This research used focus groups to investigate the views of occupational therapists from contrasting geographic areas of Thailand on the concept and practicability of the independent living movement within a Thai context. In addition, convergent interviews were employed with individuals from a region where insufficient professionals for group formation agreed to participate. Emerging themes were around the issue of differences and similarities in the concept of independent living between Western and Eastern cultures. Rather than independent living promoting an individualistic culture in Thailand, interdependent living was seen to be likely to be more suitable for a collectivistic culture like Thailand. However, independent living, along with other constructs concerning activity and participation were deemed to have been integrated with values shared by the participants. According to their construction of responsibilities, the participants felt it was crucial to- provide support for clients for independent living. Moving from an agricultural to an industrial society has caused changes in family structure in Thailand that have resulted in disabled people being pushed to live more independently. There do appear to be mechanisms within Thailand allowing independent living for disabled people to be made possible but it requires a period of time to address the barriers existing in disabled people themselves, their families, people in the community, physical environment, the Thai government and therapy professionals as well as financial barriers. To support independent living in Thailand, strategies for practice are suggested. Some strategies require cooperation and collaboration from other stakeholders in society. The client-centred and occupation- based models are viewed as being appropriate to form a frame of occupational therapy practice for promoting independent living and need to be augmented by community service, counselling and social skill, and knowledge for occupational therapists to be enabled to support independent living.

Introduction: Fatigue is the most troublesome untreated symptom during radical breast radiotherapy. This situation persists due to an uncertain aetiology and an inability to identify patients at high risk of experiencing significant fatigue during subsequent radiotherapy. Aetiological investigations of the current study concentrated on discriminating the radiotherapy-specific effects on fatigue, in a context encompassing multiple psychological and physiological covariates. Prognostic aspects sought to characterise a 'high-risk' patient. Methods: The study cohort comprised 100 women, diagnosed with Stage 0 to IIA breast cancer, and prescribed standard whole breast irradiation to 40Gy in 15 fractions over three weeks. The use of systemic therapies was an exclusion criterion. A cytokine-induced sickness behaviour model framed the study investigations, and provided a theoretical link between localised radiotherapy and systemic fatigue. The outcome fatigue was assessed before, during and four weeks after radiotherapy, using the Functional Assessment of Chronic Illness Therapy Fatigue Subscale. Volumes of tissue irradiated were derived from dose-volume histogram analysis concentrations of the cytokine interleukin-6 soluble receptor were established via enzyme-linked immunosorbent assay. Multivariate analysis determined the factors that contributed to fatigue and generated a prognostic model that classified participants to fatigued or non-fatigued groups. Results: 38% of participants experienced significant fatigue during radiotherapy, with the remainder little affected. The fatigued group recorded relatively elevated pre-radiotherapy levels of depression, and particularly anxiety, as measured by the Hospital Anxiety and Depression Scale. Depression uniquely accounted for 34% of the variance in pre-treatment fatigue. During radiotherapy, depression level and interleukin-6 soluble receptor concentration were significantly elevated in the fatigued group compared to the non-fatigued group (p < 0.0001, p = 0.01, respectively). The volume of tissue irradiated significantly affected peripheral interleukin-6 soluble receptor concentration (p = 0.003), but was not significantly associated with fatigue. A model comprising pre-treatment fatigue, anxiety and activity level (as measured by the International Physical Activity Questionnaire) reliably classified 82% of the study participants to the correct fatigue outcome (sensitivity 71.1% specificity 88.7%). Conclusion: Psychological mood is the strongest predictor of fatigue before and during radiotherapy. Inter-related data is consistent with the concept that a lower psychological mood prior to radiotherapy relates to a distinct immunological and behavioural response during radiotherapy. These aetiological insights may inform fatigue treatment pathways, and ensure the targeting of future interventions at early breast cancer patients at a high risk of experiencing fatigue.

