Objectives: The diaphragm is the primary muscle of inspiration and provides life sustaining oxygen to the body (Voyvoda et al, 2011). It is active during relaxed and effort induced ventilation. Diaphragm contraction results in pressure changes within the thorax thereby assisting in airflow into the lungs and increasing lung volumes. During this inhalation process the diaphragm moves from a dome-shaped relaxed position into a flattened shortened position.Often during the increased work of breathing in patients suffering from chronic obstructive pulmonary disease (COPD), the diaphragm does not sit in its anatomical resting position; it shortens and weakens (Watson et al, 2001). Stretching of skeletal muscles is a physiotherapy treatment modality commonly used in clinical practice. The aim of this treatment modality is to increase the length of a shortened muscle thereby improving the range of motion of said muscle and improving the specific joint motion (Wepler and Magnusson, 2011). Head down tilt positions are commonly used in cardiopulmonary physiotherapy to utilise gravity to facilitate sputum drainage from different lung segments (Pryor & Prasad, 2008; Selsby & Jones, 1990). A head down tilt position could potentially have an influence on diaphragm length if applied for a sustained period of time due to likely abdominal content displacement from a caudal to cranial position resulting in a stretch on the diaphragm. The objective was to determine if diaphragm length could be influenced by providing a stretch using the abdominal contents. Moreover, to see if this hypothesized change in length would influence the diaphragm’s function. Method: A quasi-experimental study was conducted from January to April 2012 with undergraduate physiotherapy students as study participants. Seventy five study participants were assessed for baseline outcome measures at rest. They then underwent four body position changes after which each measurement was re-recorded. These body position changes were: • lying in a head down tilt position at 15 degrees for 30 seconds • lying in a head down tilt position at 15 degrees for two minutes • lying in a head down tilt position at 30 degrees for 30 seconds • lying in a head down tilt position at 30 degrees for two minutes Ultrasound was used to measure the diaphragm length. Its function was recorded in terms of the expiratory flow generated and the thoracic expansion measured. Dyspnoea was recorded for a subjective view of tolerance of the position and vital signs were monitored throughout for the volunteers’ safety. ANOVA, Kruskal Wallis, Bartlett’s test and the student’s t test were used for statistical analysis. Results: All 75 participants completed the entire study and none were withdrawn as a result of negative side effects. The results showed that the diaphragm could be stretched by using the abdominal contents in a head down tilt position (p=0.00). The mean and standard deviation for the greatest change from rest was 38.78mm (±11.51) on the left and 39.38mm (±11.92) on the right. There were no detrimental effects to the participants’ cardiovascular or pulmonary stability. Thoracic expansion and peak flow showed an insignificant change throughout the changes in position. Thoracic expansion had a mean change of 2.48cm (±0.86) with a p value of 0.54. Peak expiratory flow rate had a change of 428.94L/min (±95.01) with a p value of 0.98. These values were less than the normal expected values for the participants. Conclusion: A change in diaphragm length is possible by applying a stretch to the muscle. A stretch can be applied by placing the participant in a head down tilt position which allows the abdominal contents to push on the underside of the diaphragm in a cranial direction. No adverse effects occurred in healthy adult individuals during the different head-down tilt positions. Respiratory function did not show a significant improvement due to the change in diaphragm length as measured by peak expiratory flow rate and thoracic expansion.

