Background: Patients with severe COVID-19 evolve to acute respiratory distress syndrome (ARDS) and require management in Intensive Care Units (ICU) where they are exposed to immobilization, immunosuppression, malnutrition, nosocomial infections; may develop ICU Acquired Weakness (ICUAW), which increases with the stay and use of mechanical ventilation (MV).There is evidence of the use of different modalities in rehabilitation to mitigate these effects. Goal: To determine the efficacy of a Multimodal Rehabilitation Program (MRP) in reducing the number of days of mechanical ventilation and stay in patients hospitalized for COVID-19 in ICU, as well as to describe its clinical and hospital characteristics. Material and Methods: An quasi-experimental study was designed, with sequential sampling and without blinding. A control and intervention group was formed, with 32 participants each. A Multimodal Rehabilitation Program (MRP) based on four therapeutic modalities was applied and the intervention was quantified through the use of proposed indicators. Results: The variation in days of ICU stay and days of MV were similar in both groups. The Multimodal Rehabilitation Index (iMR) ranged from 0.1 to 2.7 (mean = 1.2, SD = 0.7) and had significance for cut-off points ≤ 0.81 and ≤ 0.94 in mortality (p = 0.02) and Ventilator-free days at 28 days (VFDs-28) (p = 0.01). Conclusions: No statistically significant difference was found in favor of the intervention in terms of days of stay in the ICU and days of MV. Explanatorily, it was reported that iMR was related to (VFDs-28) and mortality in patients with severe COVID-19.

Despite growing interest into the role of physiotherapists in providing psychological rehabilitation to athletes during sport injury, very little research exists outside North America, Australia, and New Zealand (e.g., Hemmings & Povey, 2002). Thus, the main purpose of this research was to explore the role of UK chartered physiotherapists in the process of psychological rehabilitation from sport injuries. This thesis consists of four studies. With the intention to gain further insights into the physiotherapists’ views on the psychological aspects of their work, study one used the Physiotherapists and Sport Psychology Questionnaire (PSPQ; Hemmings & Povey, 2002) in a national survey with 361 UK chartered physiotherapists working in sport medicine. The results from the survey provided useful insights into the ways in which psychological interventions are currently employed in rehabilitation physiotherapy. In study two, these findings were explored further, by developing a questionnaire survey to explore chartered physiotherapists’ (N = 22) preferred method of sport psychology intervention training. With the purpose of gaining an insight into the physiotherapists’ personal experiences in using psychological interventions with injured athletes, study three adopted a qualitative approach, in which semi-structured interviews were conducted with seven UK chartered physiotherapists. The findings from the Interpretative Phenomenological Analysis (IPA; Smith, 1996) provided deeper understanding on physiotherapists current knowledge on, and their past experiences and opinions on using range of psychological interventions in their work with injured athletes. Similarly study four used semi-structured interviews and IPA with ten athletes who had previously encountered moderate or severe sport injuries requiring physiotherapy treatment. The findings revealed useful information on the physiotherapists’ role in providing psychological support and using psychological interventions in their work with injured athletes. In conclusion, the research presented in this thesis makes a contribution to knowledge by: (a) providing an insight into the views of chartered physiotherapists in the UK on psychological content of their practice, (b) making preliminary suggestions into how further training in sport psychology for chartered physiotherapists could be delivered, (c) enabling deeper understanding of physiotherapists current practices and past experiences in utilising selected psychological interventions in their work, and (d) giving a voice to injured athletes with regard to the role of physiotherapists in providing psychological support during sport injury rehabilitation.

