Background: Involving patients in making decisions about the management of health conditions enables clinicians (including physiotherapists) and patients to deliberate about options and share information about the clinical situation; this may help to improve patients’ adherence and self-control over their illnesses. Low back pain (LBP) is a common and debilitating problem often managed by physiotherapists. The preferences of these patients and physiotherapists for involvement in decision making and, more specifically, those of patients and physiotherapists in Arabian cultures such as Saudi Arabia is largely unknown. Aim: to explore the perceptions and preferences of physiotherapists and patients with LBP for patient involvement in decision making and information provision. Research Design: This exploratory study was conducted in Saudi Arabia using a mixed methods approach, employing structured questionnaires followed by in-depth focus groups. Methods: Phase 1: A cross-sectional study was conducted with patients with LBP (n=296) and physiotherapists (n=93) using self-completion questionnaires developed for this study to examine the above aim. Phase 2: Ten focus group studies were carried out with participants to examine the reasons for their preferences. Analysis: Descriptive and inferential statistics were conducted to examine quantitative data; verbal transcripts were analysed using framework analysis. Results: Most patients preferred to adopt a more passive role in decision making within the clinical setting, but wished to share decisions about aspects occurring elsewhere (e.g., routine daily activities and home management programs). Patients' demographic and LBP characteristics were generally significantly associated with their preferences (p < 0.001-0.05). Physiotherapists were generally paternalistic in their approach to decision making. The in-depth information derived from the focus groups confirmed the questionnaire findings and provided some reasons for participant’s preferences. Conclusion: These findings provide information on which to base future studies to investigate the possible effect of preferences on treatment outcomes and the long term ‘self-management’ of LBP.

Oesophagogastric cancer represents a major healthcare burden in the UK. Surgery is the mainstay of treatment and often represents the only chance of long-term survival. However, treatment is associated with major morbidity and mortality and a potentially irreversible deterioration in quality of life. Authorising surgery is therefore an enormous decision for patients to make, often when anxious and unwell. The aim of this thesis was to explore the provision of, and need for, information before oesophagogastric cancer surgery. A validated questionnaire surveyed patients' views of information importance, including questions about the cancer and prognosis, tests, treatments, and impact on physical and psychosocial health. Audio-recorded out-patient consultations, followed by semi-structured interviews, supplemented questionnaire data and explored information provision and patients' information preferences using thematic analysis. Patients' understanding of visual information was assessed through interviews in which patients were asked to interpret series of graphs depicting hypothetical multidimensional quality of life data. A total of 136 of 226 (60.2%) invited patients completed the questionnaire. Patients rated most information highly but, in particular, potentially sensitive information (such as survival), complex information (such as the rationale behind treatment recommendations) and quality of life. 18 (17 male) patients underwent audio-recorded consultations and interviews. Consultations were found to involve uniform, methodical, surgeon-centric discussions of the process of surgery and short-term outcomes, and inconsistent, typically patient led discussions of quality of life issues. Interviews highlighted patients' desire for information about treatment eligibility, the process of surgery itself, survival and quality of life. 132 of 194 (68%) invited patients were interviewed to assess understanding of visual information. The majority understood simple (87%) and complex (81 %) multidimensional data. Recommended. information exchange between surgeons and patients selected for oesophagogastric cancer surgery includes communication of sensitive and complex concepts as well as information regarding the process of surgery. This research will inform the development of an intervention to improve information provision before cancer surgery.

Foot function has been linked with various musculoskeletal pathologies. In recognition of the over-emphasised role of interventional trials and the underdeveloped role of observational studies in investigating such relationships, a case-control study was designed to examine the link with low back pain. Before this could proceed, several critical issues surrounding the validity and reliability of measures of 'foot-type' were examined to identify the optimal technique for use in observational research. Firstly, the ability of static measurements to reflect the dynamic state was investigated for two footprint and a calcaneal motion measure to examine a basic validity dimension. Although all measures differed between states, high correlations revealed a consistent dynamic increase. Subsequent content validity assessment involved examining the response of footprint and navicular motion measures to 50 changes in subtalar joint position. Navicular height was most sensitive (consistently changing value significantly with between 50 & 100 of calcaneal motion), whilst poor performance of footprint measures (requiring >150 of calcaneal motion to induce significant changes) compromised their further use. The original intention to categorise subjects according to subtalar axis orientation to increase the precision of this validity study was abandoned after its reliability was found to be poor. Finally, the optimal, motion-based, measures of foot-type identified were utilised in a case-control study, which recruited 64 cases with low back pain and 57 controls. A significantly higher magnitude of left-right asymmetry of calcaneal and navicular motion, and a significantly reduced score on a foot-health related quality of life assessment tool, the foot health status questionnaire, was found in cases. Despite concerns over the absolute reliability and validity of the motion-based measures used, and several limitations in the case-control design, the study implicates foot function with low back pain and suggests that further study to determine the extent of its involvement is warranted.