Introduction: Pressure sores are the most common complication post spinal cord injury. Pressure sores of the sacral area commonly occur and often lead to patients being placed on bed rest. Bed rest periods delay rehabilitation, and may lead to other complications associated with immobility. Physiotherapy is crucial for these patients to decrease complications and increase function. This study set out to establish the treatment interventions physiotherapists provide to patients with sacral pressure sores and the factors that they take into consideration when deciding whether the patient should receive physiotherapy in bed (in the ward) or in the gym environment. Methods: This was a cross sectional survey administered to physiotherapists working in neurological rehabilitation units around South Africa that treat patients with spinal cord injuries. A self-administered questionnaire was used for data collection. The questionnaires were sent to all eligible physiotherapists via email. All the data was captured onto an excel spread sheet. Data collected were presented as frequencies and percentages with the aid of tables, pie charts and bar graphs as was appropriate. Results: Thirty-nine physiotherapists responded which showed a response rate of 76%.The majority of the respondents were female (98%). There were 11 rehabilitation facilities represented in the study with the majority of the respondents being from the private sector (69%) and 31% from the public sector. The most common practice for patients with sacral pressure sores is to be placed onto bed rest (98%). Nineteen physiotherapists stated that they did not have set protocols for the treatment of patients with sacral pressure sores. The most common physiotherapy interventions (70%) when the patient is on bed rest are upper limb strengthening, lower limb passive movements, positioning into prone and side lying as well as upper limb passive movements and passive stretching. The same were done when the patient was brought to the gym except that bed mobility training then also formed part of common intervention as well as the use of the tilt table for passive standing. The treatment environment was dependant mostly on doctors’ orders and the size, grade and duration of the pressure sores. The choice of treatment techniques was guided mostly by past clinical experience or the successful experience of colleagues. Conclusion: There is a need for the development of standardised protocols when treating spinal cord injured patients with sacral pressure sores to possibly ensure maximal healing and rehabilitation. Key words: Physiotherapy management of paraplegic patients, sacral pressure sores, bed rest

Thesis (MPH) -- University of Limpopo (Medunsa Campus), 2010. / Background: Evidence exists that supports the physiological and psychological benefits associated with regular physical activity. The Transtheoretical model (TTM) of the stages and processes of change has been used worldwide to understand how people change problem behaviour, such as Physical Inactivity, and correctly categorize people according to their readiness to change from being physically inactive to being active. This model (TTM) helps Health Promoters to implement awareness campaigns according to individual’s stage of exercise change. The overall aim of this study is to determine the predictive validity and effects of using Transtheoretical model to increase physical activity of health workers at Dr. George Mukhari Hospital in South Africa. Methods: Research design: A quasi-experimental design was used. A total of 200 subjects (both medical and non-medical staff) were randomly selected from the hospital staff. The following parameters were measured at baseline: TTM Stage (Questionnaire), fitness levels (step test), BMI (Electronic scale), attitude and knowledge (Questionnaire). Phase 11: impact evaluation; exposure levels; Phase 111: Knowledge; Attitude; TTM post intervention. The results were analyzed using SPSS 17.0 version and excel programs. Chi square test was used to analyse and calculate the p-value scores. Paired Sample t-test was used to compare means and binomial and multiple logistic regressions were used to calculate predictive validity of TTM. Results: Two hundred staff members with mean age of 43.12 and standard deviation of 10.75 were investigated. Baseline results showed that the majority of the participants were at Pre-Action stage (76%) and only 24% were at Action stage; with only 27% who had Normal weight and 73% Overweight and Obese. NCDs are common in many participants, with obese ones being more affected than normal staff. Nonmedical staff had poor knowledge compared to medical staff (p<.05). Majority of staff generally had positive attitude towards PA. There was a significant difference (p<.050) between males and females in each TTM stage, with more adult males being in Action/maintenance stages compared to adult females who were mainly at pre-action stages. Majority of older patients were obese (p<.05), had a good perception about their weight and at pre-action stages. Post intervention, Mean scores of TTM (3.699) and Knowledge (3.651) were significantly (p<.05) higher at post test. Both medical and nonmedical staff mainly used Environmental re-evaluation and Self re-evaluation as processes of behaviour change. Precontemplators only used 2 processes to change behaviour. Post intervention: high levels of exposure; Processes of Change, knowledge and attitude resulted in increased TTM stages of staff (p=.000). TTM, knowledge, attitude, process of change and level of exposure were used as predictors of behaviour change and significantly predicted success post test. Overall accuracies of TTM at pre-test could be classified correctly of TTM at post test by average 66.9 % for overall participants; 78.3% for medical staff and only 65% for non-medical staff. Thus the predictor (TTM1) had significant contribution to the outcome (TTM2). Conclusion: Obesity is a common problem and is predisposed by physical inactivity because the majority of staff is old, and this puts them at risk of inactivity-related chronic diseases of lifestyle. Level of physical activity was significantly associated with BMI and may be one of the most important risk factors associated with obesity among hospital staff. The use of TTM to identify the stage of PA of healthcare workers (HCW) has enabled the researcher to design intervention programs specific to the stage of exercise behaviour of staff. Thus the predictors (TTM1), exposure levels, knowledge, attitude and Processes of change have significant contribution to the outcome (TTM2).

