Aim: To study patient-related functional outcome measures, implant survival and radiographic loosening after total wrist arthroplasty (TWA) using four different implants. To evaluate a new TWA design biomechanically and clinically. Methods: The studies included two cohort studies with prospectively collected data (n=206 and n=219), an anatomic and kinematic analysis in a cadaveric model and a pilot study (n=20). Results: The Maestro TWA had a significantly greater improvement of radial/ulnar deviation than the Biax and Remotion TWAs. Summarized patientrelated functional outcome was significantly better for the Maestro than for the Remotion TWA. Cumulative implant survival after 8 years was 94% for Remotion, and 95% for Maestro implants. Radiographic loosening five years postoperatively was present in 26% of the Biax wrists, 18% of those with Remotion, and 2% of those with Maestro. Following TWA with the new implant design in a cadaveric model, there were no statistically significant changes compared to a native wrist regarding flexion, extension, radial deviation, the extension/radial deviation component of the dart-thrower’s motion, or the circumduction range of motion. Clinically, there was significant improvement of COPM, PRWE and VAS pain scores. Wrist extension and ulnar deviation improved, while grip strength remained largely unchanged. Conclusions: TWA is a surgical procedure which may offer a high level of patient satisfaction. Implant design may affect patient-related functional outcome after TWA. Implant survival as well as the frequency of radiographic loosening differed considerably between the four types of implants and might be a result of different implant design. Kinematic analysis of the new TWA design suggests that a stable and functional wrist is achievable with this design. Surgical placement of the new total wrist implant was reproducible and the implant yielded good patient-related outcome measures in the short term. Since TWA is an evolving procedure, further studies are warranted in order to refine indications and the place for TWA in modern hand surgery.

No / Little has been written about the functional outcome of patients treated with bone transport to reconstruct a distal tibial defect. The aim of this study was to investigate the functional capabilities of patients who had undergone reconstruction with distraction osteogenesis for the treatment of a distal tibial defect in one lower limb. At least eighteen months after completion of treatment, eight patients who had no pain and were able to walk and climb stairs without difficulty performed isometric ankle plantar flexion maximum voluntary contractions while the electromyographic activity of the tibialis anterior and triceps surae muscles was simultaneously recorded. Seven of the patients also underwent gait analysis. Data for the involved limb were compared with those collected for the contralateral limb. During gait, stance time (p = 0.01), the plantar flexion angular displacement and peak moment developed during the second half of stance (p < 0.046), and the amount of ankle power generated (p = 0.02) were significantly decreased in the involved limb compared with the contralateral limb. Similar decreases were observed in the plantar flexion (p = 0.01) and dorsiflexion (p = 0.01) maximum voluntary contractions and the corresponding electromyographic activity (p = 0.01). These results suggest that adaptive changes had occurred at the level of the transported muscles, which affected both routine and maximal effort capabilities. These findings contribute to our understanding of the functional limitations of patients who have undergone bone transport with its obligatory shortening of muscle length.

In recent years, the functional outcomes of patients with right hemisphere stroke (RHS) received considerable attention due to their impact on disability, independent living, quality of life and economic burden. Hemi-inattention (HI) is a complex condition which often accompanies RHS. It is characterised by reduced alertness, attention and low spatial awareness levels. Past studies reported poor outcomes in patients with HI and inconsistent findings in regard to the relationship of HI with functional outcome. Literature review of 13 relevant studies highlighted poor research methodology which complicated interpretation of previous results. Aims: The aim of this study was to address the clinically important question “What is the relationship between early HI status (HI±) and functional change in the 1st six months after right hemisphere stroke?” by improving on research methodology from past studies. Methods: An all-inclusive stroke severity RHS sample (58 with and 35 without HI) were recruited from two stroke units and assessed on motor and cognitive factors with validated measurement tools on four occasions; baseline, hospital discharge, 6 weeks after discharge, and 6 months after stroke. A multi-level modelling approach was used to analyse change in functional progress over time with potential explanatory motor and cognitive factors. Results: HI status was only statistically significant when modelled alone. Its predictive importance greatly diminished when modelled with other factors e.g. stroke severity, time since stroke and age. Conclusion: On average, HI group membership at baseline is unrelated to functional recovery when other influential factors are also considered. The findings extend current knowledge in stroke recovery research and provide suggestions for optimal therapeutic and rehabilitation outcomes. In contrast with traditional methods of regression analysis, multi-level modelling techniques enabled important relationships to be studied in depth. This resulted in new insights into the data which can be used to inform patient management and future research in the field.