Objectives: To design, implement and evaluate an alternative physiotherapy group exercise programme used for managing chronic low back pain (CLBP) in Primary Care. Introduction: CLBP is a disabling condition with no established standard management. Conservative treatments such as supervised exercise and manual therapy have demonstrated some benefit. Group exercise programmes used in physiotherapy practice are a cost effective treatment for managing CLBP but currently lack a combination of individualized specific exercises, one to one education and manual therapy (‘hands on’ techniques). An alternative group programme was designed to address these limitations. Methods: This thesis consisted of two stages; a survey and a mixed methods design study. The physiotherapy survey was used in stage 1 to investigate what type of exercises are prescribed by physiotherapists and which group programmes are used in clinical practice for managing CLBP. One hundred and fifty-four questionnaires were distributed with a response rate of 63%. Ninety-seven percent of physiotherapists surveyed refer their CLBP patients to group programmes but only 47% of all respondents were able to refer non-English speaking patients. None of the group programmes offered manual therapy. The alternative group physiotherapy programme was developed using this research, review of the literature and consultation with service providers. In stage 2, the alternative group exercise programme was evaluated using a mixed methods preliminary study consisting of a core quantitative and supplementary qualitative phases. The alternative group programme (Group A) was compared to a standard group exercise programme used in clinical practice (Group B) in a single blinded randomised controlled trial. Participants with CLBP were allocated to the two programme groups by block randomisation. Participants in both groups attended six one-hour programme sessions over a 3-month period. Outcomes measuring function, pain, quality of life (EQ-5D) and satisfaction with treatment were used to evaluate the effectiveness of the programmes pre and post programme attendance and at 6 months. Focus groups in the qualitative phase were used to explore patients’ experiences regarding their treatment in the two group programmes. Results Stage 2: Eight-one participants were randomised to the two groups (41 in Group A; 40 in Group B). There was a drop-rate of 33% and only 41% were followed up at 6-months (n=10, Group A; n=12, Group B). There were no statistically significant differences between groups in outcome scores and apart from the EQ-5D at six months, the associated effect sizes were small. The within group analysis revealed significantly lower disability and pain scores post-programme compared to pre-programme in both groups. There were significantly higher EQ-5D scores post-programme compared to pre-programme in Group A but not in Group B. Quality of life deteriorated in Group B at 6-months. The focus group interviews showed that patients prefer individualised exercises and one-to-one education which are components of the alternative programme. Conclusion: This alternative programme may provide a suitable addition to existing programmes available for managing CLBP. This research may change the way physiotherapists deliver exercise for CLBP patients in a group setting.

Background and Rationale: Pressure ulcers (PUs) present significant threats to patients and cost billions of total healthcare expenditure. In radiography/radiotherapy, a potential for high interface pressure (IP) on radiography/radiotherapy tables may exist, however no study has investigated this to an acceptable scientific level. Thesis aims: This thesis involved two-phases. The primary aim of phase one was to investigate whether IP risks exist on radiography/radiotherapy tables. The secondary aim was to assess the perception of pain and comfort on radiography/radiotherapy tables. The aim of phase two was to determine the impact of pressure relieving interventions on IP at jeopardy areas. Method and results: In the first phase, an Xsensor pressure mapping system was used to measure IP of jeopardy areas in healthy volunteers (26 females, 23 males; aged 18-59 (mean=34.6±10.5)) on three radiography/radiotherapy surfaces, after which they completed a pain and comfort questionnaire. ANOVA identified statistically significant differences in the mean IP for head, sacrum, and heels across the three surfaces (p≤0.001). Results indicated high IP values for head (75.9±6.9mmHg) on the radiotherapy table. This high IP could induce tissue breakdown, thereby increasing the risk of developing PUs in at risk populations. Volunteers experienced most pain whilst lying on the radiotherapy table. In phase two, a thin gel intervention with low radiation attenuation, which also has no impact on image quality, was assessed to reduce IP risks identified for the head. Pressure mapping was conducted on 20 healthy volunteers (14 males (70%) and six females (30%)); aged 25-53 years (mean=34.4±7.0). Paired-samples t-test indicated a statistically significant difference in the mean IP for the head with and without the intervention; both comparisons recorded mean IP values of 62.4±6.1 and 83.9±8.1 mmHg respectively, p≤0.001. Similarly, there was statistically significant difference in the PPI of the head with and without the intervention (mean=159.8±26.8, and mean=205.1±28.2mmHg respectively; p≤0.001). Conclusion: IP risk exists for the head on radiotherapy tables. This could induce tissue injury in patients accessing prolonged interventional radiography and radiotherapy procedures for the head. A thin gel silicone intervention can reduce this risk. Further research is needed to assess its impact in at risk populations.

In this thesis, a methodology is developed to generate optimised three-dimensional voxel-based CT texture maps (3D-VTM) to examine regional heterogeneity information within tumours and their relation to tumour metabolism measured as 18F-fluoro-deoxy glucose (18F-FDG) Positron Emission Tomography (PET) distributions. Ten patients diagnosed with advanced non-small cell lung cancer (NSCLC) were investigated. For optimal texture information decoding, an optimised quantisation method is presented. The texture feature that reflects heterogeneity and which showed correlation with patients’ survival was chosen for this thesis. To account for respiratory motion effects, an in-house designed phantom was used to characterise the effects of motion on texture analysis and consequently adapt our method in that regard.