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Thesis (Ph. D.)--University of Texas at Austin, 2000. / Vita. Includes bibliographical references (leaves 160-182). Available also in a digital version from Dissertation Abstracts.

published_or_final_version / Community Medicine / Master / Master of Public Health

Stroke contributes significantly to the incidence of motor and cognitive impairments which in turn impact motor learning abilities. Upper limb (UL) motor recovery can be attributed to plasticity mechanisms which are thought to be engaged by rehabilitation interventions focussing on motor learning principles. Factors identified to optimize post-stroke motor recovery and learning include practice intensity, variable- and task-specific practice and motivation, environment of task-practice and provision of feedback. Feedback is sensory information provided either during or following task performance. Feedback provision has been suggested as beneficial for improving motor recovery after a stroke. However, the role of extrinsic feedback on motor learning of UL tasks post stroke is less clear. The global aim of this thesis was to examine the role of extrinsic feedback on motor learning of the UL in stroke. The thesis includes 4 manuscripts: 1 review paper and 3 experimental studies. The 1st manuscript systematically examines the role of extrinsic feedback on implicit motor learning after stroke for UL movements. The main finding was that provision of feedback is useful for individuals with UL hemiparesis post stroke to implicitly learn UL tasks with both sides and improve motor recovery. The 2nd manuscript was a retrospective study of UL movement kinematics describing movement quality while performing pointing and RTG tasks in relationship to clinical performance. Study objective was to estimate the concurrent and discriminate validity of movement pattern kinematic measures for both tasks. All movement pattern kinematic variables were found to be valid outcomes of UL motor impairment and can be used as outcomes in studies involving feedback provision. The majority of the variance in FMA scores was explained by trunk displacement for both tasks, which was the only variable that distinguished between levels of motor impairment severity. Participants with mild levels of UL hemiparesis used 33-300% more trunk displacement compared to controls performing similar tasks. The objective of the 3rd study was to evaluate the effects of feedback provision through the medium of a virtual reality environment (VE) compared to feedback provided in the real world physical environment (PE). Thirty two individuals with stroke were randomized to practice 72 pointing movements daily in either the VE or PE for 12 sessions. Participants in both groups were provided with feedback-terminal KR on error and speed and concurrent KP on trunk displacement. Assessments were carried out before, immediately after and at 3mos after task practice. VE group participants improved joint ranges of motion and increased scores on clinically measured arm use and reaching ability. The PE group improved clinical reaching ability, but also had greater trunk movement. Results suggest that there is an additional value in using VEs as media to provide feedback to enhance UL motor learning outcomes and recovery in chronic stroke.The 4th manuscript addresses the objective of whether and to what extent cognitive impairments in the chronic stage post-stroke are associated with the ability to use feedback for improving UL motor performance and movement patterns. Data from 24 participants were analyzed. Participants training in the VE tended to make faster movements and improved more in movement pattern outcomes compared to those training in the PE. PE and VE group changes were related to memory and problem solving ability. The majority of the variance in outcomes immediately after practice and at retention was explained by single factors or by a combination of memory, problem solving, mental flexibility, attention and depression. Results of this thesis suggest that task practice with