time to end treatment and continue on alone. B) The treatment was not the most important activity to spend time on. C) An agreement with the physiothreapist to discontinue treatment due to lack of effect. D) No viewpoint as to why they discontinued the treatment. In further analysis of category D, this group appeared to experience varoius forms of powerlessness. They felt their trustworthiness was often questioned. They experienced frustration in their life situation as others made the important descisions and they themselves had little to say.They defended themselves by talking about their own conceptions of the reasons for their impairment and what should be done about them. In comparing category D with categories A, B, C it was found that those in the latter three categories experienced varying degrees of control in different situations, whereas those in category D did not experience a feeling of control.</p><p>Conclusion: The concept of compliance in physiotherapy is ambiguous. The concept involves one part defining what will concern the other part. It is clear that the physiotherapist and the patient do not always agree about the aim of the treatment. Instead, we should develop the concept of concordance in encounters with the patients and abandon the reasoning of compliance.</p>

Lic.-avh. (sammanfattning) Stockholm : Karolinska institutet, 2008. / Härtill 2 uppsatser.

Low back pain (LBP) remains one of the most common and challenging primary care issues in the developed world. Manual occupations such as nursing are known to involve a high risk of occupational LBP, which is associated with enormous health care expenditure as well as indirect work and disability-related costs. Despite extensive efforts to reduce LBP in nurses, evidence supporting the efficacy of any specific intervention to prevent LBP is limited. / The majority of LBP prevention strategies are directed at occupational risk factors in working nurses. However, as there is some evidence that LBP is already a significant problem in nurses prior to commencing full time employment, it is proposed that nursing students should be the focus of prevention interventions. This would require prevention interventions targeting personal rather than occupational LBP risk factors. As the best personal predictor of future LBP is currently a previous history of LBP, further investigation of modifiable personal LBP risk factors is required. Consequently, the aim of this doctoral research was to identify modifiable personal characteristics that predict LBP in nursing students. / Firstly, a large survey was conducted on undergraduate nursing students and recently graduated nurses to determine patterns of LBP prevalence. Results from this study indicated that LBP prevalence was very high at the commencement of undergraduate training. Prevalence of LBP did not significantly change during nursing training, but did increase further in the first year of commencing work as a nurse. This increase may be partly explained by the reported increase in occupational exposure to bending and lifting. Age was consistent across the undergraduate year groups and did not influence these findings. It was concluded that nursing students would provide a sufficient number of new-onset LBP episodes (and thus sufficient statistical power) for a prospective study design. Further, as these nursing students were not yet exposed to the occupational LBP risk factors of working nurses, a clearer indication of the influence of modifiable personal factors on the development of LBP could be determined by examining a student cohort. / A cross-sectional study investigating the influence of personal physical, psychological and social/lifestyle factors was then conducted on nursing students. Preliminary analysis revealed clear gender differences across multiple domains. Therefore, the focus of further analysis was on the larger female sample. / In Part 1 of the cross-sectional study, an investigation of regional differences in lumbar spine posture and movement was undertaken. Analysis of spinal kinematics in this study supported and extended previous literature that has found global lumbar spine kinematics do not accurately reflect the kinematics of the upper lumbar or lower lumbar spinal regions in common postures and movements. Rather, these two regions have a degree of functional independence. This finding has implications for interpretation of measures of spinal posture, motion and loading. Further, body mass index influenced regional lumbar posture and movement, possibly representing adaptation due to load. It was concluded that regional rather than global lumbar spine measures needed to be investigated in further analyses of this doctoral research. / In Part 2 of the cross-sectional study, personal characteristics associated with LBP were investigated. Approximately one third of all subjects reported significant LBP in the 12-months preceding the study. Analysis of factors associated with LBP supported the biopsychosocial nature of LBP. Higher stress levels and use of passive coping strategies, increased physical activity levels, holding the lower lumbar spine further from end-range flexion during functional tasks and increased age, all contributed independently to the presence of LBP. These findings supported the hypothesis that modifiable personal characteristics were associated with LBP. / The importance of identifying sub-groups of LBP patients has become widely accepted. In Part 3, further exploratory analysis was conducted on this crosssectional data to determine if differences in physical and psychological characteristics were evident in two defined sub-groups of female nursing students with LBP. These sub-groups were based on O’Sullivan’s mechanism based classification system. Results indicated that two sub-groups of LBP subjects had differing physical and psychological characteristics associated with their LBP. Further, control subjects could be distinguished from each of these two sub-groups by different factors. These findings add validity to O’Sullivan’s LBP classification system. Further, the findings may suggest that different combinations of psychological and physical factors are linked to LBP in different sub-groups in this population, and therefore may require different intervention approaches based on these factors. / In the final stage of this doctoral research, the cohort of female nursing students was followed prospectively for 12-months. The focus of further analysis was on identifying modifiable personal predictors in a sub-group of subjects with new-onset LBP. The results of this study strongly supported that personal factors from multiple domains are predictors of new-onset LBP. After controlling for previous LBP, age and body weight, regression analysis identified that smoking, increased physical activity levels (both exercise and spinal loading), higher stress levels, reduced back muscle endurance, greater posterior pelvic tilt in slump sitting and more accurate spinal repositioning in sitting were all independent predictors of new-onset LBP. These findings have implications for the development of prevention and management interventions for LBP in nurses. / Results from this doctoral investigation support the multi-factorial and biopsychosocial nature of LBP. The important distinction of this research when compared to previous work is the selection of a cohort at the beginning of their working life, with a focus on modifiable personal, rather than occupational factors, associated with LBP. Factors from physical, psychological and social/lifestyle domains were all independently associated with significant new-onset LBP in female nursing students. Interventions utilising a prevention approach that targets modifiable characteristics, such as those identified in this cohort of nursing students, may have the potential to reduce the impact of occupational LBP in this group. These preliminary findings have important implications for future LBP research and clinical interventions.