It is well known that engaging in physical activity (PA) reduces the risk of developing non-communicable diseases and improves general health. However, at the time of this research, less than half of the UK population met the recommended levels of PA (DH, 2010). Physical activity referral schemes (PARS) are one of the interventions available in primary care (NICE, 2006a) for disease prevention and health improvement, despite a high dropout rate (Gidlow, 2005) and unknown long-term effectiveness (Pavey et al., 2011). The main aim of the four studies presented in this thesis was to explore the adherence and behaviour change towards PARS in Northamptonshire. The first study measured the long-term change in PA levels after participation in Activity on Referral (AOR). The key outcome was a significant increase in self-reported long-term PA levels (mean difference 1000 MET minutes/week) for 105 adhering participants from a total of 2228 participants. One in every 21 referred individuals self-reported an increase in PA at 12 months. To explore the high levels of non-adherence, an interpretative phenomenological analysis (IPA; Smith, 1996) was conducted with seven non-adhering AOR participants. The findings showed that being listened to at the point of referral, a range of positive experiences during the induction, alternative opportunities to increase activity, and potential to re-engage in PARS were some of the factors that enhanced adherence. Even though currently the key behaviour change measure for a PA intervention is an increase in PA, there is no gold standard self-reporting PA measure. Therefore, the third study was a comparison that tested the applicability of the new General Practice Physical Activity Questionnaire (GPPAQ) and the internationally validated International Physical Activity Questionnaire (IPAQ). The GPPAQ is recommended to be used as a screening tool by health professionals for the latest PARS called Let‟s Get Moving (LGM). There was a significantly weak association between IPAQ and GPPAQ. Hence, the GPPAQ is only recommended to be used as a PA screening tool and not for evaluating PA levels for PARS research studies. The final study was based on the new LGM physical activity care pathway which included a brief intervention using Motivational Interviewing (MI), a communication style that elicits the individuals‟ ambivalence regarding PA. Eight out of 21 participants self-reported a PA increase at 6 months and the MI used during the PARS was coded at beginner level. The two PARS included in this thesis were compared for adherence; LGM adherence was 65% compared to 23% AOR adherence at 3 months. In conclusion, this research has demonstrated that PA levels do increase for PARS participants in the long term, but the dropout rate can be concerning. By using a mixed-methods approach, the lived experience of participants enhances the understanding of reasons behind non-adherence. The comparative study involving LGM and AOR samples showed that interventions with elements of MI might be a better investment of commissioned resources.

A Tomografia por Emissão de Pósitrons (PET - Positron Emission Tomography) é uma modalidade de imagens para o diagnóstico em Medicina Nuclear. São utilizados radiofármacos emissores de pósitrons que possibilitam obter imagens que representam o processo bioquímico dessas substâncias no órgão ou tecido de interesse in vivo. São detectados, em coincidência, os fótons provenientes da aniquilação pósitron/elétron, que ocorre dentro do corpo do paciente. Esta informação é posteriormente utilizada para a reconstrução do objeto em estudo. Atualmente, existem dois tipos de equipamentos capazes de realizar estudos tomográficos por emissão de pósitrons: o dedicado e a câmara PET/SPCET. Este trabalho abordou este último tipo, que permite também a realização de exames habituais de Medicina Nuclear, que usam emissores de fótons. Existem dificuldades inerentes ao método de aquisição destas imagens que afetam a quantificação de índices ou atividade. Elas estão relacionadas ao fato de a emissão de radiação obedecer a uma distribuição de Poisson, às interações físicas da radiação com o corpo do paciente e com o detector, ao ruído devido à natureza estatística destas interações e de todo o processo de detecção, assim como à metodologia de aquisição dos exames (preparo e posicionamento do paciente, taxa de contagens etc.). Correções são propostas na literatura que não são totalmente implementadas pelos fabricantes: de espalhamento, de atenuação, de eventos aleatórios, do tempo morto, de decaimento, da resolução espacial e de outras características do equipamento. O objetivo deste trabalho foi o de realizar um estudo dos métodos aplicados por dois fabricantes, assim como algumas influências das características técnicas das câmaras PET/SPECT na obtenção do índice de SUV (Standardized Uptake Value). Para isso, dados de simuladores físicos, dispostos em várias montagens, foram obtidos com uma câmara no modo 3D e outra no modo 20. Constatou-se também que a forma das fontes usadas para calibração influencia no resultado final e impõe novos desafios para a quantificação em uma situação clínica. Por fim, no momento da quantificação, a região de interesse deve ser escolhida de acordo com aquela usada para a determinação dos coeficientes de correção e calibração. Verificou-se que é viável realizar quantificações com câmaras PET/SPECT, inclusive o índice SUV. Para tanto, além das correções citadas anteriormente, é imprescindível ter o equipamento bem ajustado, assim como a obtenção de coeficientes para normalização da sensibilidade e correção do efeito de volume parcial. / Positron Emission Tomography (PET) is a Nuclear Medicine imaging modality for diagnostic purposes. Pharmaceuticals labeled with positron emitters are used and images which represent the in vivo biochemical process within tissues can be obtained. The positron/electron annihilation photons are detected in coincidence and this information is used for object reconstruction. Presently, there are two types of systems available for this imaging modality: the dedicated systems and those based on gamma camera technology. In this work, we utilized PET/SPECT systems, which also allows for the traditional Nuclear Medicine studies based on single photon emitters. There are inherent difficulties which affect quantification of activity and other indices. They are related to the Poisson nature of radioactivity, to radiation interactions with patient body and detector, noise due to statistical nature of these interactions and to all the detection processes, as well as the patient acquisition protocols. Corrections are described in the literature and not all of them are implemented by the manufacturers: scatter, attenuation, randoms, decay, dead time, spatial resolution, and others related to the properties of each equipment. The goal of this work was to assess these methods adopted by two manufacturers, as well as the influence of some technical characteristics of PET/SPECT systems on the estimation of SUV. Data from a set of phantoms were collected in 3D mode by one camera and 20, by the other. We concluded that quantification is viable in PET/SPECT systems, including the estimation of SUVs. This is only possible if, apart from the above mentioned corrections, the camera is well tuned and coefficients for sensitivity normalization and partial volume corrections are applied. We also verified that the shapes of the sources used for obtaining these factors play a role on the final results and should be dealt with carefully in clinical quantification. Finally, the choice of the region of interest is critical and it should be the same used to calculate the correction factors.