feedback and attention to movement quality and presence of cognitive deficits may help ensure better motor learning outcomes related to recovery of UL post-stroke / Certaines déficiences motrices et cognitives peuvent persister suite à un accident vasculaire cérébral (AVC) et avoir un impact sur les habiletés d'apprentissage moteur. La récupération motrice du membre supérieur (MS) peut être attribuée aux mécanismes de plasticité qui seront impliqués dans diverses interventions basées sur les principes d'apprentissage moteur. Les facteurs été identifiés comme étant importants pour optimiser la récupération et de l'apprentissage moteur suite à un AVC sont l'intensité, la spécificité, la motivation, l'environnement et la rétroaction. La rétroaction consiste en des informations données pendant ou après l'exécution de la tâche. Cependant, le rôle de la rétroaction extrinsèque sur l'apprentissage moteur des MS suite à un AVC est moins clair. Le but de cette thèse était d'examiner le rôle de la rétroaction extrinsèque sur l'apprentissage moteur du MS suite à un AVC. Quatre papiers ont été inclus : une revue de la littérature et 3 études expérimentales. Le premier papier consiste en une revue systématique de la littérature documentant le rôle de la rétroaction extrinsèque sur l'apprentissage moteur des MS suite à un AVC. Les résultats suggèrent que la rétroaction est utile pour permettre aux individus présentant une hémiparésie du MS suite à un AVC d'améliorer la capacité motrice des deux membres supérieurs. Le 2ième papier est une étude rétrospective sur la cinématique du MS qui décrit la relation entre la qualité du mouvement et la performance clinique. L'objectif était de vérifier la validité concurrente et discriminante de la cinématique pour les tâches de pointage et d'atteinte avec préhension. Toutes les variables cinématiques étaient valides et peuvent être utilisées dans les études avec une rétroaction. Les participants avec une hémiparésie légère au MS utilise de 33-300% plus le déplacement du tronc que les participants sains. L'objectif de la troisième étude consistait à comparer les effets d'une rétroaction dans un environnement virtuel (ER) comparativement à un environnement physique (EP). 32 individus ayant subi un AVC ont effectués 72 mouvements de pointage par jour dans un ER ou dans un EP sur 12 sessions. Tous les participants ont pu bénéficier d'une rétroaction à la fin de la session sur la précision et la vitesse ainsi qu'une rétroaction sur le déplacement du tronc durant la tâche. Une amélioration de l'amplitude articulaire a été constatée dans l'EV permettant d'augmenter le pointage à la mesure clinique de l'utilisation du bras, ainsi qu'à la tâche d'atteinte. Les participants entrainés dans l'EP ont amélioré la tâche d'atteinte et une plus grande compensation du tronc. Les résultats de cette étude suggèrent que l'utilisation d'un EV avec rétroaction permet d'améliorer l'apprentissage et la récupération motrice du MS suite à un AVC. L'objectif du dernier papier consistait à déterminer si la présence de déficiences cognitives est associée à l'habileté d'utiliser une rétroaction dans le but d'améliorer la performance motrice. Les participants entrainés dans l'EV ont démontré une tendance à effectuer des mouvements plus rapides et ont amélioré davantage leur patron de mouvement que les individus entrainés dans l'EP. Les changements obtenus dans les deux groupes (24 participants) étaient reliés à la mémoire et aux habiletés de résolution de problèmes. Une importante proportion de la variance au niveau des variables cinématiques mesurées immédiatement et 3 mois après la pratique était expliquée par un ou plusieurs facteurs : la mémoire, l'habileté à résoudre des problèmes, la flexibilité mentale, l'attention et la dépression. Les résultats de cette thèse suggèrent que la pratique d'une tâche en présence d'une rétroaction appropriée et une attention particulière à la qualité du mouvement, en présence de déficits cognitifs pourraient résulter en un meilleur apprentissage moteur lié à une meilleure récupération des MS suite à un AVC.

