Clinical reasoning is a vital skill for physiotherapy professional practice and can be thought of as the thinking and decision making processes used in clinical practice. Learning experiences in traditional pre-registration physiotherapy courses may neglect the development of clinical reasoning and thus the link between theory and practice where clinical reasoning is embedded into the curriculum within other subjects. A new case based, cardiorespiratory, technology enhanced learning module was introduced to second year BSc (Hons) Physiotherapy students on a traditional course, with the aim of improving the link between theory and practice and developing clinical reasoning. Students were asked to participate in wikis in small groups to develop problems and treatment plans for six patient cases. The introduction of a wiki allowed students to practise skills required for clinical reasoning, such as evaluation and making treatment decisions but it also changed the underlying pedagogy for the new module to a constructivist approach rather than a behaviourist approach. It was unclear how this would influence the students’ learning and their development of clinical reasoning. This research sought to develop an understanding of these issues.

The focus of this thesis was to understand the influence of a conceptual model of practice upon occupational therapists in a British health and social care setting. Case study methodology was used to explore the clinical practice of Occupational Therapists (OTs) in one county in England who implemented the Canadian Model of Occupational Performance (CMOP) (CAOT 1997a, 2002). The research focused upon a deeper understanding of the complex interactions between individual factors and the case being examined. This required examination of three sources of data, namely meeting minutes, artefacts and participant interviews. Each was examined separately and then themes from all three units were examined to identify themes from across the dataset to understand inter-relationships to support the development of theoretical propositions and contribute to theory building. This study identified that use of a single model, the CMOP actively encouraged practice development in this county and was a dynamic and multifaceted social process.

Photodynamic therapy (PDT) is a non-invasive treatment method used for treating superficial skin lesions such as non-melanoma skin cancer (NMSC). The combination of light, a photo- sensitive molecule and oxygen results in selective tissue destruction. Even though PDT has resulted in many successful treatment outcomes, the treatment parameters such as required light dose and preferred light source have not yet been optimised. Since monitoring of the treatment progress is limited to surface observations, it is difficult to observe what is happening under the surface of the skin. In this thesis, the development of complex numerical modelling techniques is considered with the aim of increasing the understanding of how PDT works within the living skin tis- sue. In particular, the potential of using daylight as an alternative therapeutic light source is explored. Daylight PDT is associated with lower experienced pain and has the potential of reducing pressure on the clinics as well as the number of treatment occasions. A Monte Carlo radiation transfer (MCRT) model was developed to track photon propagation during treatment. The first theoretical investigation of daylight PDT is presented where the results indicate a potential treatment depth of over 2 mm, which is sufficient for treating superficial skin cancer lesions. Additional models are developed, which consider the drug interaction and the diffusion of the drug. To include different patient characteristics and more detailed skin models, multi-layered tissue as well as complex three dimensional tumour tissues are included within the MCRT model framework. There is no such thing as a generic patient, making it difficult to generate standardised treatment protocols. The research performed in this thesis provides further insights into light interaction with skin tissue for different patient and treatment characteristics, which is a vital step towards achieving more individualised treatment regimes.

Polymer gels were used with magnetic resonance imaging (MRI) to measure three-dimensional absorbed dose distributions for beta particles, electron and x-rays beams that are used in radiotherapy. The manufacturing processes and calibration procedures for two dosimeters (hypoxic PAG and normoxic MAGIC gels) were investigated. The response of both gels was energy independent over a range of electron and photon energies commonly used for radiotherapy. However, dose response of both gels was dependent on the temperature at the time of MR scanning, while MAGIC was also dependent on the temperature at the time of irradiation, which had not been previously reported. Results suggest that MAGIC gel is superior to PAG, since it is easier to manufacture and unaffected by oxygen diffusion through wall materials. The potential usefulness of both types of gel in different areas of radiotherapy was studied, including vascular brachytherapy. Results were compared with doses measured using radio- chromic film, confirming that dose distributions for vascular brachytherapy sources with a high dose gradient can be measured using PAG. However, because of the disadvantages of the gel manufacturing process and the need for access to a high-resolution scanner, it was concluded that radio-chromic film would be the method of choice for routine quality assurance in brachytherapy. PAG and MAGIC gels were also used for dosimetry across the junction of 6MV photon and 12MeV electron fields that are often used in radiotherapy. Different photon field configurations were studied, and dose profiles were measured. For each configuration either significant "hot" or "cold spots" were measured, with good agreement between the MAGIC and PAG and radio- chromic film. This work has confirmed the usefulness of gel dosimetry in radiotherapy in general, and in beta and electron dosimetry in particular. In addition, these studies have quantified the advantages of normoxic gels over the hypoxic PAG.

