published_or_final_version / Social Work and Social Administration / Master / Master of Philosophy

published_or_final_version / Mental Health / Master / Master of Social Sciences

Clinical research has shown that patients experience difficulty in adjusting to their pre-morbid worker roles after they have been through a back rehabilitation programme. The pressure and competitiveness of modern day society to achieve competence and to survive has proven to be stressful, both for the injured and uninjured, the unemployed and employed. Back rehabilitation and the successful return of the injured worker to the workplace have been of great interest to industry for the last decade, due to the ever-increasing support of legislature for the injured. There is a range of medical interventions available but few of these achieve successful outcomes due in part to the fact that many intervention strategies do not take the patients perspectives into consideration. Therefore, the purpose of the study was to explore back rehabilitated clients perceptions and experiences of the challenges they face in adapting to their worker roles.

Background: Goal setting is accepted ‘best practice’ in stroke rehabilitation however, there is no consensus about what the key components of goal setting interventions are, how they should be optimally delivered in practice and how best to involve stroke survivors in the process. This PhD by publication describes the development and initial evaluation of a theory-based goal setting and action planning framework (G-AP) to guide goal setting practice in community based stroke rehabilitation settings. Included studies: The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided the development and conduct of a programme of research which included the following studies: (i) a review of the literature to identify theories of behaviour change with most potential to inform goal setting practice (Paper 1) (ii) a causal modelling exercise to map identified theoretical constructs onto a goal setting process and convening of a multi-disciplinary task group to develop the theoretical process into a Goal setting and Action Planning (G-AP) practice framework (Paper 2) (iii) a process evaluation of the G-AP framework in one community rehabilitation team (Paper 3) (iv) a United Kingdom (UK) wide survey to investigate the nature of services providing community based stroke rehabilitation across the UK and what goal setting practice is in these settings in order to understand the context into which an evaluation of the G-AP framework could be introduced (Paper 4) Main Findings: The review of the literature identified three theories of behaviour change that offered most potential to inform goal setting practice: Social Cognitive Theory, Health Action Process Approach and Goal Setting Theory. These theories contained constructs directly relevant to the goal setting practice: self-efficacy, outcome expectancies, goal attributes, action planning, coping planning and appraisal and feedback. The causal modelling and Task group exercise: (i) Informed development of the G-AP framework into a four stage, cyclical process that included (i) goal negotiation and setting (ii) planning and measuring confidence (iii) action and (iv) appraisal, feedback and decision making. (ii) Proposed mechanisms of action: successful completion of action plans resulting in incremental improvements in goal sub-skills and self-efficacy. (iii) Predicted outcomes G-AP was likely to impact on: goal attainment and improved rehabilitation outcomes. The process evaluation suggested that each stage of the G-AP framework had a distinct purpose and made a useful contribution to the overall process. Overall, G-AP was acceptable and feasible to use but implementation of novel aspects of the framework (coping planning and measuring confidence) was inconsistent and health professionals had concerns about the potential impact of unmet goals on patients’ wellbeing. Patient reports suggested that (i) the experience of goal non-attainment could facilitate adjustment to limitations resulting from stroke and (ii) feeling involved in the goal setting process can incorporate both patient-led and professional-led approaches. The survey findings highlighted the variability that exists in community based stroke rehabilitation services in the UK (e.g. the patients they see; the input they provide). Goal setting is reportedly used with all or most stroke survivors in these services; however, practice is variable and may be sub-optimal. Conclusions: G-AP is the first practice framework which has been explicitly developed to guide health professionals through a systematic, theoretically based and patient centred goal setting process in community based stroke rehabilitation. G-AP is a cyclical process that that has four key stages, proposed mechanisms of action and has shown promise as an acceptable, feasible and effective framework to guide goal setting practice. The complexity that exists within community based stroke rehabilitation services, and the variability in usual goal setting practice used within them, should be considered when designing a study to evaluate the effectiveness of G-AP in routine practice.

Health Studies / (D. Litt. et Phil. (Health Studies))