A Tomografia por Emissão de Pósitrons (PET - Positron Emission Tomography) é uma modalidade de imagens para o diagnóstico em Medicina Nuclear. São utilizados radiofármacos emissores de pósitrons que possibilitam obter imagens que representam o processo bioquímico dessas substâncias no órgão ou tecido de interesse in vivo. São detectados, em coincidência, os fótons provenientes da aniquilação pósitron/elétron, que ocorre dentro do corpo do paciente. Esta informação é posteriormente utilizada para a reconstrução do objeto em estudo. Atualmente, existem dois tipos de equipamentos capazes de realizar estudos tomográficos por emissão de pósitrons: o dedicado e a câmara PET/SPCET. Este trabalho abordou este último tipo, que permite também a realização de exames habituais de Medicina Nuclear, que usam emissores de fótons. Existem dificuldades inerentes ao método de aquisição destas imagens que afetam a quantificação de índices ou atividade. Elas estão relacionadas ao fato de a emissão de radiação obedecer a uma distribuição de Poisson, às interações físicas da radiação com o corpo do paciente e com o detector, ao ruído devido à natureza estatística destas interações e de todo o processo de detecção, assim como à metodologia de aquisição dos exames (preparo e posicionamento do paciente, taxa de contagens etc.). Correções são propostas na literatura que não são totalmente implementadas pelos fabricantes: de espalhamento, de atenuação, de eventos aleatórios, do tempo morto, de decaimento, da resolução espacial e de outras características do equipamento. O objetivo deste trabalho foi o de realizar um estudo dos métodos aplicados por dois fabricantes, assim como algumas influências das características técnicas das câmaras PET/SPECT na obtenção do índice de SUV (Standardized Uptake Value). Para isso, dados de simuladores físicos, dispostos em várias montagens, foram obtidos com uma câmara no modo 3D e outra no modo 20. Constatou-se também que a forma das fontes usadas para calibração influencia no resultado final e impõe novos desafios para a quantificação em uma situação clínica. Por fim, no momento da quantificação, a região de interesse deve ser escolhida de acordo com aquela usada para a determinação dos coeficientes de correção e calibração. Verificou-se que é viável realizar quantificações com câmaras PET/SPECT, inclusive o índice SUV. Para tanto, além das correções citadas anteriormente, é imprescindível ter o equipamento bem ajustado, assim como a obtenção de coeficientes para normalização da sensibilidade e correção do efeito de volume parcial. / Positron Emission Tomography (PET) is a Nuclear Medicine imaging modality for diagnostic purposes. Pharmaceuticals labeled with positron emitters are used and images which represent the in vivo biochemical process within tissues can be obtained. The positron/electron annihilation photons are detected in coincidence and this information is used for object reconstruction. Presently, there are two types of systems available for this imaging modality: the dedicated systems and those based on gamma camera technology. In this work, we utilized PET/SPECT systems, which also allows for the traditional Nuclear Medicine studies based on single photon emitters. There are inherent difficulties which affect quantification of activity and other indices. They are related to the Poisson nature of radioactivity, to radiation interactions with patient body and detector, noise due to statistical nature of these interactions and to all the detection processes, as well as the patient acquisition protocols. Corrections are described in the literature and not all of them are implemented by the manufacturers: scatter, attenuation, randoms, decay, dead time, spatial resolution, and others related to the properties of each equipment. The goal of this work was to assess these methods adopted by two manufacturers, as well as the influence of some technical characteristics of PET/SPECT systems on the estimation of SUV. Data from a set of phantoms were collected in 3D mode by one camera and 20, by the other. We concluded that quantification is viable in PET/SPECT systems, including the estimation of SUVs. This is only possible if, apart from the above mentioned corrections, the camera is well tuned and coefficients for sensitivity normalization and partial volume corrections are applied. We also verified that the shapes of the sources used for obtaining these factors play a role on the final results and should be dealt with carefully in clinical quantification. Finally, the choice of the region of interest is critical and it should be the same used to calculate the correction factors.