This longitudinal, qualitative study explored the learning experiences of physiotherapy students from non-traditional backgrounds undertaking an innovative part-time programme. Non-traditional characteristics included maturity, prior and ongoing employment as physiotherapy assistants and weaker academic backgrounds. The phenomenographic methodology followed is an approach associated with research into student learning. Seventeen students in the 2000 cohort participated in five semi-structured interviews undertaken at intervals across the four-year programme. Topic areas which research has identified as influencing students' learning and learning outcomes were explored at each stage of the study relative to experiences in the preceding time period. These included motivational factors, curriculum design and delivery, learning and assessment experiences in academic and clinical settings, and perceptions of the concepts of learning, understanding and memorisation. Verbatim transcriptions of interview tape recordings were coded manually and an iterative process followed to identify discreet categories of description which, together, captured the full range of responses on the topics addressed at each set of interviews. To identify temporal changes, the number of responses associated with each category, and for each student, was recorded. A rich picture of the experiences, attitudes and behaviours of participants was found. The findings identified that they strove for achievement of the high quality learning outcomes necessary for effective clinical practice and lifelong learning. Students' life experiences and high levels of motivation were important learning resources. Although some aspects of the programme were challenging, the participants' weaker academic backgrounds did not prevent them from successfully meeting the requirements of higher education. Feedback on the design and delivery of the programme was also positive. Temporal stability around conceptual perceptions was found. Further research into the learning experiences and behaviours of physiotherapy students from both traditional and non-traditional backgrounds is needed, as is more longitudinal research into student learning in general.

Respiratory motion induces uncertainty in External Beam Radiotherapy (EBRT), which can result in sub-optimal dose delivery to the target tissue and unwanted dose to normal tissue. The conventional approach to managing patient respiratory motion for EBRT within the area of abdominal-thoracic cancer is through the use of internal radiological imaging methods (e.g. Megavoltage imaging or Cone-Beam Computed Tomography) or via surrogate estimates of tumour position using external markers placed on the patient chest. This latter method uses tracking with video-based techniques, and relies on an assumed correlation or mathematical model, between the external surrogate signal and the internal target position. The marker's trajectory can be used in both respiratory gating techniques and real-time tracking methods. Internal radiological imaging methods bring with them limited temporal resolution, and additional radiation burden, which can be addressed by external marker-based methods that carry no such issues. Moreover, by including multiple external markers and placing them closer to the internal target organs, the effciency of correlation algorithms can be increased. However, the quality of such external monitoring methods is underpinned by the performance of the associated correlation model. Therefore, several new approaches to correlation modelling have been developed as part of this thesis and compared using publicly-available datasets. Highly competitive results have been obtained when compared against state-of-the-art methods. Marker-based methods also have the disadvantages of requiring manual set-up time for marker placement and patient positioning and potential issues with reproducibility of marker placement. This motivates the investigation of non-contact marker-free methods for use in EBRT, which is the main topic of this thesis. The Microsoft Kinect is used as an example of a low-cost consumer grade 3D depth camera for capturing and analysing external respiratory motion. This thesis makes the first presentation of detailed studies of external respiratory motion captured using such low-cost technology and demonstrates its potential in a healthcare environment. Firstly, the fundamental performance of a range of Microsoft Kinect sensors is assessed for use in radiotherapy (and potentially other healthcare applications), in terms of static and dynamic performance using both phantoms and volunteers. Then external respiratory motion is captured using the above technology from a group of 32 healthy volunteers and Principal Component Analysis (PCA) is applied to a region of interest encompassing the complete anterior surface to demonstrate breathing style. This work demonstrates that this surface motion can be compactly described by the first two PCA eigenvectors. The reproducibility of subject-specific EBRT set-up using conventional laser-based alignment and marker-based Deep Inspiration Breath Hold (DIBH) methods are also studied using the Microsoft Kinect sensor. A cohort of five healthy female volunteers is repeatedly set-up for left-sided breast cancer EBRT and multiple DIBH episodes captured over five separate sessions representing multiple fractionated radiotherapy treatment sessions, but without dose delivery. This provided an independent assessment that subjects were set-up and generally achieved variations within currently accepted margins of clinical practice. Moreover, this work demonstrated the potential role of consumer-grade 3D depth camera technology as a possible replacement for marker based set-up and DIBH management procedures. This brings with it the additional benefits of low cost, and potential through-put benefits, as patient set-up could ultimately be fully automated with this technology, and DIBH could be independently monitored without requiring preparatory manual intervention.