Occupational therapists are known to use storytelling and storymaking in their clinical practice to assist people with disability to visualise and work towards a positive future which they, themselves, can construct. Little work seems to have been done using the same medium of storytelling with occupational therapists in order to explore aspects of their professional life, career and possible future. The aim of this study was thus to investigate the use of narrative in research and in occupational therapists' clinical practice, and to examine its potential for exploring occupational therapists' career stories. Qualitative research was undertaken drawing on the biographical tradition, life history research and narrative inquiry for its methodology. A total of seven taped interviews were recorded with die agreement of two female occupational therapists who had been in practice for a minimum of eight years. In conversation, they told the story of their entry to the profession and of the ups and downs of their career as an occupational therapist. Emotions such as pleasure and pain seemed to be experienced as their stories emerged. Their narratives produced rich data. Systematic analysis revealed characteristics of both the storytelling process and of the narrative itself. The nature of the occupational therapists' careers and the context in which they were played out became apparent. Despite there being only two participants, their stories illustrated how their work was strongly guided by their personal values. Their stories revealed that triumphs and setbacks at work could be experienced in different ways. Their reflective comments made during the storytelling process sometimes offered new insights into these experiences, so that telling the story became, for them, a way of reviewing the issues and seeing them in a new light. The findings also showed that the therapists' career could not easily be isolated from their home life. The two appeared to be inter-dependent, and in this study were perceived to be in balance. Both occupational therapists expressed satisfaction about their professional and personal life and, as a result, were unwilling to project too far into the future about how their career might develop. It was concluded that storytelling, and the reflection involved in producing the narrative, could assist a therapist to explore issues and dilemmas that occurred at work. The process of telling the story could help to redefine the situation in relation to the context in which it was occurring and could help to determine a satisfactory future course of action. It is possible that storytelling in a confidential relationship with another could assist the professional development, not only of occupational therapists but also of other health professionals. A forum, such as in a mentorship arrangement, could allow work-related issues, career options or opportunities to be explored for their costs and benefits and enable better informed career decisions to be made.

Radiation-induced genetic instability has been observed in survivors of irradiated cancerous and normal cells in vitro and in vivo and has been determined in different forms, such as delayed cell death, chromosomal aberration or mutation. A well defined and characterized normal human-diploid AG1522 fibroblast cell line was used to study giant-nucleated cell (GCs) formation as the ultimate endpoint of this research. The average nuclear cross-sectional areas of the AG1522 cells were measured in um^2. The doubling time required by the AG1522 cells to divide was measured. The potential toxicity of the Hoechst dye at a working concentration on the live AG1522 cells was assessed. The yield of giant cells was determined at 7, 14 and 21 days after exposure to equivalent clinical doses of 0.2, 1 or 2 Gy of X-ray or proton irradiation. Significant differences were found to exist between X-ray or proton irradiation when compared with sham-irradiated control populations. The frequency of GCs induced by X-rays was also compared to those formed in proton irradiated cultures. The results confirm that 1 Gy X-rays are shown to induce higher rates of mitotically arrested GCs, increasing continually over time up to 21 days post-irradiation. The yield of GCs was significantly greater (10%) compared to those formed in proton populations (2%) 21 days postirradiation. The GCs can undergo a prolonged mitotic arrest that significantly increases the length of cell cycle. The arrest of GCs at the mitotic phase for longer periods of time might be indicative of a strategy for cell survival, as it increases the time available for DNA repair and enables an alternative route to division for the cells. However, the reduction in their formation 21 days after both types of radiation might favour GCs formation, ultimately contributing to carcinogenesis or cancer therapy resistance. The X-ray experiments revealed a dose-dependent increase in the GCs up to 14 days after irradiation. Although the proton irradiation was less efficient in producing GCs, their frequency was elevated in a dose-dependent manner 7 days after irradiation, with persistent expression of nuclear deformity as an indicator of genetic instability. In addition to the quantification of the GCs, the proliferation of a small fraction of giant cells formed at 14 days after 0.2 Gy of proton irradiation was observed to divide into asymmetrical, normal-sized daughter cells. These results might have important implications in evaluating risk estimates, or could act as a potential radioprotective assay for a dose-limiting parameter for delayed effects in healthy tissues during radiation therapy treatment.

