Background: Many people living with chronic stroke are not involved in any form of ongoing rehabilitation, despite having ongoing impairments and limitations in activity and participation. The approach to structuring practice of functional tasks, as part of ongoing rehabilitation, can incorporate diverse techniques. Current texts advocate that physiotherapists construct stroke rehabilitation programmes that incorporate Motor Learning principles, however the evidence to support this is limited. No evidence related to stroke exists as to whether functional tasks should be practised in their entirety (whole practice) or in component parts (part practice). The primary aim of the work reported in this thesis was to investigate the effects of a home exercise programme based on Motor Learning principles of part practice (PP) or whole practice (WP) of selected functional tasks for people at least six months after a stroke. Methodology: A single blind, randomised controlled trial was undertaken, with participants allocated to either a part practice experimental group (PP), a whole practice experimental group (WP) or a control (Con) group. Both experimental groups followed a four week exercise intervention programme of functional tasks based on PP or WP. Outcome measures were undertaken at baseline, at the end of a four week intervention (wk 4), at short-term follow-up (wk 4.5) and at long-term follow-up (wk 16). Outcome measures utilised were the Barthel Index (BI), Motor Assessment Scale (MAS), Timed Up and Go over 2 metres (TUG2m), Step Test, Frenchay Arm Test (FAT), Hospital Anxiety and Depression Scale (HADS), Frenchay Activities Index (FAI)and the Stroke Impact Scale (SIS). Differences between the groups at each measurement point were examined using a Kruskal Wallis test. Differences within each group over time were analysed using a Friedman’s Anova, followed up by a Wilcoxon’s Signed Ranks test using a Bonferroni correction where a significant difference was found. Results: Sixty four people with late-stage stroke were recruited and provided informed consent. Data were available for analysis for 60 participants (median time since stroke 21 months). No statistically significant differences were found between the three groups at any point for any of the dependent outcome variables. A number of statistically significant within group changes were found in all groups. Most statistically significant changes were demonstrated by PP including on the BI from baseline to wk 4.5; on the MAS from baseline to weeks 4, 4.5 and 16; on the Step Test from baseline to weeks 4, 4.5 and 16 and on the FAT from baseline to week 4. On more global measures the PP group reported statistically significant improvements on the SIS in the domains of strength, mood and mobility from baseline to wk 4; and in the SIS participation domain from baseline to wk 16; as well as a statistically significant within group improvements on FAI from baseline to wk 4. Conclusions: People with late-stage stroke demonstrated capacity for improvements in a number of measures of impairment, activity, participation and mood. The PP group demonstrated improvements, over time, in more of the outcome measures relating to physical ability than either WP or Con groups. Implications for clinical practice and further research are discussed.

With the rising obesity and the increasing age of the population, a large proportion of patients who undergo Total Knee Arthroplasty (TKA) are obese. Knowing the health risks associated with obesity, it is important to determine if the outcomes of a TKA is compromised in obese patients. Significant discrepancies in the findings of previous studies assessing the effect of body mass index (BMI) on TKA outcomes were observed in a literature review, thus making it difficult to confirm an effect of obesity measured as BMI on the outcomes after TKA. This thesis comprises two studies which further explored the effects of BMI and other body composition measures on the outcome of TKA. 1. The aim of a retrospective epidemiological study was to assess the effect of BMI on patient reported outcomes after TKA. 2. The aim of the prospective cohort study was to assess the effect of body composition, measured by waist circumference (WC), waist to hip ratio (WHR), bioelectrical impedance analysis (BIA), ultrasonography (US) and BMI, on patient reported outcomes after TKA. It was concluded from these two studies that group division of obesity based on the classification of BMI greater or less than 30 kg/m2 could not identify an effect of obesity on outcomes. However, on using BMI as a continuous variable, an adverse effect of BMI on knee function and overall physical health was evident for higher BMI ranges. Body composition measures of BIA and US did not detect an effect of obesity for any outcomes. Effect of obesity detected by BMI and WC was similar. The negative association of BMI and outcomes observed was very weak across BMI ranges of 25-30 kg/m2and a significant association was achieved due to poorer patient reported physical function (indicated by Short Form 12 and Oxford Knee Score questionnaires) in some cases with very high BMI values (> 40 kg/m2). In addition to this finding, the lack of group difference when outcomes were evaluated across a BMI of 30 kg/m2in the two studies and the disparity between studies in the results when using a BMI classification of 30 kg/m2 supported the conclusion that a BMI classification across a cut-off value of 30 kg/m2 does not predict a poor result in obese after TKA. However, because of the limited number of highly obese (> 35kg/m2) participants in both studies of the thesis and often in previous studies, no definite conclusions regarding the effect of higher obesity levels on the outcome of TKR can be drawn from the studies in this thesis. Adequately powered future studies with more morbidly obese participants could give more definitive answers to the effect of BMI and other measures of body composition on outcomes following TKA.

