This thesis uses the International Classification of Functioning, Disability and Health (ICF) model (World Health Organisation, 2001) to explore the multidimensional presentation of strengths and problems in young people with cystic fibrosis (CF), firstly examining its theoretical “fit” to the health condition, and secondly using it to characterise the performance of those with CF. Few studies in the literature demonstrate such an holistic approach to the physiotherapy assessment and management of this population. It was expected that this description of performance would provide a framework for identifying key areas for physiotherapy exercise intervention. This then formed the basis for further studies to examine the effect of a targeted exercise program (compared to current exercise practice) on inpatient outcomes, as well as on outcomes of outpatient management. The position paper included provides theoretical support for the ICF model as an appropriate tool in the management of young people with CF. Building on this, Study 1 explored the practical utility of the ICF model for describing the presentation of young inpatients and outpatients with CF. Eighty-four participants with CF were recruited as a consecutive series who satisfied selection criteria to provide a cross-sectional view at younger (7-12 years, n=51) and older (13-17 years, n=33) ages. Musculoskeletal, respiratory and physiological measures represented the body structures and functions domain, the six-minute walk test and jump tests were included in the activities domain, and participation was described by the Cystic Fibrosis Questionnaire–Revised Version and Fels Physical Activity Questionnaire. Contextual factors were also considered (age, gender, inpatient/outpatient status). In this exploratory study, performance of this population was compared to normative data where available. Also, correlations between measures within and between ICF domains were examined as suggested by the model itself. Finally, effects of contextual factors on performance were investigated using univariate analysis of variance. This first study and the position paper support the ICF model as an effective tool for describing performance of young people with CF, and for investigating functional relationships within and between domains. Results showed significant differences in this population compared to normative data, and interrelationships were identified within and between ICF domains. Between inpatients and outpatients in the specified age groups, there was a statistically significant difference in means for a number of measures, whereby inpatients displayed consistently poorer mean scores than outpatients, with this effect significantly stronger in the older age group. The application of the ICF model was useful for highlighting areas to target in physiotherapy exercise intervention, and for substantiating selected measures to assess the program’s effectiveness across domains. Study 2 was a randomised controlled trial with blinded assessor, which investigated the effectiveness of a 10-14 day inpatient-based exercise program (the Cystic Fibrosis: Fitness Challenge) (CF:FC) tailored for young people with CF (7-17 years). The CF:FC program (n=15) included exercise strategies based on recommendations from previous work in the field, and from findings from Study 1. This program included a portable exercise package (FitKitTM) designed to be adaptable to limited space environments such as at the hospital bedside, important when inpatients with CF are isolated according to infection control procedures. Participants in the control program (n=16) received the current exercise practice provided for young people with CF at a tertiary hospital, which included mainly aerobic-type activities to affect airway clearance. Performance on study measures (scoped within the framework of the ICF model, presented in Study 1) were compared pre- and post-intervention (admission and completion of the inpatient exercise program) between the groups. This trial showed significant improvements for participants in both groups from admission to discharge for a range of measures, including respiratory function, muscle strength and quality of life measures. Participants in the intervention group showed significantly greater improvements for some measures, for example: ankle dorsiflexor strength, six-minute walk distance and perception of their respiratory status. The continuation of the intervention and control programs into the outpatient setting was the focus of Study 3. The FitKitTM was provided for the intervention group, incorporating strategies to enhance adherence including a physical activity log (PAL) and internet-based follow-up. The control home exercise program consisted of the current practice provided on discharge. Interestingly, the control group improved significantly in hip abductor strength and six-minute walk distance during the outpatient period, whereas the intervention group sustained the improvements gained in the inpatient period but generally showed no further significant improvement. When the change from inpatient admission to outpatient follow-up was considered, it was apparent that greater improvements during the inpatient period provided a ‘buffer’ to accommodate for possible deteriorations in function in the outpatient phase. Issues regarding adherence to exercise programs during the outpatient period are discussed. This thesis confirms the usefulness of the ICF model for describing young people with CF, guiding assessment and review processes to achieve comprehensive management, and strengthening the evidence-base for targeted physiotherapy exercise intervention. A novel, tailored exercise program is introduced which is effective during inpatient periods, and provides a maintenance effect during outpatient periods, but strategies to enhance adherence during outpatient periods require further investigation.