A Masters Dissertation submitted to the Department of Speech Pathology and Audiology School of Human and Community Development, Faculty of Humanities University of Witwatersrand Johannesburg, in fulfillment of the requirements for the degree Master of Arts in Speech Pathology, November 2017 / Background: Traumatic Brain Injury (TBI) is a serious public health problem worldwide. It is a major cause of death among younger adults and is a leading cause of lifelong disability in persons who survive it. There are a large number of young adults living with life-long disabilities as a result of traumatic brain injury worldwide, with higher numbers existing in South Africa. Whilst previous research internationally has examined issues of community integration and difficulties experienced by persons with traumatic brain injury and their significant others or caregivers, a paucity of research of this nature exists in South Africa. This study intended to explore whether a gap in clinical practice exists with regard to aspects of intervention and support, underpinned by an ambiguous definition of community integration for survivors of traumatic brain injury and their significant others Method: The main aim of the study was to explore existing feelings of community integration and active participation in patients with traumatic brain injury who have been discharged from rehabilitation services in private practice in Johannesburg, South Africa. In this study, the sample comprised of 10 survivors of TBI and 10 significant others (SOs). The objectives were to describe and compare participants and significant others’ or caregivers experience of community integration and factors that influenced the perceptions by each (i.e. the patient and the caregiver) as well as to document barriers and facilitators to community integration and active participation within the, familial, social and work context. Lastly the study aimed to determine if the qualitative analysis of formal assessment measures (FIM and CIQ-R) match perceptions of persons with TBI with regard to Community Integration (Landrum et al., 1995). Results: Across various areas of comparison, participants who scored higher in the CIQ-Rand FIM measures, often expressed more subtle difficulties or challenges that landed up going undetected and ultimately contributed to their personal feelings of poorer community integration. Various studies, including the current study reveal that significant others have many unmet needs in terms of what they know and what they should expect with regard to handling their loved one with a TBI. Implications: This research has highlighted the fact that our South African context is lacking with regard to ongoing management of individuals surviving TBI, with reduced funding available for outpatient therapies, a lack of post discharge programmes and a general lack of education and information given to family members of TBI survivors upon discharge. As such this should be a major focus of health care providers in the future. This research revealed many subtleties that impact perceptions of community integration but go undetected by formal measures. Such subtleties could be used to direct specialised programmes, which should be made available to TBI survivors post discharge from rehabilitation services. Keywords: traumatic brain injury; community integration; rehabilitation; functional outcomes; private practice, developing countries, community resources, south Africa / XL2018

A research report submitted in partial fulfilment of the requirements for the degree of Master of Arts in Social and Psychological Research to the Department of Psychology, School of Human and Community Development, The University of the Witwatersrand, Johannesburg, South Africa, 2017 / Introduction. The provision of appropriate long term care facilities for people with acquired brain injury is a portentous issue internationally. There is a global lack of long term care facilities for people with acquired brain injury and they are often placed in facilities for the physically disabled or the elderly. It is unclear whether these facilities are suitable and what effect they may have on well-being and social isolation. Aim. This interpretive phenomenological study explored how adults with acquired brain injury experience living in such long term care facilities. Additionally, it described how such living arrangements impact on social isolation, a particularly devastating psychosocial consequence of acquired brain injury. Method. One-on-one, semi-structured interviews were conducted with seven adults who had acquired a brain injury. Each participant had been living in a long term care facility for at least one year. They were asked questions related to their general lived experience as well as specific questions to explore their experience of social isolation. Findings. Thematic content analysis of the interview data led to the following five categories of themes: overall evaluations (guarded approval, and disapproval); general lived experience (autonomy, choice, freedom, burden, boredom, and basic needs); social isolation (loneliness, companionship, and belonging); sources of isolation (living with the disabled, different disability, age differences, pets, and facility setup); and sources of well-being (positivity, and meaning). The main findings were that the general lived experience of people with ABI was mainly negative. The facilities generally met only basic needs and seldom met higher level psychological needs. Social isolation was commonly reported among residents with ABI in long term care facilities and was linked to age differences and having a brain injury in a facility geared for people with other disabilities. The findings were understood in relation to Bronfenbrenner’s ecological systems theory and Maslow’s hierarchy of needs. Conclusions. The findings of this study contribute towards filling a theoretical gap in understanding the lived experience of people with ABI in long term care facilities and how this contributes to social isolation. The findings have potential value to family members of people with acquired brain injury considering various living arrangement options. They can also be useful for long term care facilities housing people with brain injury to make changes that may result in greater well-being of their residents. / MT 2018

A research report submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Arts in Clinical Psychology. Johannesburg, 2016 / Substance dependence is a global issue that is becoming significantly more problematic. This is due to the fact that it does not just have a devastating effect on the individual but results in profound spin-off effects, which impact society as a whole. Much research has been conducted within this area and contemporary research has seemed to focus on the link between attachment styles and substance abuse. Since its conception by John Bowlby, attachment theory has achieved an empirical authority that has contributed to its popularity in modern times. However, despite this renewed interest there still exists a gap in the literature around the role that relationships, throughout the lifespan, play in areas such as pathology and recovery. Consequently, this research embarked on an interpretive phenomenological exploration of the way relationships impact the lives of individuals suffering from substance dependence. Adults in recovery from substance dependence were individually interviewed about their experiences of their relationships during and after their years of abusing substances. Hermeneutical phenomenological analysis was used to analyse this data and it revealed a typical model of pathology where a negative childhood experience had cascading effects that culminated in the later dependence on substances. Participants all highlighted relationships with themselves or others as pivotal to either seeking substances or to going into recovery. These themes were then located within Bowlby’s (1976, 1980) developmental pathways framework in order to make sense of the progression of substance dependence along the lifespan as it manifested in these participants. / MT2017

