More young people are participating in organised sport, due to growing physical activity promotion programmes. This may increase the risk of injury in adolescents. The rate of injury in football, in particular at a professional level has increased. There is a lack of literature in Scottish youth football in different aspects of sports injuries. There is a need in sports medicine for a static and dynamic standing balance and proprioception tests to quantify balance ability in adolescents. Although there are many studies focussing on the risk of falls in the elderly there are few studies of balance and measures of proprioception and muscle strength in young and adolescent sports participants. Young football players were selected as the target population of these studies, because of the growing number of young participants in this popular sport, as well as the vulnerability of this group to sports injury during their growth. Knee injuries commonly occur during sports activity. The consequences of ACL injury, in particular, are more serious and costly compared to the injuries of other joints. Football players suffer from an increased of knee injuries. In various stages of rehabilitation of the injured athlete after ACL injury a sensitive method of evaluation is required to identify neuromuscular impairment. This thesis reflects the results of four studies on different aspects of sports injury. The first study, the retrospective epidemiology section, looked at the prevalence of sports injury in youth football players, using a self administered questionnaire as the data collection instrument. The focus of the research was football related injuries, which happened during the season 2002-2003. The subjects of this study were 221 young Scottish football players aged between 12 and 19 years old. The second or reproducibility study was designed to examine whether the results from one of the main equipment tools utilised in this study were reproducible and consistent. This part of the study aimed to determine the test-retest reliability of one tester dynamic unipedal and bipedal balance in two groups of youth football players and young active adults. A group of healthy active adults (over 19 years old) participated in the first part and a group of younger adults (under 19 years old) participated in the second part of the reproducibility study. The extension to the second study was designed to compare balance and strength in professional and non-professional players and non-football players.

Introduction: Football is one of the most popular sports world-wide. As with any sport, there is a risk of injury during participation. Therefore screening procedures are important not only to reduce the risk of injury but also for developing subsequent injury prevention programmes. Assessing functional movement is vital in screening in order to examine an athlete’s ability to perform fundamental tasks required for a specific sport. Currently in football no standardised functional screening protocols are widely available. Aim: To Develop a Functional Movement Screening Tool for Football Method Phase 1: A modified online, two round Delphi consensus panel was utilised to establish which tests should be included in a Functional Movement Screening Tool for Football. The panel of experts consisted of Physiotherapists working in Premiership Football. Results Phase 1: 14 Premiership Football Physiotherapists participated in Round 1 and 8 Premiership Football Physiotherapists in Round 2. After the completion of two rounds, the Delphi consensus panel identified 12 tests that should be included in a Functional Movement Screening Tool for Football. Method Phase 2: An online questionnaire survey was used to explore the level of agreement of Physiotherapists working in non-Premiership football on the 12 tests selected in Phase 1. This was distributed through email, postal invites and via twitter. Each participant was asked to rate their level of agreement with each test selected for the Functional Movement Screening Tool for Football. Results Phase 2: 26 Physiotherapists working in non-Premiership football agreed with the inclusion of 10 out of the 12 tests selected by the consensus panel in Phase 1. The single-leg squat, deep squat, in-line lunge, Y-balance test, modified Thomas test, internal rotators of the hip assessment, vertical jump test, external rotators of the hip assessment, adductor/groin flexibility test and gastrocnemius test were included in the final Functional Movement Screening Tool for Football. Discussion: A total of 40 Physiotherapists working in football collectively identified 10 tests to be included in a Functional Movement Screening Tool for Football. Although 10 tests have been identified for inclusion in the screening tool, standardised procedures still need to be defined for each test. Interestingly the tests selected for inclusion in the Functional Movement Screening Tool for Football were a combination of functional, balance, performance and muscle length tests. This highlights either a lack of understanding around the term functional movement or identifies a need for an overall screening tool in football as no standardised protocol is widely available at present. Conclusion: A screening tool specific for football has been developed. The use of a modified Delphi consensus panel successfully recruited and gained the views from Premiership Football Physiotherapists, a population which is normally difficult to access. Further research into the reliability and validity of the screening tool need to be examined in future studies. Successful methods for overcoming barriers in performing football research have been identified; in particular twitter may serve as a valuable resource for knowledge sharing in football.