Aim: This thesis set out to make an original contribution to knowledge with regard to methods of assessing muscle size and architecture in the CKD and ESRD population, and to assess the ability to improve the muscle size and architecture, and symptoms of uraemia, by implementing an anabolic intervention (resistance exercise training) in the CKD population. Outcome measures: Ultrasound was shown to have high validity (against gold standard MRI measures; ICCs: VLACSA 0.96, VL depth 0.99, fat depth 0.98) and intra-rater reliability (ICCs: VL depth 0.98, total muscle depth 0.97, fat depth 0.99; MDC: VL depth 0.14cm, total muscle depth 0.19cm, fat depth 0.22cm) in measuring regional body composition at the mid-VL site in the CKD population. There were significant (p<0.01) correlations between US-derived measures of (mid-VL) muscle size and architecture with strength and function (larger muscle mass and/or pennation angle positively correlated with higher strength and/or functional performance). Patient-reported uraemic symptoms were worse (p<0.01) in those with reduced strength and/or function. Intervention results: An anabolic (resistance training) intervention (12-weeks, randomized to once [RT1 n=7] or three times [RT3 n=10] per week, 80%1RM) brought about significant improvements over time (p<0.01) in all measures of muscle size and architecture (VL depth, total muscle depth, VLACSA, pennation angle). Interaction effects (group*time) were only seen in pennation angle (p<0.05) and VLACSA (p<0.01) where RT3 gains were greater than RT1 from week 8 onwards. All measures of strength, function, and uraemic symptoms improved over time (p<0.01) with no interaction effects (no difference from greater training frequency/ volume). Clinical and research implications: The intervention results suggest implementing a RT form of “prehabilitation” in early stage (CKD3) patients just once per week is sufficient to bring about statistically and clinically important changes in strength and function that benefit the patient through reduced frequency and/or intrusiveness of uraemic symptoms (improved health-related quality of life), with minimal time-commitment. Further research should examine if there is additional benefit to the significantly greater increases in VLACSA and pennation angle observed in RT3, with regards to long-term maintenance of functional improvements, and whether an RT1 or RT3 programme delays the progression of CKD, the need for RRT, and patient mortality.