This thesis uses the International Classification of Functioning, Disability and Health (ICF) model (World Health Organisation, 2001) to explore the multidimensional presentation of strengths and problems in young people with cystic fibrosis (CF), firstly examining its theoretical “fit” to the health condition, and secondly using it to characterise the performance of those with CF. Few studies in the literature demonstrate such an holistic approach to the physiotherapy assessment and management of this population. It was expected that this description of performance would provide a framework for identifying key areas for physiotherapy exercise intervention. This then formed the basis for further studies to examine the effect of a targeted exercise program (compared to current exercise practice) on inpatient outcomes, as well as on outcomes of outpatient management. The position paper included provides theoretical support for the ICF model as an appropriate tool in the management of young people with CF. Building on this, Study 1 explored the practical utility of the ICF model for describing the presentation of young inpatients and outpatients with CF. Eighty-four participants with CF were recruited as a consecutive series who satisfied selection criteria to provide a cross-sectional view at younger (7-12 years, n=51) and older (13-17 years, n=33) ages. Musculoskeletal, respiratory and physiological measures represented the body structures and functions domain, the six-minute walk test and jump tests were included in the activities domain, and participation was described by the Cystic Fibrosis Questionnaire–Revised Version and Fels Physical Activity Questionnaire. Contextual factors were also considered (age, gender, inpatient/outpatient status). In this exploratory study, performance of this population was compared to normative data where available. Also, correlations between measures within and between ICF domains were examined as suggested by the model itself. Finally, effects of contextual factors on performance were investigated using univariate analysis of variance. This first study and the position paper support the ICF model as an effective tool for describing performance of young people with CF, and for investigating functional relationships within and between domains. Results showed significant differences in this population compared to normative data, and interrelationships were identified within and between ICF domains. Between inpatients and outpatients in the specified age groups, there was a statistically significant difference in means for a number of measures, whereby inpatients displayed consistently poorer mean scores than outpatients, with this effect significantly stronger in the older age group. The application of the ICF model was useful for highlighting areas to target in physiotherapy exercise intervention, and for substantiating selected measures to assess the program’s effectiveness across domains. Study 2 was a randomised controlled trial with blinded assessor, which investigated the effectiveness of a 10-14 day inpatient-based exercise program (the Cystic Fibrosis: Fitness Challenge) (CF:FC) tailored for young people with CF (7-17 years). The CF:FC program (n=15) included exercise strategies based on recommendations from previous work in the field, and from findings from Study 1. This program included a portable exercise package (FitKitTM) designed to be adaptable to limited space environments such as at the hospital bedside, important when inpatients with CF are isolated according to infection control procedures. Participants in the control program (n=16) received the current exercise practice provided for young people with CF at a tertiary hospital, which included mainly aerobic-type activities to affect airway clearance. Performance on study measures (scoped within the framework of the ICF model, presented in Study 1) were compared pre- and post-intervention (admission and completion of the inpatient exercise program) between the groups. This trial showed significant improvements for participants in both groups from admission to discharge for a range of measures, including respiratory function, muscle strength and quality of life measures. Participants in the intervention group showed significantly greater improvements for some measures, for example: ankle dorsiflexor strength, six-minute walk distance and perception of their respiratory status. The continuation of the intervention and control programs into the outpatient setting was the focus of Study 3. The FitKitTM was provided for the intervention group, incorporating strategies to enhance adherence including a physical activity log (PAL) and internet-based follow-up. The control home exercise program consisted of the current practice provided on discharge. Interestingly, the control group improved significantly in hip abductor strength and six-minute walk distance during the outpatient period, whereas the intervention group sustained the improvements gained in the inpatient period but generally showed no further significant improvement. When the change from inpatient admission to outpatient follow-up was considered, it was apparent that greater improvements during the inpatient period provided a ‘buffer’ to accommodate for possible deteriorations in function in the outpatient phase. Issues regarding adherence to exercise programs during the outpatient period are discussed. This thesis confirms the usefulness of the ICF model for describing young people with CF, guiding assessment and review processes to achieve comprehensive management, and strengthening the evidence-base for targeted physiotherapy exercise intervention. A novel, tailored exercise program is introduced which is effective during inpatient periods, and provides a maintenance effect during outpatient periods, but strategies to enhance adherence during outpatient periods require further investigation.

Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model. / Graduate / 0571 / 0382 / 0384 / jazkim@uvic.ca

Spasticity is highly prevalent in neurological conditions involving upper motor neuron lesions (UMNL). Lower limb spasticity is known to impair gait and limit participation in physical activity. Multimodal interventions including botulinum toxin A, orthoses, and physiotherapy have shown longer lasting improvements compared to unimodal interventions. Studies to date, however, have not examined the long term efficacy of this multimodal intervention nor have they examined the impact across a breadth of domains necessary to comprehensively and fully understand its impact. The aim of this study was to investigate the efficacy of a multimodal intervention to treat lower limb spasticity in adults using a longitudinal mixed-methods approach, including a comprehensive set of outcome measures spanning the domains of the International Classification of Functioning, Disability and Health (ICF) model. Seven-teen participants with chronic UMNL were included in the analysis as per inclusion criteria and showed improvements at 6 and 12 months, compared to baseline, within all domains of the ICF model. / Graduate / 2015-04-24 / 0571 / 0382 / 0384 / jazkim@uvic.ca