The complexity of the pathophysiology of tennis elbow is reflected by the lack of consensus on management and remains a therapeutic challenge. This study was a prospective randomised, assessor-blinded trial. 64 patients with tennis elbow referred by their GP to either the physiotherapy, orthopaedic or MSK CAT services, subject to eligibility criteria, were randomised into one of 3 treatment arms: injection, ultrasound or exercise, to which the assessor remained blinded. The outcome measures of thermal difference, median frequency (MDF), patient-rated tennis elbow evaluation questionnaire (PRTEE), pain-free grip strength (PFG) and patient preference were assessed twice at baseline, at 10 days, 6 weeks and 6 months and analysed as an intention to treat analysis. In the short term of 6 weeks injection was the most effective treatment demonstrating both statistically significant and minimum clinically important differences (MCID) for PFG and PRTEE in comparison to ultrasound and exercise. Patients had a strong preference for injection and a strong aversion for exercise. No statistically significant differences were found between ultrasound and exercise although a MCID was found in favour of ultrasound for thermal difference and MDF at 10 days. In to the long term of 6 months, although this was on a limited subgroup, no statistically significant differences were found between any of the groups. A MCID was found in favour of ultrasound for MDF and a MCID was found in favour of exercise over injection for all aspects of PRTEE and over ultrasound for PRTEE pain only. This research supports the superior effectiveness of injection in the short term of 6 weeks and should be advocated for patients who present early with severe limiting pain and have important short term goals, although patients need to be warned that a 1/3rd will have a recurrence of symptoms within 6 months. In contrast, for those patients who present with moderate to low pain physiotherapy including exercise and/ or ultrasound should be advocated. Thermal difference is a sensitive outcome measure for tennis elbow. Continuous 3 MHz therapeutic ultrasound at 2W/cm2 for 5 minutes utilises thermal effects which optimise the healing process and demonstrate an accumulative effect of ultrasound in to the long term. Further research on the effectiveness of a combination of injection with physiotherapy is required.

Contemporary research into training load in team sports primarily focusses on the physiological load demands, whereas the biomechanical load still remains largely unexplored. While the former refers to the work-energy relationship when the players move around the pitch, the latter refers to the external forces the players are exposed to from their movements around the pitch. Monitoring of the biomechanical load helps practitioners estimate the stresses on an athlete’s musculoskeletal structures as a consequence of the external forces acting on their body. Monitoring of the biomechanical load is currently restricted to laboratory settings, but the recent introduction of GPS devices with integrated accelerometers in team sports may enable practitioners to monitor whole-body biomechanical load during training sessions and match-play. The aim of this thesis was therefore to explore if body-worn accelerometry can be used for whole-body biomechanical load monitoring in team sports. The first study of this thesis showed that although a linear relationship exists between body-worn accelerometry (e.g. from GPS integrated accelerometers) and whole-body accelerations, the linear relationship based on Newton’s second law of motion is weak regardless of accelerometer location (trunk, pelvis or tibia). Body-worn accelerometry only measures the acceleration of the segment it is attached to and is therefore inadequate to measure the complex multi-segment dynamics of the whole body during team sports movements. The second study of this thesis did however offer a potential solution to that problem, and it was demonstrated that the complex multi-segment dynamics of the body and the associated ground reaction forces (GRF), a surrogate for whole-body biomechanical load, can be estimated with a mass-spring-damper model (MSD-model). Nonetheless, the MSD-model’s accuracy to estimate GRF slightly decreases for sharp changes of direction at high intensities, because the absorption of energy and generation of energy are decoupled. Finally, a novel approach to estimate GRF from the combination of trunk-mounted accelerometry and a MSD-model was introduced in this thesis. This approach showed that trunk accelerometry data has the potential to generate the eight model parameters required to estimate GRF from a MSD-model, though further work is required in particular towards improving the model’s ability to estimate GRF across a wide range of activities. The novel approach introduced in this thesis has the potential to give practitioners in team sports the opportunity to monitor whole-body biomechanical load due to player-ground interaction in the field, a necessity if they wish to predict the consequent musculoskeletal structural adaptations of training sessions and match-play.

Sepsis and multi-organ failure are the most frequently reported causes of death in burn injuries. Their early identification allows therapies and resources to be targeted in a more effective and efficient way. Due to its frequent antibiotic drug resistance Acinetobacter baumannii (MRAB) is increasingly causing a problem in burns units. New strategies need to be found to combat infection and sepsis in the burn ICU. This study examines the potential of the Albumin Creatinine Ratio, a marker of systemic endothelial dysfunction in predicting outcomes, sepsis and multi-organ failure; the role of Acinetobacter in causing organ failure; and explores for the presence of the cathelicidin, LL-37 in the burn wound and examines it potential utility for treating infection and sepsis. It was found that ACR on admission and at 48 hours is predictive of patient outcomes and the development of sepsis, and may be of use predicting multi-organ failure. Multi-organ failure occurs more frequently in MRAB patients compared to those patients with drug sensitive Acinetobacter baumannii. The number of agency nursing staff and work intensity are possible contributing factors in MRAB acquisition. LL-37 has been found in both acute burn wounds as well as in the grafted healing burn wound and is active against drug resistant Acinetobacter baumannii. ACR can therefore identify those patients at risk of sepsis and may have a role in predicting multi-organ failure. MRAB acquisition in the burns intensive care unit is a significant cause for concern as patients are more likely to suffer from multi-organ failure as well as prolonging their hospital stay and resulting in poorer outcomes. LL-37 has many functions and importantly plays a role in the body’s innate immune system. In the era of increasing antibiotic resistance it may provide a novel therapeutic role in treating MRAB infection.