Rehabilitation programme following anterior cruciate ligament (ACL) reconstruction is multifaceted and may be influenced by a variety of factors. The role of the environment for care and the levels of supervision from physiotherapists on the outcomes of ACL rehabilitation, have not received robust attention in the literature. In this thesis, two trials were carried out to investigate the role of these factors on the outcomes of ACL rehabilitation. In the first trial, a total of 76 patients [hospital-based rehabilitation group, n = 48 (age: mean ± sd: 31.5 ± 12.1 yr, height: 1.74 ± 0.06 m, body mass: 78.2 ± 10.8 kg, waiting time: 37.3 ± 33.7 months) and community-based rehabilitation group, n = 28 (age: mean ± sd: 34.5 ± 9.9 yr, height: 1.71 ± 0.07 m, body mass: 75.2 ± 12.4 kg, waiting time: 31.1 ± 26.7 months)] self-selected themselves into the hospital- and the community-based rehabilitation programmes. The patients in both the hospital- and the community-based rehabilitation programmes were assessed by selected patient-reported outcome measures (PROMs) included IKDC, KOOS, K-SES, VAS and Lysholm at four different occasions (pre-surgery and at the 6th, 12th and 24th weeks post-surgically). Significant differences at early phase of rehabilitation (up to 12th week post-surgery) on PROMs of function, favouring the outcomes of the hospital-based rehabilitation programme compared to the community-based rehabilitation programme, were observed. However, no differences between the outcomes of the latter two programmes were observed across 24 weeks rehabilitation programme following ACL reconstruction. This suggested that community-care had offered a similar environment to the hospital for achieving the outcomes of rehabilitation. In the second trial, the patients in the hospital-based rehabilitation programme (n=48) were iii further randomly allocated to the fully-supervised and the minimally-supervised rehabilitation groups [ fully-supervised rehabilitation group, n=24 (age: mean ± sd: 32.2 ± 11.1 yr, height: 1.73 ± 0.07 m, body mass: 75.8 ± 10.7 kg, waiting time: 35.8 ± 29.4 months), minimally-supervised rehabilitation group, n=24 (age: mean ± sd: 31.0 ± 13.2 yr, height: 1.75 ± 0.06 m, body mass: 80.6 ± 10.7 kg, waiting time: 28.8 ± 25.1 months)]. The patients in both the fully-supervised and the minimally-supervised rehabilitation groups were assessed on four different occasions (pre-surgery and at the 6th, 12th and 24th week post-surgery) on estimates of function (single-leg hop), physical performance (peak force, rate of force development, sensorimotor performance and electromechanical delay) and musculoskeletal performance (anterior tibio-femoral displacement) alongside the selected PROMs. Significant differences during the early phase of rehabilitation (up to 12th week post-surgery), favouring outcomes of the fully-supervised rehabilitation programme on some aspects and the outcomes of the minimally-supervised rehabilitation programme on other aspects, were observed. However, similar knee function across 24 weeks rehabilitation was observed on the selected objective measures and PROMs amongst the outcomes of the latter two rehabilitation programmes. This indicated that the outcomes of ACL rehabilitation had not influenced by the levels of supervision from the physiotherapists. In short, the environment and the levels of supervision from rehabilitation team were less likely to influence the final outcomes of ACL rehabilitation.

Chapter one of this thesis offered a general insight on the anterior cruciate ligament (ACL) injury and the outcome measures of ACL rehabilitation while chapter two was a systematic review on the effects of “accelerated rehabilitation” after ACL reconstruction surgery. The review concluded that 5 out of 10 randomised control trial studies had demonstrated moderate relative effect sizes in terms of improved knee laxity, neuromuscular performance, range of motion and some patient-reported outcome measures following accelerated rehabilitation for patients with ACL reconstruction. Chapter three was a systematic review in which the genetic influence on responsiveness to strength conditioning and the outcomes of knee after ACL reconstruction were investigated. The findings revealed that intra-genotypic responses to strength conditioning were heterogeneous and that duration, intensity and frequency of strength conditioning were factors that contributed to the differential responses of genotypes in regulating gains in strength. Chapter four (study one) was a randomised control trial in which the effects of quantified accelerated conditioning rehabilitation, anthropometric and orthopaedic-related factors on the outcomes of knee performance were investigated following ACL reconstruction. Participants (n= 40) were prescribed either accelerated rehabilitation in the first 12 weeks post-surgery (n=20) or contemporary (n=20) ACL rehabilitation. Participants were assessed in four different testing occasions; pre-surgery (0), 6, 12 and 24 weeks post-surgery. The findings revealed there was significant group by