This research explores the student experience and formation of a professional identity on undergraduate and postgraduate occupational therapy and physiotherapy programmes at Hillside University. In my administrative role, I was aware that the student experience on these programmes did not reflect the typical “college experience” associated with transitions into student and campus life and then towards qualification. These health profession students make simultaneous transitions into higher education, and into a profession through practice placement settings where they learn skills and work alongside health professionals. Thus, they navigate between two worlds of very distinct modes of learning and socialisation, with the shared objective of a professional qualification and career. Using a phenomenological approach, the study explores those transitions through the subjective eyes of the participants. Data was gathered using semi-structured interviews with first and final year students on both UG and PG professional courses over one academic year, offering a longitudinal perspective and revealing students’ personal experiences of the formation of a professional identity through learning and socialisation. The study reveals how students engage less in traditional student activities due to anticipated periods on placements, and some non-standard start dates, and how students develop a strong focus on their learning and close cohort and peer groups bonds. The research found that as practice placements were experienced, students became more engaged with their future professions in the placement contexts, and also more distant with the university and its conceptualisation of a learner’s identity. These aspects of student experience could be further explored, with more pre-registration health courses being developed and increasing numbers in the Health Faculty on programmes with placements, it is important for the HEI to recognise this and ensure these student perspectives are considered.

No description available.