Doctor of Philosophy / The aim of the studies reported in this project was to examine factors associated with the prevention and management of trapeziometacarpal osteoarthritis, both in musculoskeletal physiotherapists and the general patient population. Two studies were undertaken to investigate factors associated with the aggravation of thumb pain in musculoskeletal physiotherapists. Study 1 was a survey of the prevalence of thumb pain, and allowed determination of the most aggravating spinal manipulative therapy technique. It identified that 83% of respondents complained of an aggravation of thumb pain due to the performance of spinal manipulative therapy techniques, with 85-87% of the painful respondents complaining of thumb pain aggravated by unilateral and central PA glides. Study 2 was conducted to determine whether the alignment of the joints of the thumb during performance of these glides was associated with thumb pain. This observational study of 129 musculoskeletal physiotherapists performing a PA glide identified that aligning the metacarpophalangeal and interphalangeal joints in extension was associated with a lower prevalence of work-related thumb pain. Therefore, it is suggested that musculoskeletal physiotherapists be taught to perform these techniques with the joints of their thumb in extension in an effort to reduce the development of work-related thumb pain. Furthermore, it is suggested that those who are unable to maintain this alignment voluntarily be provided with a thermoplastic thumb splint to maintain the extended alignment. Two studies were undertaken to investigate the conservative and surgical management of patients with trapeziometacarpal osteoarthritis. Study 3 was a randomised controlled trial conducted to compare the efficacy of a new thumb strap splint and an abduction exercise regimen against the standard approach to conservative management of trapeziometacarpal osteoarthritis, namely a short opponens splint and pinch exercise regimen. While there was no additional benefit of one approach over the other, all participants improved in the outcomes of pain, strength and hand function over the six-week period of intervention. Nevertheless, some people find that symptom relief from conservative intervention is inadequate and short-lived, requesting surgery for the treatment of disabling and persistent pain from trapeziometacarpal osteoarthritis. Study 4 was a systematic review, conducted to determine evidence of efficacy of one surgical procedure over another. This review identified six randomised controlled trials of surgery for trapeziometacarpal osteoarthritis. While there was evidence of no difference in the reduction in weakness between the procedures, there was insufficient evidence to confirm that there was no difference in the outcomes of pain, contracture, hand function, or patient global assessment. Furthermore, there was sufficient evidence to conclude that trapeziectomy had significantly fewer adverse effects, and trapeziectomy with ligament reconstruction and tendon interposition (LRTI) had significantly more, when compared with the other procedures analysed in this review. It is suggested that the decision as to which intervention is most appropriate for a given patient be based upon the individual patient’s requirements, the extent of disease, and the demands placed upon the joint by domestic duties, work, leisure and recreational activities. The studies presented in this project assist in formulating preventative and management strategies for people with trapeziometacarpal osteoarthritis.