The goal of this thesis was to investigate the hypothesis whether symptomatic remission for patents with schizophrenia spectrum syndrome would provide practical and qualitative benefits for patients and for society. The first work (Paper I) examines the relationship between cross-sectional remission and the patients’ practical resources. The patients’ adaptations to society as well as their employments, living situations and social networks were studied. Their activity of daily living resources are described in terms of the extent to which they could pursue various undertakings autonomously. Their need for care was also studied. The results showed that the patient group that had achieved remission scored better on all of the variables studied, had better resources and less need for medical care and sheltered housing. The second work (Paper II) analysed the relationship between cross-sectional remission and quality of life, burden placed on patients by the illness, and the patients’ satisfaction with care received and with their medication, and also their capacity for understanding their symptoms and their illness. Even the results of this study showed that the patients in the remission group had a better quality of life, bore a lesser burden, were more satisfied with their care and had better insight into their illness. The third work (Paper III) studied the patients’ neurocognitive capacity to see if a higher capacity resulted in a higher percentage of patients achieving remission. The results showed unequivocally that the patients in remission consistently performed better in the cognitive tests. They also showed that they even had a larger vocabulary indicating a higher premorbid capacity. The fourth work (Paper IV) followed the patients over an average time of 65 months. In this study, the patients’ needs for medical care and for housing were investigated. Patients who were not in cross-sectional remission at baseline had for all the measured variables a higher consumption than those in remission even if the differences were not significant, except for patients who lived in sheltered housing and who had greater need for medical care. Taking all these findings together, the result of this thesis shows that the attainment of remission provides practical and qualitative advantages to the patients and to society.

More than 15 million people worldwide will suffer a stroke each year two thirds will die or be left permanently disabled. Accordingly, stroke represents an enormous financial burden on the community, due to the cost of hospitalisation, treatment and rehabilitation of stroke patients. Despite the significance of this public health problem, a safe and widely applicable stroke therapeutic remains elusive. Cerebral oedema is widely recognised as a common and often fatal complication of stroke that is associated with worsened outcome. However, the exact mechanisms of oedema formation remain unclear, with current therapies largely ineffective in addressing the mechanisms of cerebral swelling, and also being associated with their own negative side-effect profile. This thesis characterises the role of neurogenic inflammation and the neuropeptide, substance P (SP), in mediating the development of blood brain barrier breakdown, cerebral oedema and resultant functional deficits following stroke, using a rodent model of reversible cerebral ischaemia. The findings of this thesis demonstrate that increased SP immunoreactivity, particularly of the penumbral tissue vasculature, is a feature of tissue perfusion following stroke, but not in non-reperfused infarcts. The central role for SP in the breakdown of the BBB following stroke and the associated deleterious effects of such breakdown was confirmed by studies using an NK₁ receptor antagonist. These antagonists conferred a profound attenuation of BBB breakdown, cerebral oedema formation, neuronal death and injury, and the associated development of functional deficits following reversible stroke. Similarly, depletion of all neuropeptides by capsaicin pre-treatment also reduced both histological abnormalities and functional deficits following stroke, confirming the central role of neuropeptides in the secondary injury process after stroke. The NK₁ receptor antagonist was able to be safely combined with the currently approved treatment for stroke, tPA, producing a synergistic effect of greater protection from the ischaemic insult. In particular, histological and functional outcome were markedly improved, as well as a reduction in the risk of intracerebral haemorrhage and death. Furthermore, the NK₁ receptor antagonist was effective even when administered up to 8 h following the onset of ischaemia, and in a variety of stroke severities. We conclude that SP plays a central role in the secondary injury that occurs following stroke, in particular, the genesis of BBB breakdown and cerebral oedema. Accordingly, combination therapy of tPA and an NK₁ receptor antagonist may offer a novel therapeutic strategy for the clinical management of ischaemic stroke of varying severity. / http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1298280 / Thesis (Ph.D.) -- The University of Adelaide, School of Medical Sciences, 2007