Proprioception is the awareness of joint position in the space. Any disturbance in performance of this sense, such as that caused by muscular fatigue, may cause instability in the joint and make it susceptible to injury. Therefore our objective was to estimate the extent to which muscular fatigue alters the proprioception of the upper extremity in healthy adult subjects. Eighteen healthy subjects participated in this study. Twelve subjects were assigned to a fatigue group who were asked to do a reaching task while grasping a wooden block. They had to match the block with its corresponding target displayed on a flat screen, in one of three different orientations (vertical and ±30°, 10 repetitions each) with blocked vision. Following this reaching task, the subjects performed a series of resistive movements against an elastic band in order to induce muscular fatigue. The reaching task was then repeated, immediately after the fatiguing exercise. Six other subjects were assigned to the non fatigue group, who performed exactly the same protocol, but without the fatiguing phase. An independent t-test showed a significant difference both in the distribution and in the mean change of endpoint position in the fatigue group compared to the non fatigue group. However, a repeated measure ANOVA revealed no significant change in orientation. In this study, we found that position reproduction ability was greatly changed in the presence of muscular fatigue whereas no difference was found in orientation. The result of this study could serve as a basis for further research on upper limb proprioception and neuromuscular control. / La Proprioception est la perception de la position d'une articulation dans l'espace. Tout trouble au niveau de cette modalité, tel que celui causé par la fatigue musculaire, peut causer de l'instabilité dans l'articulation et la rendre susceptible à une blessure. Par conséquent, notre objectif était d'estimer l'étendue avec laquelle la fatigue musculaire modifie la proprioception du membre supérieur chez des sujets adultes. Douze sujets en bonne santé ont été assignés à un groupe avec fatigue, auquel on avait demandé d'effectuer une tâche d'atteinte en saisissant un bloc de bois. Ils devaient toucher, avec le bloc, une cible de même forme affichée sur un écran plat, dans l'une de trois différentes orientations (vertical et ±30°, 10 répétitions chaque), sans vision. Puis, les sujets devaient exécuter une série de mouvements avec résistance contre un ruban élastique, de façon à induire la fatigue musculaire. Finalement, les sujets répétaient la tâche d'atteinte.Six autres sujets ont été assignés au groupe sans fatigue, qui a suivi le même protocole, mais sans la phase de fatigue. Un test de t a démontré une différence significative dans la distribution et dans le changement moyen de la position finale dans le groupe fatigue comparé au groupe sans fatigue. Cependant, une mesure ANOVA répétée n'a révélé aucun changement significatif pour l'orientation. Dans cette étude, nous avons trouvé que l'habilité de reproduction de la position à été grandement changée en présence de fatigue musculaire alors qu'aucune différence n'à été trouvée pour l'orientation. Le résultat de cette étude pourrait servir de base à des recherches plus approfondies sur la proprioception et le contrôle neuromusculaire du membre supérieur.

Evidence is accumulating that individuals with chronic low back pain (LBP) have altered movement coordination; however, the exact nature of this impairment is unknown. To clarify the relationship between pain and altered coordination this thesis characterized postural control in two cohorts of individuals with LBP (those with a history of pain who were in a quiescent period and those who were in an active pain period), relative to individuals without LBP. Automatic postural responses (APRs) as measured by joint torque and myoelectric responses were characterized following multi-directional support surface translations. Given that the active pain cohort had greater pain than the quiescent group, they might be more susceptible to volitional effects on movement. Therefore this cohort as well as the control group also performed a voluntary activity of daily living, the sit-to-stand (STS) movement, to quantify the influence of pain on a volitional movement. Their performance was then compared to the performance of the healthy control group. The first study demonstrated that the APRs of healthy individuals used a redistribution of the contributions of hip/trunk vs. ankle torques depending on the perturbation direction. The relative contribution of joint torques appears to be determined by the biomechanical constraints imposed by a specific perturbation direction. In the second study, individuals with LBP in a quiescent period demonstrated increased sagittal plane ankle torque during the passive epoch (50-100ms after perturbation onset) and reduced peak trunk torques following perturbation, suggesting that they may have increased stiffness at the ankle and use a response strategy of active trunk stiffening, due to co-contraction of musculature. In the third study, individuals with LBP