Introduction. Patient falls occur frequently in the acute hospital setting and are one of the most common adverse events experienced by hospitalised patients. In-hospital falls have negative outcomes for patients, causing injuries in up to half of those who fall. Falls in hospital create additional costs for health services due to increased length of stay (LOS), and greater health resource use. In contrast to much research focused on in-hospital falls worldwide, little is known about the rate, contributing factors and outcomes of inpatient falls in the state sector in South African hospitals. At the research hospital, a Falls Policy has been in place since 2013. The chosen falls risk screening tool, the Morse Falls Scale (MFS), had not been locally validated, and therefore its ability to accurately discriminate between patients who fall and patients who do not fall was unknown. A focused analysis of local falls incident reporting, and a description of contributory factors and consequences of falls, could better inform and target falls and fall injury prevention. Furthermore, this research may assist in service development and refining the Falls Policy. Methodology. The aim of this study was to obtain broad-based data on the magnitude of patient falls, and to identify factors contributing to falls. The aim was achieved in two parts, the first was a retrospective record review design. Predictive risk factors for falls were explored by comparing two patient groups, a Fall-Group and a Non-fall Group. In the FallGroup, further objectives related to describing circumstances surrounding fall events, including activities patients were performing at the time of the fall, the time of day and day of week the fall occurred, locations of fall events, and the clinical consequences sustained as a result of the fall. The use of the existing falls risk screening tool, the MFS, as well as its predictive accuracy to correctly identify patients at increased risk of falling was investigated. Second, a survey of nurses at the research hospital was undertaken to examine nurses' knowledge, attitudes and beliefs around the Falls Policy and current falls prevention practices. Results. There were 171 reported fall events during the ten-month period, representing 11.77% of adverse events and a falls rate of 0.73 per 1000 patient occupied bed days (POBD) during this time. Significant predictive risk factors for falling were a longer LOS and having a greater number of comorbid conditions. While the mean age of the sample was 50.0 years (SD=17.3 years), the Fall Group was significantly older than the Non-fall Group (p = .004). There were significantly more deaths in the Fall Group (p = .001), and this group had a longer average LOS (p < .001) compared to the Non-fall Group. The only sub-scale from the MFS that was significantly associated with falls was walking status. Minor-moderate clinical consequences were experienced as a result of the fall in 97% of cases (n=124). This study demonstrated that the MFS in use in the hospital has a low predictive accuracy of 55% at the current cut-off score of 50. At this score, the MFS has a sensitivity of 35.9% and a specificity of 75.4%. While an initial MFS was found in each of the cases, there was only evidence of a repeat MFS in 13 participants (9.7%) in the Fall Group. The nursing survey showed 70% of respondents had not had training on the Falls Policy (n=93) and only 37% (n=49) reported receiving regular feedback on fall rates. Receptiveness of most (66%, n=91) nurses to more training in falls prevention is encouraging. Discussion. The fall rate of 0.73 falls per POBD was lower than expected when compared to international studies. At the research hospital, when the Falls Policy was introduced in 2013, a fall was not defined in the policy and as highlighted in the nursing survey, there still appears to be lack of clarity on the fall definition. The MFS had a low predictive accuracy at the current cut-off score. The low sensitivity and specificity of the MFS in this setting may be due to the MFS not being updated regularly as per the Falls Policy. A further reason for the MFS poor predictive value may be the younger age group found in this sample when compared to international studies where the scale has performed better. Recommendations. The poor predictive value of the current risk screening tool found in this study is concerning. Therefore, further investigation into whether the MFS performs better if it is updated more frequently, and if completed in full, as per the Falls Policy, is recommended. Alternatively, the hospital should consider all patients with multiple comorbidities and those with longer length of stays at high risk, and provide interventions to minimise risk as per the Falls Policy. Future research into factors contributing to fall events and falls prevention should follow a prospective design and be supported at management as well as ward level. Further investigation into the most appropriate way to reduce harm from falls is recommended at the research site. Conclusion. This descriptive study provides a starting point for the hospital to examine the Falls Policy and falls prevention strategies currently in use. It is hoped that the study will contribute to local awareness-raising and capacity-building and help the hospital evaluate current practice and set a baseline for improvement.

Background: Progressive respiratory muscle weakness and ineffective cough contributes to pulmonary morbidity and mortality in children with neuromuscular disease. Inspiratory muscle training aims to preserve or improve respiratory muscle strength, reduce respiratory complications and improve health-related quality of life. Objectives: To describe South African physiotherapists' knowledge and respiratory management strategies and determine the safety, viability, acceptability and efficacy of inspiratory muscle training for children 5-18 years with neuromuscular disease. Methods: Four studies were conducted: i) a quantitative descriptive survey; ii) a systematic review using Cochrane methodology; iii) a prospective, pre-experimental observational study and iv) a prospective, cross-over randomised controlled trial using a standardised 12-week inspiratory muscle training intervention. Results: i) South African physiotherapists (n=64) reported being aware of international clinical practice recommendations, however they favoured manual airway clearance techniques. The use of inspiratory muscle training in chronic management was well supported by South African physiotherapists. ii) Results of the systematic review (seven included studies; n=168) suggested that inspiratory muscle training may be effective in improving inspiratory muscle strength. There was insufficient evidence for an effect on patient morbidity or health-related quality of life. iii) The pre-experimental, pilot study (n=8) suggested that a six-week inspiratory muscle training programme was safe, viable, acceptable and associated with a significant increase in inspiratory muscle strength. iv) The cross-over randomised controlled trial (n=23) did not show evidence of a difference in the primary outcome measures (number of hospitalisations and respiratory tract infections) between intervention and control periods. There were no adverse events related to inspiratory muscle training. Inspiratory muscle strength (Pimax) and peak expiratory cough flow increased by 14.57 (±15.67)cmH2O and 32.27 (±36.60)L/min respectively during the intervention period compared to a change of 3.04 (±11.93)cmH2O (p=0.01) and -16.59 (±48.29)L/min (p=0.0005) during the control period. There was no evidence of change in spirometry, functional ability or total health-related quality of life scores following the intervention. Overall participant satisfaction with inspiratory muscle training was high and adherence was good. Conclusions: Inspiratory muscle training in children with neuromuscular disease is well tolerated, appears to be safe and is associated with significant improvements in inspiratory muscle strength and cough efficacy.