The purpose of this investigation was to assess the efficacy of a multifaceted gait analysis approach using a group of twenty osteosarcoma patients who underwent limb salvage surgery. Mean age at time of surgery was 16.1 years (range: 7-29), mean age at time of evaluation was 23.55 years (range: 11-43). Nine patients were treated with a Stryker Howmedica Modular Resection System (Stryker Kalamazoo, USA) and eleven patients were treated with a Stanmore custom made prosthesis (Stanmore implants worldwide Ltd, Stanmore, UK). Ten control participants with a mean age of 24.9 (range: 14-36) were recruited for the study. Ethical approval was gained through The University of Queensland Ethics Committee and The Royal Children’s Hospital and Health Service district Ethics Committee. Investigations included subjective, kinematic, kinetic, electromyographic and bioenergetic assessments. The subjective assessment incorporated results from the Musculoskeletal Tumour Society Rating Scale (MSTS) and the Toronto Extremity Salvage Score (TESS). Overall impairment was found to be 83.33% according to results of the MSTS and overall disability was found to be 86.00% according to results of the TESS. Kinematic findings showed that limb salvage participants walked with reduced velocity (p < 0.01) and increased step asymmetry (p < 0.01). Patients exhibited an increase in plantarflexion during the loading response (p < 0.001) and during terminal stance (p < 0.05), and an increase in dorsiflexion during mid-stance (p < 0.001). Knee kinematics revealed reduced extension during the loading response (p < 0.001) and increased frontal plane excursion throughout the gait cycle (p < 0.01). Patients exhibited increased lateral lean during loading response at the trunk (p < 0.05). Kinetic findings revealed a reduction in the magnitude of vertical ground reaction force during the loading response (p < 0.001) and a reduction in the magnitude of the anterior/posterior ground reaction shear force during terminal stance (p = 0.01). Furthermore, the internal ankle plantarflexor moment in terminal stance was reduced (p < 0.001), all sagittal plane knee moments were reduced (p < 0.05) and the internal hip adductor moment in terminal stance was reduced (p < 0.01). Electromyographic findings found that the limb salvage participants activated their rectus femoris for a significantly prolonged period (p < 0.5) and exhibited increased bilateral co-contraction of their rectus femoris and medial hamstring muscles (p < 0.05) compared with control participants. Bioenergetic findings revealed that the limb salvage participants exhibited an increased energetic cost (p < 0.01) and consumption rate (p < 0.01). Moderate correlations were observed between electromyographic and bioenergetic findings. Multivariate methods suggested that muscle removal, knee extension strength and knee flexion range of motion were all significant predictors of locomotor function. Length of bone resection and time from surgery were not predictive of post-operative function. The findings supported the efficacy of a multifaceted gait analysis approach for the assessment of pathological function under research conditions. The combined approach, using multiple measurements, allowed determination of functional status following musculoskeletal alteration. This enabled identification of primary and secondary compensations and allowed recommendations for improved treatment and rehabilitation.

More than 15 million people worldwide will suffer a stroke each year two thirds will die or be left permanently disabled. Accordingly, stroke represents an enormous financial burden on the community, due to the cost of hospitalisation, treatment and rehabilitation of stroke patients. Despite the significance of this public health problem, a safe and widely applicable stroke therapeutic remains elusive. Cerebral oedema is widely recognised as a common and often fatal complication of stroke that is associated with worsened outcome. However, the exact mechanisms of oedema formation remain unclear, with current therapies largely ineffective in addressing the mechanisms of cerebral swelling, and also being associated with their own negative side-effect profile. This thesis characterises the role of neurogenic inflammation and the neuropeptide, substance P (SP), in mediating the development of blood brain barrier breakdown, cerebral oedema and resultant functional deficits following stroke, using a rodent model of reversible cerebral ischaemia. The findings of this thesis demonstrate that increased SP immunoreactivity, particularly of the penumbral tissue vasculature, is a feature of tissue perfusion following stroke, but not in non-reperfused infarcts. The central role for SP in the breakdown of the BBB following stroke and the associated deleterious effects of such breakdown was confirmed by studies using an NK₁ receptor antagonist. These antagonists conferred a profound attenuation of BBB breakdown, cerebral oedema formation, neuronal death and injury, and the associated development of functional deficits following reversible stroke. Similarly, depletion of all neuropeptides by capsaicin pre-treatment also reduced both histological abnormalities and functional deficits following stroke, confirming the central role of neuropeptides in the secondary injury process after stroke. The NK₁ receptor antagonist was able to be safely combined with the currently approved treatment for stroke, tPA, producing a synergistic effect of greater protection from the ischaemic insult. In particular, histological and functional outcome were markedly improved, as well as a reduction in the risk of intracerebral haemorrhage and death. Furthermore, the NK₁ receptor antagonist was effective even when administered up to 8 h following the onset of ischaemia, and in a variety of stroke severities. We conclude that SP plays a central role in the secondary injury that occurs following stroke, in particular, the genesis of BBB breakdown and cerebral oedema. Accordingly, combination therapy of tPA and an NK₁ receptor antagonist may offer a novel therapeutic strategy for the clinical management of ischaemic stroke of varying severity. / http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1298280 / Thesis (Ph.D.) -- The University of Adelaide, School of Medical Sciences, 2007