leg by time interaction using ANOVA and repeated measures on the latter two factors with superior scores in the accelerated group for the change scores of some sub-sections of KOOS. When controlling for body mass, waiting time and unstructured physical activity, scores associated with objective neuromuscular measures showed significant interaction (group by time by leg) from pre-surgery to 12 weeks post-surgery with superior scores favouring the accelerated group. This showed that the accelerated rehabilitation offered advantages over the contemporary practice coincident with enhanced conditioning and that orthopaedic-related factors were influential in determining the outcomes of ACL rehabilitation. Chapter five (study two) explored the correlation amongst the objective and subjective functional and objective neuromuscular outcome measures. Participants from study one (n=40) took part in this study. While there was no correlation between the change scores of the objective functional (single leg hop) and the subjective functional (KOOS, K-SES, Lyhsholm, IKDC) outcome measures, the absolute scores associated with sub-sections of KOOS had shown the most consistent correlation with objective measures (KOOS and sensorimotor performance [SMP] of the quadriceps;-0.46, peak force of the quadriceps; -0.34, and anterior tibio-femoral displacement [ATFD]; -0.32). Change scores for SMP and KOOS and for the single leg hop and Lysholm showed the highest correlation in the hierarchy of objectively-measured determinants of knee functional performance. Overall, there was a lack of robust and significant linkage amongst the functional and objective neuromuscular outcome measures. Chapter six (study three) investigated the influence of angiotensin converting enzyme (ACE) I/D gene polymorphisms on the responsiveness of function and physical performance to rehabilitation training following ACL reconstruction. Participants (n=40) from the previous two studies participated in this study that involved obtaining blood samples for DNA and genotyping for ACE I/D polymorphism. The findings revealed that one (peak force for quadriceps) out of 5 objective functional and neuromuscular measures had shown significant interaction (ACE genotype by time by leg) in response to rehabilitative training favouring the D allele over the I allele group. It was concluded from this exploratory trial that there was some evidence to suggest that planning for ACLR rehabilitative care might be optimised by using the conditioning-response characteristics associated with the individual.s genotype of the ACE I/D. There was a 15% of variance in the peak force (quadriceps at 12 to 24 weeks post-surgery) favouring the D allele group, indicating that strength training could be possibly prescribed routinely earlier to patients carrying the D allele. The last chapter of the thesis (chapter seven) was a general discussion that synthesised the findings of all the three studies of the thesis including their limitations and future directions.

This thesis is based on six studies which address questions around the use of accelerometers to measure physical activity and sedentary behaviour of pre-school children: are shorter epochs more accurate? Which epochs are most accurate? Are there advantages to using triaxial accelerometers? Which cut-points are most accurate? Are different generations of Actigraph accelerometers comparable? What is the recommended wear time to provide a reliable estimate of habitual physical activity and sedentary behaviour? Analysis of 7-10 day accelerometry data, collected from 31 pre-school children (mean (SD) age 5.9 (0.7) y), suggests that shorter epochs (15 s) result in significantly greater estimates of time spent in moderate-to-vigorous physical activity (MVPA) in comparison to 60-s epochs (p <0.05). When compared against a direct observation method, Children’s Activity Rating Scale (CARS), with 32 pre-school children (4.4 (0.8) y) during 1 hour of free-play, 15-s epochs were more accurate than 60-s epochs. Comparison of the triaxial RT3 against a uniaxial accelerometer, suggests no advantage of the RT3 accelerometer. The Puyau et al. (2002) cut-points had the ‘best’ agreement with estimates of sedentary behaviour, light intensity and MVPA against the CARS. Different generations of accelerometers were not comparable, however, application of a correction factor to the GT1M data (7164 = GT1M/0.91) may improve comparability of total physical activity. Finally, analysis of 7 day accelerometry data from 112 pre-school children (3.7 (0.7) y) suggests that 3 days of 7 hours provides a reliable estimate of habitual physical activity and that inclusion of weekend days is not necessary. This thesis highlights the implications that methodological decisions can have over apparent estimates of physical activity and sedentary behaviour and has made recommendations for accelerometry use. Ideally, there needs to be a move towards consensus, as, only by adopting standardised approaches to accelerometry use, will comparison between study outcomes become meaningful.