Whiplash-associated disorder (WAD) causes substantial social and economic burden, with ≥70% patients classified as WADII. Effective management in the acute stage is required to prevent development of chronicity for approximately 60% patients. A novel Active Behavioural Physiotherapy Intervention (ABPI) addressing both physical and psychological components of WAD was developed and evaluated as a complex intervention for acute WADII through a sequential multiphase project. Each phase was conducted using rigorous, precise and transparent methodologies according to pre-defined protocols. A systematic review and meta-analysis found that the combination of active physiotherapy and behavioural interventions may be a useful strategy. A modified Delphi study (international research and UK clinical whiplash experts) identified the underlying principles, and physiotherapy and behavioural treatment components of the ABPI. As no underpinning psychological theory was identified, the ABPI was further developed employing self-efficacy enhancement from social-cognitive theory to enable individualised management. A cluster-randomised, double-blind, parallel two-arm (ABPI: standard physiotherapy) pilot and feasibility trial (evaluating procedures, feasibility and acceptability ABPI) employed both quantitative and qualitative methods. Findings supported that the ABPI was potentially valuable (95% ABPI participants fully recovered with low number treatment sessions) and acceptable to physiotherapists and patients, supporting a definitive trial (with minor modifications).

There are over one million deaths from road traffic collisions. In Afghanistan, there have been 2005 UK battle injuries over 10 years. Advances in military trauma care have improved survival, resulting in more severely injured individuals entering the trauma care pathway. Improved understanding of immunoendocrine changes after severe trauma may facilitate novel interventions to improve outcomes. We prospectively recruited 102 severely injured patients at the QEH Birmingham; 52 military and 50 civilian patients with a mean Injury Severity Score of 27.2±13.9. Blood and 24-hr urine were collected at baseline (injury < 24h) and at regular intervals from while in hospital and at 3,4, and 6 months. Results demonstrated a reduced neutrophil function following a surge of DAMPs and cytokines that were released into the circulation. Both DHEA and DHEAS were significantly down-regulated (p < 0.0001). Serum testosterone was initially completely suppressed (p < 0.0001) but normalised after week 4. Protein and muscle loss followed a U-shaped curve; catabolism began to recovery 4-6 weeks following injury. In conclusion, the acute response to severe injury comprises increased glucocorticoid activation and down-regulation of adrenal and gonadal androgens. Delineation of whether the endocrine changes are beneficial or adverse will determine the potential for future intervention studies.

This thesis recalls and surveys the work of major theorists in the field of Trauma theory, including Freud, Charcot, Prince, Caruth and Leys. It will consider if literature can provide a positive response to the attestation and representation of trauma. For Derrida, testimony must always remain irreducible to evidence or proof. This secret at the heart of every telling is what is at stake for survivors of trauma. Further, pain (either physical or mental) is that which precisely can't be shared between subjects it cannot be denied neither can it be confirmed. On the one hand it induces certainty (I feel pain) and on the other, doubt (I can't see or feel your pain). One's pain is entirely aversive, a secret that evades language. How does this affect the textual production of trauma narratives? And how are those narratives received? The definition of testimony, that it alone can't constitute a 'proof whilst possibly recuperating one's right to 'tell' insomuch as one can construct an apparatus to evade censorship by government or other authorities, reduces that telling to a fiction, a story; which could be described as akin to the violence of blocking one's ears, refusing to partake in witnessing, a dismissal of subjectivity/sovereignty. Can literature and the art of testimony confront the impossibility of a proper response to trauma, a trauma that evades language and majority discursive practices?.