This thesis investigates position awareness of the low back, measured using an electrogoniometer, in participants with and without recurrent non-specific low back pain (NSLBP). The ability to appreciate body position and movement makes an essential contribution to control of posture and functional movement. Pain may impair this awareness and initiate or exacerbate joint damage. Impairment of position awareness in the low back has been reported in patients with chronic low back pain. In addition, work-related activities may impair positional awareness, particularly in people experiencing LBP. The accuracy, stability and through range test-retest reliability of the electrogoniometer was assessed. It was found to be a reliable measure of degrees during movement in the sagittal plane between 0 to +/- 60 degrees, when compared to measurements using a calibrated, highly accurate, bevel protractor (mean error differences below 0.5 degrees for all tests). Low back position awareness was measured before and after a shift of work, in sitting and standing, in 61 people with recurrent NSLBP and 40 without a history of LBP. In addition, secondary analysis investigated the effect of occupation (manual workers, sedentary workers, drivers) on position sense. Low back position awareness was also measured in 50 people with recurrent NSLBP and 50 without a history of LBP during mid-range of sagittal plane movement of the low back in sitting; and when trying to return to a "good" sitting posture. There were no differences between participants with and without recurrent NSLBP in repositioning accuracy of the low back during any of the studies. When investigating the effect of occupation however, only sedentary workers achieved the power required for analysis. People with LBP positioned their "good" sitting posture significantly closer to end-range of low back extension, than people without LBP (12.47 SD8.46, v’s 16.51 SD9.41 degrees respectively; P=0.026). Recurrent NSLBP and sedentary work-related activities did not affect accuracy of position awareness in the low back. In people with recurrent NSLBP however, the position of their "good" sitting posture closer to end-range low back extension could lead to greater compressive loading of pain-sensitive spinal tissue, as well as increases in facet joint forces and shear forces on discs. These mechanisms may be aetiologic in the recurrence and maintenance of LBP. This finding may have implications for clinical practice, with consideration perhaps given to assessing the position of "good" sitting posture and its relationship to end-range in patients with LBP. Future research should investigate this further in larger populations of people with and without LBP, including specific sub-groups of LBP.

No description available.

The following study examined the psychological reactions following hand injuries and the interrelationship of coping styles (in particular, emotion-versus problem-focused coping), post-traumatic stress disorder reactions and psychological distress in this client group, compared to a comparison group of individuals with non-traumatically induced hand deformities (primarily Dupuytren's contractures). The hypothesized positive impact of problem-focused coping and negative impact of emotion-focused coping on psychological outcome was also investigated. A total of 25 individuals with hand injuries and 20 individuals with a hand deformity were interviewed. This involved completion of a semi-structured interview plus a range of standardized assessment scales including the COPE (coping inventory), the Post-traumatic Stress Disorder Inventory, the Impact of Event Scale and the Hospital Anxiety and Depression Scale (HAD). The majority of hand injury sufferers were seen six days to four weeks after their injury and three participants were seen at a longer duration of injury between 10 months to three years. Individuals were followed up at an average of approximately four months. The results showed significantly higher levels of PTSD symptomatology, anxiety and negative affect (at time 1) and emotional distress (at time 2) in the hand injury group compared to the comparison group. Increased use of emotion-focused coping in the hand injury group at time 2 coincided with differences in appraisal. The hand injury group appraised their injury as more threatening than the comparison group and loss appraisals were their predominant form of appraisal at time 2, whereas challenge appraisals were predominant in the comparison group. Positive associations emerged between both problem- and emotion-focused coping, PTSD symptoms and HAD anxiety and depression scores, although the correlations with emotion-focused coping tended to account for more common variance compared to those with problem-focused coping. Cross-lagged panel correlations indicated a possible causal influence of emotion-focused coping on total PTSD-I scores, intrusion on the Impact of Event Scale and anxiety (providing some support for the negative impact of emotion-focused coping). Analysis also suggested a possible role of problem-focused coping in the onset of anxiety symptoms, in addition to a bi-directional relationship between problem-focused coping and total PTSD-I scores. However, the failure of these results to reach statistical significance cannot provide conclusive evidence for these effects. The findings are discussed in relation to previous research and suggestions are made for future studies.