This thesis addresses current issues regarding assessment of physical activity (PA) and physical function (PF) status of haemodialysis (HD) patients, specifically: What is the recommended wear time to provide a reliable accelerometer estimate of habitual PA and sedentary behaviour? Can similar outcomes from different accelerometers be used interchangeably? Do subjectively and objectively estimated PA outcomes agree closely enough to be pooled? Which PF assessments are potentially most ‘useful’? This thesis also explores potential risk factors of arterial stiffness, a strong predictor of mortality in this population. A PA reliability study involving 70 maintenance HD patients (55.9 ± 15.7 years) over a seven-day monitoring period indicated one dialysis day and two non-diaysis days with a minimum of eight hours wear per day would provide reliable estimates of PA and sedentary behaviour regardless of accelerometer employed, and allowed 90% sample retention. Concordance studies indicated broad agreement for similar outcomes obtained via ActivPAL and Actigraph GT3X accelerometers but they were not interchangeable. ActivPAL is recommended for monitoring steps taken and time seated, Actigraph activity count output for total/overall PA. Questionnaire and accelerometer estimated PA outcomes may not be used interchangeably or pooled. More of the shared variance of physical performance was explained by clinical, demographic and habitual PA factors than for self-reported functional status thus recommending the former. Age, blood pressure and HD vintage were determinants of arterial stiffness, however PA and cardiorespiratory fitness did not appear to be risk factors in this sample. This thesis makes clear recommendations regarding implementation of PA and PF assessment methods, and illustrates their application on sample retention, as well as characterising and potentially identifying individuals at risk of poor outcomes. Emergence of HD vintage as a risk factor for arterial stiffness underscores the need for further research into adjunctive lifestyle interventions to manage health threats in this population.

Rehabilitation following Anterior Cruciate Ligament (ACL) Reconstruction (ACLR) benefits most patients electing ACLR surgery. Contemporary practice offers limited adaptation of the service to the needs of individual patients. This thesis focuses on a Randomised Control Trial (RCT) that evaluated the effects of a novel formulation of patient-centred musculoskeletal rehabilitation involving the Performance Profiling Technique (Butler and Hardy, 1992). Performance Profile Management (PPM), a programme of rehabilitation, was adapted to incorporate patient-physiotherapist negotiation and agreement on decisions for subsequent rehabilitation and treatment strategies. Therefore, the primary aim of the research was primarily to assess the efficacy of individually-tailored, self-managed rehabilitative care (PPM) in comparison to contemporary (CON) clinical practice. The latter would facilitate an understanding of patient needs and verify the circumstances in which rehabilitation might be enhanced by allowing individuals to play a key role in designing their treatment and recovery. A secondary clinical aim was to evaluate the strength of relationships amongst Patient-Based Outcome Measures (P-BOMs) and Clinician-Based Outcome Measures (C-BOMs). Currently, it is unknown which combination of outcome measures (P-BOMs or C-BOMs) delivers an optimum global assessment of functional and physical performance capabilities during patients’ post-surgical rehabilitation. A clinically-relevant and significant association amongst P-BOMs and C-BOMs might indicate correct scaling of patients’ own capability perceptions with those measured using objective assessment methods (C-BOMs) and endorse the utility for the clinical use of P-BOMs.