This thesis is situated in the context of simulation-based education (SBE) within cardio-respiratory physiotherapy in the UK. A pragmatic mixed methods study has provided a comprehensive examination of the use of SBE from two perspectives: 1) physiotherapy education and 2) pre-registration physiotherapy students’ experiences of managing a deteriorating patient in a simulation context. Two national surveys in Phase 1 provided the first insight into the spectrum of SBE utilised in pre-registration and postgraduate physiotherapy education in the UK between 2009 and 2010. National inconsistencies in simulation provision and accessibility were identified. Financial costs, time and access to simulation centres/laboratories reportedly influenced the use of SBE within cardio-respiratory physiotherapy education. Phase 2 combined SBE and video-reflexive ethnography (VRE) methods to elicit a unique and comprehensive exploration of performance, behaviours, errors and personal experiences of 21 final year (pre-registration) physiotherapy students from one higher education institution in the UK. This study has identified the multi-layered impact of personal experiences and behaviours on practices, clinical decisions, dynamics and the complexities and interconnectivity of participants to the simulation environment. The range of errors identified by this study also highlights the complexity of managing an acutely deteriorating patient in a simulation context. The combination of SBE and VRE allowed the participants to explore errors and defences erected within the scenario and their impact on patient safety. The findings of this thesis emphasise the importance of scenario design, considering the learner’s level of experience, prior knowledge and sequencing of abstract skills before requiring contextualisation within a complex scenario. Carefully planned and executed SBE and VRE methods can provide a safe learning environment to allow participants to explore routine, evolving and complex situations whilst allowing them to learn to be become comfortable with making and exploring errors. Thus, the findings provide valuable insights to inform future research regarding physiotherapy practice and integration of educational methods to augment patient safety awareness and enhance safe healthcare practice. The key message of this thesis is that SBE is a valuable learning modality to explore the complexities of healthcare education and practice.

No description available.

Background: Anterior cruciate ligament (ACL) injury is associated with pain, limited function and reduced quality of life (QoL), with prevalence associated with sports participation, which represents a clinical and financial burden to patients and healthcare systems. ACL reconstruction is the main treatment and pre-operative physiotherapy potentially plays a role in preparing patients for surgery and improves post-surgery health outcomes. Its effectiveness on patients’ health outcomes pre- and post-surgery and awareness of patients and healthcare professionals have not been investigated in the Kingdom of Saudi Arabia (KSA). There is a lack of standardised protocols used in practice for pre-operative physiotherapy management of patients undergoing ACL reconstruction, and the clinical and financial effects have not been investigated. Aims: This thesis aims to develop a standardised pre-operative physiotherapy programme for patients undergoing ACL reconstruction based on clinical and literature evidence, and to investigate the effectiveness of the developed protocol in KSA. Methods: This study included three inter-related phases. Phase 1 - a survey of the prevalence of ACL injury in Riyadh, KSA, and of pre-operative physiotherapy awareness of healthcare professionals and ACL-deficient patients. A sample of 200 patients and 200 practitioners was surveyed and the Ministry of Health and 3 hospitals were contacted about ACL injury cases. Phase 2 - a systematic review of literature on pre-operative physiotherapy programmes and effectiveness in ACL injury management. Phase 3 - a quasi-randomised clinical trial of a standardised pre-operative protocol, using Phase 1 and 2 findings. This protocol was administered to ACL-deficient patients undergoing reconstruction in KSA. Two patient groups were included: an intervention group (n = 39), who received the developed pre-operative programme; and a control group (n = 45), who did not receive pre-operative physiotherapy. The primary outcome measures were based on the Knee injury and Osteoarthritis Outcome Score (KOOS), and secondary outcomes included range of motion, quadriceps and hamstring muscle strength, health status (using the EQ-5D-5L tool), pain score, QoL and resource use. Results: Phase 1 showed ACL injury is the most prevalent knee related injury (53%), with young, active participants being mostly affected (60%). The prevalence in Riyadh (31 per 100,000) was similar to international figures. 82% healthcare professionals were aware of pre-operative physiotherapy, whereas 55% of surveyed patients were aware. Phase 2 suggested that pre-operative physiotherapy is beneficial to ACL injury patients. Phase 3 demonstrated that primary and secondary outcomes were improved prior to surgery in the intervention group compared to baseline (p < 0.01). Post-surgery outcome measures were better in the intervention group than the control group (p < 0.05) except function in sports activity, which was similar. The incremental cost-effectiveness ratio (ICER) related to pre-operative physiotherapy intervention was estimated at 13449 SR (£2241) per QALY gained and the intervention was cost-effective. Conclusions: The findings showed the clinical and cost-effectiveness of the developed, evidence-based pre-operative protocol in preparing patients for ACL reconstruction and improving health outcomes post-surgery. Therefore, pre-operative physiotherapy for ACL injury should be integrated routinely into the Saudi healthcare system.