in an active pain episode demonstrated earlier but not altered peak torque magnitudes, and increased muscle activation, which may indicate increased muscle spindle sensitivity or increased postural gain. In the fourth study individuals with active LBP performed the STS movement with no speed alterations but with a strategy that relied more on distal joint contributions, which may reflect a cognitive decision to restrict trunk excursion. En masse, these findings suggest that altered movement strategies persist in the chronic, recurrent LBP population between painful episodes, which may reflect an intention to restrict trunk movement. Individuals with chronic LBP who are in an exacerbation of their pain appear to have a generalized heightened postural response to unexpected perturbation that may reflect a short-term modification to a heightened pain state. These individuals also move to restrict their trunk during volitional movements such as the STS. Such alterations, if repeated, may lead to persistent abnormal movement patterns that could increase the susceptibility to future LBP episodes, as demonstrated by individuals in a quiescent period of their pain cycle. Interventions that focus on a return to increased variability and distribution of movement could enhance movement precision, through tissue and neuromuscular changes, and lead to a reduction of the frequency and severity of pain recurrence. / Il est de plus en plus démontré que la coordination des mouvements est altérée chez les individus souffrant de douleur chronique au dos (DCD). Toutefois, la nature exacte de cette déficience demeure inconnue. Afin de clarifier la relation entre la douleur et la coordination des mouvements, l'objectif de cette thèse était de caractériser et comparer les stratégies de contrôle postural chez deux groupes d'individus souffrant de DCD (ceux ayant déjà eu de la douleur mais étant dans une période quiescente et ceux souffrant présentement de douleur) et chez un groupe de sujets n'ayant jamais souffert de DCD. Les réponses posturales automatiques (RPAs), telles que mesurées par les moments de force articulaires et les réponses myoélectriques, ont été examinées suite à la présentation de brefs déplacements multidirectionnels, en translation, de la surface de support. Comme les individus souffrant de DCD en période active étaient plus susceptibles de montrer un comportement altéré dans leurs mouvements, ils ont également exécuté une activité de la vie quotidienne, soit de passer de la position assise à la position debout, afin de quantifier l'influence de la douleur sur un mouvement volontaire. Leur performance a pu être comparée à celle des personnes en santé. Les résultats de la première étude ont démontré que les RPAs des individus en santé impliquent une redistribution des contributions des moments à la hanche et au tronc par rapport aux moments aux chevilles, qui dépend de la direction de la perturbation. La contribution relative des moments articulaires semble être déterminée par les contraintes biomécaniques imposées par la direction spécifique de la perturbation. Dans la seconde étude, le moment à la cheville, dans le plan sagittal et pendant la période passive (soit 50-100 ms après le début de la perturbation), était plus grand chez les individus avec DCD en période quiescente alors que la valeur maximale du moment au tronc était diminuée en réponse à la perturbation. Ces résultats suggèrent que ces individus ont peut-être augmenté la rigidité passive de leurs chevilles et utilisé une stratégie de raidissement actif du tronc, grâce à la co-contraction musculaire. Dans la troisième étude, les individus souffrant de DCD avec douleur active ont montré des pics de moments plus tôt, mais de même amplitude, ainsi qu'une activation musculaire augmentée, ce qui peut indiquer une sensibilité accrue des fuseaux musculaires ou un gain postural amplifié. Les résultats de la quatrième étude n'ont pas révélé de différence dans la vitesse d'exécution de la tâche assis-debout chez les individus souffrant de DCD avec douleur active. Cependant, ils semblent avoir opté pour une stratégie reposant plus sur la contribution des articulations distales, ce qui peut paraître comme une décision cognitive visant à restreindre l'excursion du tronc. L'ensemble des résultats obtenus démontre que des stratégies de mouvement altérées persistent chez les individus souffrant de DCD avec épisodes de douleur active, reflétant une intention de restreindre le mouvement au niveau du tronc. Les personnes ayant une DCD et qui sont dans une période où la douleur est présente semblent avoir une réponse posturale augmentée généralisée suite à une perturbation inattendue, ce qui peut être l'expression d'une modification à la hausse, à court terme, de leur état de douleur. Ces individus bougent également en limitant les mouvements du tronc lors de mouvements volontaires comme celui de passer de la position assise à la position debout. Ces changements, s'ils sont répétés, peuvent conduire à l'utilisation persistante de patrons de mouvements anormaux qui peuvent entraîner une susceptibilité à des épisodes de douleur au dos dans le futur.