The ability of light to affect and modify human activity, both physiologically and psychologically has been known for many centuries. The treatment of wounds with light with varying properties has seen a dramatic rise over the last twenty years, from initial reports of the "magic laser" in the 1970's, to recent well controlled clinical trials. However, one of the major problems facing researchers and clinicians in elucidating the mechanisms by which light can modulate wound repair, is that of the different parameters of the light sources used, be they true laser devices, monochromatic light sources or. broadband wavelength units. This thesis describes a series of in vitro studies of the effects of varying the parameters of three light sources a) directly on fibroblast proliferation and b) indirectly, via supernatant from light-irradiated macrophage-like U-937 cells. The effect of U-937 cells was investigated because, as well as playing a pivotal role in wound debridement, macrophages playa central role in mediating the body's inflammatory and immune responses, mainly through the release of various polypeptide growth factors and cytokines and these can modulate wound healing. The experiments reported here show that there is a clear dose-response effect on the proliferation of fibroblasts when grown in macrophage-conditioned medium in which U-937 cells had been subjected to energy densities of 2.4, 4.B and 7.2J/cm2 using a monochromatic light source of 660nm at a frequency of 5kHz. Earlier work had shown that of a number of wavelengths examined, this wavelength evoked the greatest response. 2.4, 4.Band 7.2J/cm2 produced an increase in fibroblast proliferation above that of the sham-irradiated sample, 7.2J/cm2 producing the greatest effect. 9.6 J/cm2 was found to be inhibitory. The relationship between energy density and power density was investigated using the same model, but with a pure laser light source (820nm, frequency 5kHz). The U-937 cells were exposed to either 400mW/cm2 or 800mW/cm2 at energy densities of either 2.4 or 7.2J/cm2 (the doses giving the lowest and highest response in the previous experiment). There was a statistically significant difference in fibroblast proliferation between the 400mw/cm2 and Boomw/cm2 treatments, BoomW/cm2 producing the greatest cell proliferation at an energy density of 2.4J/cm2• There was no significant difference between the sham-irradiated sample and the 400mw/cm2 treated group. In contrast, using an energy density of 7.2J/cm2, the 400mW/cm2 treatment produced a greater increase in fibroblast proliferation than the sham-irradiated sample and there was no significant difference in cell number between the sham irradiated sample and 800mw/cm2 sample. The 400mW/cm2 sample produced a greater increase in cell proliferation than the 800mW/cm2 sample. Using the same model as above, the effects of two broadband (400-2000nm, continuous wave) light sources, of which one was 95% and the other 14% polarised, were investigated using energy densities of 1.44 and 2.88 Jjcm2• The proliferative response was greatest in the cultures exposed to supernatants from macrophages treated with the 95% polarised light source for both the energy densities used. The direct effect of 860 nm laser light (continuous wave) on the proliferation and succinic dehydrogenase levels of human forearm fibrobasts was investigated using energy densities of 2 and 16 Jjcm2• At an energy density of 2Jjcm2, succinic dehydrogenase and fibroblast proliferation levels increased to above that of the sham-irradiated sample, however, at an energy density of 16Jjcm2, succinic dehydrogenase levels and fibroblast proliferation were inhibited. The results presented in this thesis indicate either stimulation or inhibition of cellular activity which can be induced by specific levels and types of light irradiation and helps to elucidate the mechanism of action of light-producing devices at the cellular level.

In the first part of this work, an Anthropometric Test Dummy (ATD) was used to obtain torso acceleration data for Shaken Baby Syndrome (SBS). These data were used to drive computational simulations of SBS, in studies of the effect of neck stiffness and head-torso impact on injury risk. Finally, physical models were used to investigate the strain induced in brain tissue during shaking. Clinical literature describes victims of Shaken Baby Syndrome (SBS) as young infants with life-threatening brain injuries, and poor long-term outcome. However, biomechanical studies using ATI)s to study head motion during shaking have been inconclusive about the capacity for shaking alone to cause these injuries 11,21. This work comprises a series of investigations into these conflicting findings. Torso acceleration data for SBS, obtained using a specially constructed ATD, were found to be consistent with previous findings. The data were used to simulate shaking in computational studies of SBS, using Rigid Body Models (RBM) of the infant head and neck. Parametric studies were used to investigate the importance of neck stiffness in assessing the injury capacity of SBS, and showed that in order to exceed current injury criteria for SBS, impact was required. Head torso impact was then simulated, and although this resulted in higher injury risk than shaking alone, criteria for injuries associated with SBS were not reached. Since these investigations did not predict brain injury in cases of SBS without impact, the origins of injury criteria were reviewed. It was found that they are derived from single high energy events, which is distinct from the type of motion in SBS. In order to establish if cyclic, low-energy motion contributes to brain injury in SBS, Physical Continuum Modelling was used to study strain in brain tissue during shaking. A test rig was constructed to shake silicone gel models, and high-speed video used to capture the motion of optical markers with in the gel. Their movement was tracked using optical flow methods, and Green-Lagrangian strain derived by tensor algebra. No evidence was found to indicate a build up in strain between cycles, but published critical strains for damage to neural tissue were exceeded. Although shaking alone was not found not induce head motion in excess of brain injury criteria, tissue damage criteria were exceeded. The application of current brain injury criteria to SBS maybe therefore be inappropriate.