Functioning Assessment Short Test (FAST) är ett instrument framtaget för att mäta funktion hos patienter med bipolär sjukdom. FAST fyller en potentiellt viktig funktion och både forskare och kliniker betonar betydelsen av att mäta funktion hos denna patientgrupp. Syftet med denna studie var att undersöka intern konsistens, interbedömarreliabilitet, faktorstruktur och samtidig validitet hos den svenska versionen av FAST. Datamaterialet samlades in på Affektiva mottagningen vid Psykiatri Sydväst och 219 patienter deltog i studien. Faktoranalysen gav stöd för sex faktorer. Interbedömarreliabiliteten var relativt låg och visade på signifikanta skillnader mellan olika bedömare. Även då resultaten preliminärt visade att FAST har tillfredsställande validitet och intern konsistens för att användas i det praktiska arbetet, bör de psykometriska egenskaperna hos den svenska versionen av FAST utvärderas ytterligare i kommande studier.

京都大学 / 0048 / 新制・課程博士 / 博士(人間健康科学) / 甲第18199号 / 人健博第16号 / 新制||人健||2(附属図書館) / 31057 / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 黒木 裕士, 教授 足立 壯一, 教授 三谷 章 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

Introduction: Colorectal cancer (CRC) survivors may experience functional deficits due to cancer-associated impairments. However, we do not understand their type and extent of functional deficits and how we could measure the associated cause of functional deficits, such as fatigue. As the survival of CRC survivors improves, the burden of living with functional deficits can be high. Purpose: My research program aims to understand (1) the functional changes and deficits that CRC survivors experience and (2) how to best measure fatigue in this population. Methods: To address the first aim, we used the data from the International Study of the Risk Factors for Gastrointestinal Bleeding and Cardiovascular Events after Gastrointestinal Bleeding to examine individuals’ functional abilities within 1 year of gastrointestinal cancer diagnosis (CRC being the most prevalent type). For the second aim, we conducted a systematic review on fatigue measures in adults with inflammatory bowel disease (IBD) because the causes, severity, and impact of IBD and CRC- related fatigue might be similar. We identified fatigue measures in the IBD population, appraised their psychometric properties, and recommended the most psychometrically robust and feasible measures for clinical and research use, indicating the optimal measures for CRC survivors. Results: After gastrointestinal cancer diagnosis, the majority (~70%) performed fewer functional tasks, mostly in the instrumental activities of daily living; and about 44% had more difficulty walking. Our review identified 16 measures, reviewed the content and psychometric properties, and recommended the Functional Assessment of Cancer Therapy Instrument-Fatigue and the IBD- Fatigue scale for research and clinical use in IBD and CRC populations. Conclusion: We provided a novel understanding of the functional deficits that CRC survivors experience and recommended the optimal measures for assessing CRC-related fatigue. As CRC survivors commonly experience fatigue, fatigue should be measured to understand its role in the functional abilities of CRC survivors. / Thesis / Master of Science Rehabilitation Science (MSc) / More people are living with colorectal cancer (CRC), but may have problems performing their daily activities (i.e. functional problems) due to cancer-associated impairments. However, we do not understand the extent of these impairments and functional problems. We used a sample of people with newly-diagnosed gastrointestinal cancer (CRC being the most common type) to understand their type and extent of functional problems. People were found to participate less in functional activities and particularly have more difficulty walking after a cancer diagnosis. Fatigue is common among those with CRC and may primarily cause functional problems. However, it is not commonly measured, and it is unclear how to best measure fatigue among them. Therefore, we reviewed key qualities of 16 fatigue measures in a similar population (inflammatory bowel disease, IBD) and recommended the Functional Assessment of Cancer Therapy Instrument-Fatigue and the IBD-Fatigue scale (English) as the most promising measures for those with CRC.