Stroke is the leading cause of disability in the United States. The majority of stroke survivors have persistent arm dysfunction, which impedes their daily task performance. Mirror therapy (MT) as an adjunct to occupational therapy (OT) has been shown to be effective in upper extremity (UE) recovery post-stroke. Two protocols, unimanual mirror therapy (UMT) and bimanual mirror therapy (BMT), have been used in OT practice; however, research specifically comparing these two intervention protocols is absent. The purpose of this study was to compare: (a) home-based UMT and BMT protocols, and (b) both MT protocols to home-based traditional occupational therapy (TOT) regarding upper limb recovery post-stroke. Twenty-two chronic stroke participants were randomized into one of three groups: UMT, BMT, or TOT. The Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), ABILHAND, grip strength, and the Stroke Impact Scale (SIS) were administered pre- and post-intervention. Participants received outpatient OT 2 days/week for 45 minutes, plus a home program 30 minutes a day, 5 days/week for 6 weeks. A repeated measure ANOVA, Kruskal-Wallis Test, and Wilcoxon Ranked-Signed Test were used to compare the three groups, and 95% confidence intervals (CI) and effect sizes were calculated. There was a main effect of time for all groups, except for SIS-strength and activities of daily living (ADL); however, no group differences were noted on any of the measures. When comparing UMT and BMT, the effect size for all measures, except for grip strength, favored UMT. In comparing both mirror groups to TOT, UMT had a moderate to large effect size on the ARAT, FMA, and ABILHAND, as compared to the small effect size for BMT. Furthermore, 95% CI data for the ABILHAND showed clinical significance in favor of UMT compared to TOT, but not for BMT. This study showed that all groups improved over time and UMT may be more beneficial for UE recovery in chronic stroke individuals, compared to either BMT or TOT. However, given the small sample size, future studies comparing the two mirror protocols are necessary for more definitive conclusions to better inform clinicians of the optimal mode of MT treatment.

Unilateral deficits resulting from stroke manifest as reduced velocity, decreased cadence and asymmetries in temporal, spatial and force parameters during ambulation. Gait asymmetries and compensatory strategies employed during gait result in a higher mechanical energy cost that limits activity and community participation. Despite conventional rehabilitation efforts, individuals often remain with chronic gait deficits after stroke. Robotic-based therapies have been developed as an alternative to conventional rehabilitation. These therapies offer the means to provide task-specific training at an intensity greater than that of conventional approaches; however, to date outcomes have been similar to that of conventional training. One factor potentially contributing to the limited efficacy of robotic training is the active-assist control strategy that is often employed. This type of training strategy reduces the users’ engagement in the learning process and limits skilled learning. The tethered pelvic assist device (TPAD) is a robotic device that employs actuated tethers at the pelvis to guide the user along a pre-set movement trajectory. While other robotic devices restrict movement to a fixed trajectory, the TPAD promotes shifting weight onto the paretic limb, but permits users to freely move the limb to navigate spatiotemporal aspects of training independently. This allows individuals to participate in the problem-solving process required for motor learning to occur, facilitating a more active role in the motor task itself, and thus promoting learning. Earlier work utilized the TPAD to reduce gait asymmetry in a population of individuals in the chronic phase after stroke in a single training session (Bishop et al., 2015; Vashista, 2015). Results demonstrated an increase in propulsive forces of the affected limb as a result of the intervention, but these gains did not transfer to overground gait. A follow up study explored the feasibility and efficacy of two different training strategies using the TPAD (Bishop et al., 2017). Both training strategies proved feasible and similarly efficacious. The current work examines the feasibility and preliminary efficacy of a five-day intervention using the TPAD with faded visual feedback and a short bout of task-specific overground training to reduce gait asymmetry in a population of individuals at least six months after stroke. Participants underwent a series of three Pre Test assessments within a one-week interval prior to initiating the intervention. Training occurred over five consecutive days, with a Post Test assessment administered on conclusion of Day 5 of training. A one-week Follow Up assessment was also recorded. Results demonstrated this intervention coupling TPAD training with additional tenets of motor learning including visual feedback and salient task-specific overground training was feasible in terms of safety, tolerance and adherence. Further, while participant’s load asymmetry was not significantly reduced on the treadmill from Baseline to Post Training (p >0.05), there was a significant improvement in stance symmetry during overground gait (F = 8.498, p = 0.002). These results suggest that the integration of motor learning tenets with robotic TPAD training was useful in facilitating gains to overground walking. Implications to the broader scope of robotic training suggest that creating an environment in which the user plays a more active role is useful at maximizing effects of robotic training. Future work should include comparison groups (TPAD treadmill training, overground training, and combined TPAD and overground training) with a more robust sample size for a longer duration of training to parse out contributing factors to overground gains. Future work should also consider a longer training and follow up interval in an effort to determine whether individuals are able to maintain improvements longer than the immediate post training period.