Background: Low back pain (LBP) is associated with pain-related beliefs, coping strategies and anxiety and depression. Culture is known to affect the pain experience through language, beliefs, and attitudes. Most investigations into the effectiveness of pain management programmes (PMP) that aim to reduce emotional distress and unhelpful beliefs, encourage activity and participation and promote long-term self-management have been carried out in Western countries. This has implications for implementing PMPs for LBP in Bahrain. Methods: Five studies were conducted: 1) a systematic review of studies assessing for determinants and predictors of self-reported LBP disability in non-Western cultures. In Bahrain 2) translation, cross-cultural adaptation and psychometric testing of the Roland-Morris Disability Questionnaire (RMDQ), Back Beliefs Questionnaire (BBQ) and Pain Coping Strategies Questionnaire (CSQ); 3) a cross-sectional survey of factors associated with LBP disability; and 4) a qualitative exploration of beliefs and experiences of patients living with LBP were carried out to inform 5) feasibility and acceptability testing of a physiotherapist-led PMP. Results: 1) The systematic review identified 12 studies from eight non-Western countries. Evidence was strong for fear-avoidance beliefs having a low association with LBP disability. Evidence was moderate for a moderate association between LBP disability and pain intensity, and no association with symptom duration. 2) The translated and cross-culturally adapted Arabic RMDQ, BBQ and CSQ were comprehensible, acceptable, valid and reliable self-report outcome measures. Their psychometric properties were comparable to other versions. 3) The cross-sectional survey (n=199) showed age, gender, pain intensity, back pain-related beliefs, fear-avoidance beliefs, ability to ignore pain, control pain and decrease pain, depression and anxiety explained 34.7% of the variance in LBP. 4) Five themes emerged from the qualitative study (n=18); i) loss of independence and change of identity causes distress; ii) beliefs and attitudes towards low back pain; iii) trying to cope with LBP; iv) experiences within the healthcare system; and v) participants’ assessments of their needs. 5) Feasibility testing of the PMP (n=23) showed 16 participants completed the programme, and 9 (60.0%) were retained at 6 months. Participants found the intervention credible and acceptable. At 6 months, LBP disability, pain intensity, back-pain beliefs, the ability to reinterpret pain sensations, fear-avoidance beliers about work and depression scores indicated better outcomes. However 6 month scores also indicated higher catastrophising, fear-avoidance beliefs about physical activity and anxiety levels. Conclusions: The experiences of Bahraini patients with LBP were similar to findings reported in the Western literature; however some factors differed due to the influence of Muslim Arab culture. The results encourage the use of a culturally-modified biopsychosocial approach to pain management in Bahrain, and other cultures. Therefore, culturally-specific factors such as differences in the LBP experiences between genders, culturally-specific examples and activities, religious coping strategies, and use of catastrophic expressions were taken into consideration when designing the PMP. Participants found the intervention credible and acceptable, but as in Western PMPs, there were high attrition rates. Changes such as the incorporation of value-based goals and the use of booster phone calls are suggested to improve adherence and facilitate behaviour change. The results of this thesis warrant further investigation into the effectiveness the physiotherapist-led PMP in Bahrain for LBP.

The ability to verify absorbed dose distributions produced by intensity modulated radiotherapy (IMRT) using dynamic multileaf collimation is of great concern in the clinical application of this technique. This thesis investigates two approaches using an Elekta SL/ linear accelerator operating in dynamic mode (Elekta Oncology Systems, Crawley, UK). A novel strip ionisation chamber array, located at the beam aperture, was designed and used in conjunction with a specialised electrometer. This also recorded cumulative accelerator monitor units (MU) via an isolated interface to the accelerator. The chamber signal, recorded as a function of MU, proved suitable for collimator position verification for the case of a dynamic wedge, but was found not to be suitable for more general cases in which the leaves moved independently. A tube camera-based electronic portal imaging device (EPID) (Theraview , Cablon Medical, Leusden, The Netherlands) was investigated in a further approach to verification. This EPID has not been previously studied for dosimetry and several unreported effects associated with the video system were identified. The phosphor Gd202S:Tb, which is used as the x-ray detector, was also studied by direct measurements of luminescence using a photomultiplier tube. It was confirmed that the optical signal was independent of accelerator pulse repetition frequency, and that there was no long- lived luminescence (afterglow) following prolonged irradiation, which is of concern in dosimetry of dynamic deliveries. The EPID was applied to the verification of collimator position using a specially constructed camera interface that triggered recording of the cumulative MU. The EPID was also assessed as a method of measuring the integrated dose distribution delivered during a dynamic sequence, and a method proposed to overcome unreliable triggering of image acquisition in such cases. Dark current and persistence of the camera target were found to complicate measurements. Images were also found to exhibit optical scattering, which is an inherent characteristic of camera- based EPIDs. Results of a physical means of reducing the effect using an optical rejection screen were compared to an ionisation chamber for static and dynamic cases, and it was shown that the optical rejection screen is limited in its effectiveness in removing optical scatter. Dose profiles obtained from the EPID agree with ionisation chamber measurements in-air within 6 % for plain fields, and within 15-25 % for static and dynamically produced wedged fields. It was concluded that both approaches studied can be applied to the verification of IMRT but with limitations, and that an ideal system has yet to be found.