The evolution of humans to an upright stance has led to a change in the postural relationship between the human pelvis and the lower limb. However, despite the uncovering of the femoral head anteriorly, the bipedal hip remains inherently stable due to its bony anatomy and strong ligamentous support. Deviation from normal osseous anatomy results in a loss of constraint to dynamic movement with pathological translation of the femoral head (1,2). A similar scenario is expected with compromise of the surrounding soft tissue structures. A presentation of nine clinical cases describes the condition thought to result from compromise of the anterior hip ligaments. A triad of clinical signs are described. To investigate the patho-mechanical mechanism in these patients, a magnetic resonance imaging (MR.I) study of symptomatic hips was performed. Although increased joint , translation was not demonstrated in this study, distinctive appearances of the iliofemoral ligament were identified. Results of a cadaveric study then go on to demonstrate the stabilizing roles of the anterior capsular ligaments. With damage to the anterior capsule, increased translation of the femoral head was seen not only throughout movement range, but specifically correlated with the functional positions of the iliofemoral and pubofemoral ligaments. The concept of instability of the hip due to soft tissue laxity is postulated to result in progressive damage to the labrum and chondral surfaces as the femur abuts the acetabular rim during extra-physiological motion. Chronic capsular injury may destabilise previously asymptomatic hips with subsequent development of pain in young, active patients. Knowledge of the function of the capsule and its reinforcements is critical if hip surgeons are to manage these patients appropriately and understand the implications of capsular compromise on long-term function.

It has been theorised that self-perception is integral to the regulation of exercise and production of an optimal performance. This concept has not been examined in an anterior cruciate ligament (ACL) reconstructed population where the consequences of injury and surgery may provide a substantive perturbation to perceptual capabilities. Ratings of perceived exertion (RPE) have previously been shown to enable prediction of exercise task duration (TD) during running and cycling activities in healthy individuals, but this has yet to be explored in intermittent and isolated muscle exercise that is typically utilised during resistance training and ACL rehabilitation. Accordingly, this thesis investigated: i) the relationship between self-perceived knee function and objective measures of musculoskeletal performance at a range of time-points across the ACL-rehabilitation period; ii) the relationship between two paradigms of self-perception (RPE; perceived TD) and TD in healthy individuals during an intermittent isometric fatigue task (IIF) under various conditions of increasing exercise stress. Self-perceived knee function measured via subjective rating scales was only moderately correlated with objective performance towards the latter stages of the rehabilitation period, highlighting a disparity between perceived and actual capabilities during the early to intermediate stages of recovery (pre-surgery to 24 weeks). In contrast to previous research in running and cycling exercise, the investigation of self-perception and TD during an IIF revealed evidence of both linear and curvilinear trends in perceptual response. Linear trends were observed at exercise intensities of 60% to 80% of baseline volitional peak force, whilst curvilinear patterns of response were apparent at intensities of 60% peak force, and under conditions of exercise-induce muscle damage. Evidence of a negatively accelerating curvilinear response may reflect an underestimation of performance, and questions the utility of self-perception to predict TD in isolated muscle exercise. These combined findings highlight a need for further research before confirming the efficacy of self-perception with regard to regulating exercise during rehabilitative-type activities.

Introduction: Establishing best practice for knee replacement is important given the large number of procedures performed. Research into knee replacement is problematic given that implant failure is a rare event. The logistical and financial costs associated with prospective clinical trials are therefore high. Research using national arthroplasty registers may overcome some of these difficulties. Aim: To assess whether research performed on data recorded by the National Joint Registry for England and Wales has the ability to answer clinically relevant research questions relating to knee replacement surgery. To determine if registry research is able to answer specific clinical questions that are unsuited to prospective randomised clinical trial designs. Methods: Analyses was performed using combined data from the National Joint Registry for England and Wales (NJR) and the Department of Health Patient Reported Outcome Measures (PROMs) project. Results: Nine specific analyses investigated the ability of registry data to ask pertinent clinical questions relating to three areas of practice: unicondylar knee replacement (UKR), total knee replacement (TKR), revision knee replacement (RTKR). Discussion: Registry analyses are well suited to the analysis of rare outcomes such as implant revision and death. In comparison to prospective clinical trial designs they are cheaper, consume less time and resources and have the ability to identify associations and additional factors that may potentially influence outcome. As they use current national data they are more representative of “real-time” national practice and as such overcome some of the problems of generalisability associated with more rigidly designed clinical trials. However, as no information is collected about clinical decision making, drawing strong causal inferences from this type of data is problematic. Conclusion: Using registry data it is possible to answer a range of clinically important research questions. However, due to their limitations, it is necessary to combine information from these observational databases with clinical trial data before robust recommendations that influence clinical practice can be made. The key question researchers have to answer now is how registry data and clinical trial data can be effectively integrated.

No description available.