A radiotherapy treatment is a clinical treatment which makes use of ionizing radiation to treat cancerous diseases. However, the ionizing radiation interacting within the cells can lead to DNA damage in both the cancerous and normal tissues. Therefore the exact knowledge of the dose delivered to the patient is essential because it greatly affects the effectiveness of the treatment. Dosimetry is usually performed by air ionization chambers however their use in the dosimetry of small photon beams is limited by their large sensitive volume. The ideal detector has a small, water-equivalent sensitive volume but the design of the detector and the presence of the encapsulation materials placed in close proximity to the sensitive volume can cause perturbations to the radiation fluence. The Monte Carlo method is the ideal tool because it allows a detailed investigation of the perturbation effects of each detector component but a Monte Carlo model often requires detailed information of the device which can be difficult to access. In this study, an experimental approach involving the use of CT scans and fluorescence spectroscopy in the measurements of the physical properties of a liquid ion chamber was explored. The performance of eight single crystal CVD diamond detectors in the dosimetry of photon beams was also assessed. One of the drawbacks of diamond detectors is the dose rate dependence. The evaluation of the dose rate dependence using clinical photon beams is controversial because the dose rate can be varied by either changing the source to detector distance or the Pulse Repetition Frequency of the LINAC machine. A simple analytical model of the charge collection dynamics was written in the Matlab code to understand the effects introduced by a pulsed radiation beam. The outcome of this study correlates the PRF dependence with the presence of deeper traps.

The studies presented in this dissertation examine distant healing using both quantitative and qualitative methods. Distant healing purportedly works through the mental intention of one living system affecting another at a distance. The literature to date shows mixed results with regards to its efficacy and very little examination of the experience of healers and healees who practice and receive distant healing outside of research settings. This thesis aims to clarify some of the gaps in the literature and to direct future investigations of distant healing through the development of a more comprehensive model of distant healing. To better understand the components that may contribute to distant healing, the first study presented in this thesis is designed to understand the role that belief and expectancy may have on outcomes in a trial of distant healing. Quantitative approaches to the study of distant healing have yielded mixed results (Astin, Harkness & Ernst, 2000), with some studies showing small positive effects of distant healing and others no effect or a slight negative effect. This clinical trial utilized a partially blind design to measure the impact of awareness of receiving distant healing. Therefore, half of the participants were blind to their allocation condition, while the other half were aware of their assignment to either the healing or no healing condition. While no effect of distant healing was found overall, there was an apparent effect of knowledge of allocation, with those aware they were receiving healing reporting better outcomes than those aware that they were not receiving healing (d = 0.76). This effect was not, however, significant in the analysis of covariance, and thus should be interpreted with caution. In the future, studies with a similar design and larger sample size should be pursued to confirm the effect of expectancy on healing outcome. The characteristics and perspectives of healers are largely ignored in the available literature, and may aid in understanding the phenomenon of distant healing. The primary goal of the second study was to investigate healer characteristics (N = 130) in the areas of personality, spirituality, exceptional experiences, boundaries and emotional intelligence. This was achieved using questionnaire measures and comparisons with population norms where available. Also included in the study was a series of open-ended questions that asked participants to define and describe spiritual healing and healers. Thematic analysis revealed that healers believed factors such as skill of the healer and healee receptivity to be especially important to the healing process. It was also recognized that healing might not be appropriate in all situations. For example, healers report that it should not be considered as a primary form of treatment for a broken leg and it may not be as effective if the healee is in a negative and unsupportive environment. Qualitative investigations of distant healing have been limited, with much of the research focusing more broadly on spiritual healing or other alternative approaches to healing. The third study investigated the experience of distant healing as reported by healees with a strong cultural context of belief or acceptance in the possible efficacy of mental healing. This study took place in Sri Lanka, and the healees were recipients of distant healing from a Buddhist monk and healer, Bhante Seelagawesi. Healees were interviewed about their experiences. Interpretive phenomenological analysis (IPA) of interviewees’ accounts revealed participants’ attitudes towards traditional and modern approaches to healing, such that while they showed an awareness and acceptance of the latter, they often preferred the former. The experiences were overwhelmingly positive, however a number of factors, in addition to distant healing, appeared to be therapeutic. There was a strong community aspect to healing, and overall a theme of empowerment was evident. Overall, these studies allow us to build a more complete and holistic model of the distant healing phenomenon, which is presented in the final chapter. The studies also fill in some of the gaps found in the current literature, particularly by utilizing a mixed methods approach and focusing on both efficacy and also healer and healee accounts.