Musculoskeletal physiotherapy is the most common intervention for chronic low back disorder. Any observation on clinical practice or investigation into the clinical and scientific literature indicates that musculoskeletal physiotherapy encompasses a plethora of treatment modalities and approaches. The aim of the present investigation was to determine the most common intervention(s) that comprise musculoskeletal physiotherapy and to critically explore their empirical therapeutic basis. Two components were highlighted as the most frequently employed interventions; namely manually applied therapy (manual therapy) and exercise(s) to rehabilitate the lumbar spine's stabilising system. In the course of an extensive literature search, work was uncovered that suggested that the mechanisms required for spinal stability could be better facilitated using methods other than those in current clinical use. These discoveries culminated in the creation of a ten-week rehabilitation programme which was primarily developed to facilitate rehabilitation of spinal stabilisation but also permitted an empirical analysis of this component of musculoskeletal physiotherapy. The efficacy of the regime was then assessed in comparison to manual therapy and to a control (an education booklet) in a randomised controlled trial. Following a series of pilot studies, 300 patients with chronic low back disorder were randomly assigned to groups and completed their respective management programmes. Data were collected on pain, disability, handicap, impairment and quality of life prior to entry and at three, six, twelve and twenty-four months post intervention. The results indicated a consistent trend for greater improvement in the spinal stabilisation group in the pain, handicap, impairment, disability, dysfunction and medication variables. These trends reached statistical significance at the three-month follow-up stage as evidenced by quality of life (P = 0.025), at the six-month follow-up stage in pain (P = 0.009) and dysfunction (P = 0.042) and at the one-year follow-up stage in medication (P = 0.007), dysfunction (P = 0.048), disability (P = 0.0098) and quality of life (P = 0.003). It was therefore concluded that the spinal stabilisation programme was a more effective component of musculoskeletal physiotherapy (when analysed in isolation) than manually applied therapy or an education booklet in the management of chronic low back disorder. Various sub-analyses of the data were conducted. Subjects who entered the study with high levels of low back pain (greater than 50 numerical rating scale) demonstrated a statistically Significant reduction in pain levels (P = 0.04) in both the manual therapy group and the spinal stabilisation group in comparison to the education control group at the three-month follow-up stage. These data provide empirical evidence towards the efficacy of these two musculoskeletal physiotherapy management regimes as being effective in pain reduction in comparison to an active control intervention. This has not hitherto been demonstrated on patients with chronic low back disorder.

The aim of this thesis was to evaluate the effect of exercise training and inspiratory muscle training and to describe pulmonary function, respiratory muscle strength, physical performance and health-related quality of life (HRQoL) following lung cancer surgery. Study I was a randomised controlled trial including 78 patients radically operated for lung cancer. The intervention group received 10 sessions of supervised exercise training in addition to home-based exercise; the control group was instructed on home-exercise alone. Supervised compared to non-supervised exercise training did not result in differences between groups in HRQoL, except for the SF-36 bodily pain domain four months after the surgery. No effects of supervised training were found for any outcome after one year. Study II was descriptive and was based on the study I sample. We evaluated the course of recovery of HRQoL and physical performance up to one year following surgery. All patients improved HRQoL and physical performance one year after the surgery, reaching values comparable to a reference healthy population. The walked distance was positively associated with the SF-36 domain for physical functioning. Study III was descriptive, included 81 patients and evaluated the influence of surgery on respiratory muscle strength, lung function and physical performance two weeks and six months after surgery. We found that respiratory muscle strength was not affected after the second postoperative week and that muscle-sparring thoracotomy did not deteriorate respiratory muscle strength, compared to video-assisted thoracic surgery. Compared to preoperative values, physical performance was recovered, whereas lung function remained reduced six months postoperatively. Study IV was a randomised controlled trial including 68 patients at high risk of developing postoperative pulmonary complications (PPC). This study evaluated the effects of two weeks of postoperative inspiratory muscle training in addition to breathing exercises and early mobilisation on respiratory muscle strength and the incidence of PPC. Additional inspiratory muscle training did not increase respiratory muscle strength, but improved postoperative oxygenation. Respiratory muscle strength was recovered in both groups two weeks postoperatively.

No description available.