Plan de negocio para la implementación de un centro privado de Medicina Física y Rehabilitación para la población pediátrica en el distrito de Jesús María, en Lima: “CENAFEL” Centro Especializado en el Niño Activo y Feliz. Nuestra propuesta es satisfacer una necesidad altamente sentida en población pediátrica con discapacidad psicomotriz y alteraciones en su desarrollo y crecimiento normal. La propuesta está motivada por la limitada oferta especializada por parte de instituciones prestadoras de la salud. Más aún, el 6.7% de la población general de Lima Metropolitana tiene algún tipo de discapacidad y se calcula que la prevalencia en menores de 18 años asciende al 8%. Nuestra meta es poder atender a una proporción desatendida, principalmente de la zona 6 y 7 de Lima Metropolitana, lo que incluye pacientes en cola de espera de las principales IPRESS, con capacidad de pago de bolsillo, que estén dispuesto a pagar por nuestros servicios. La mejor estrategia para abarcar a esta población, es la de enfoque y buscaremos marcar un nuevo standard en la calidad de atención. CENAFEL ofrecerá consulta en Medicina Física y Rehabilitación, terapia de lenguaje, física y ocupacional. La inversión será de S/. 197,972 soles con un financiamiento del 80% con deuda y un 20% con capital. La proyección a diez años muestra un TIRF del 121% y el VANF de S/. 683,017.00 soles, determinando que el proyecto es rentable y viable. / Business plan for the implementation of a private center for Physical Medicine and Rehabilitation for the pediatric population in the district of Jesus Maria, in Lima: "CENAFEL" Specialized Center for the Active and Happy Child. Our proposal is to satisfy a highly felt need in the pediatric population with psychomotor disability and alterations in their development and normal growth. The proposal is motivated by the limited specialized offer by health institutions. Moreover, 6.7% of the general population of Metropolitan Lima has some type of disability and it is found that the prevalence in children under 18 years of age rises to 8%. Our goal is to serve an unattended proportion, mainly from Zone 6 and 7 of Metropolitan Lima, which includes patients waiting in line with the main IPRESS, with the capacity to pay out of pocket, who are willing to pay for our services. The best strategy to cover this population is the focus and we will seek to set a new standard in the quality of care. CENAFEL will offer consultation in Physical Medicine and Rehabilitation, language, physical and occupational therapy. The investment will be S/. 197,972 soles with 80% financing with debt and 20% with capital. The 10-year projection shows an IRRF of 121% and the VANF of S/. 683,017.00 soles, determining that the project is profitable and viable. / Tesis

Massage was professionalised in Britain in 1895 by the Society of Trained Masseuses (STM), a small group of nurses and midwives mainly concerned with giving general massage to neurasthenic women. By the end of the First World War the massage profession had been transformed - a key participant in the rehabilitation of the nation’s wounded soldiers; publically, medically and politically acclaimed; and a specialism fully embryonic of physiotherapy. This thesis examines the professionalisation of massage from c.1880-1920. It argues that in order to fully understand the development of the profession in this period we have to move away from institutional teleologies, linear narratives of ‘medical control’ and embrace the myriad of socio-cultural, economic, political and professional forces driving and shaping this process. To explore these wider forces this thesis looks beyond internal institutional dynamics and examines a number of locations where massage was practised. Beginning with an examination of how massage was translated from a traditionally lay-treatment into the language of medical orthodoxy, this thesis considers its adoption into British medicine, its development as a practice and a profession, and its entry into the First World War. Fiercely contested both medically and ethically throughout the period, the practice of massage offers a new lens through which to examine the complex socio-cultural and professional negotiations shaping the course of professionalisation. This thesis argues that debates about massage, gender and intimacy were intricately woven into the formulation of professional boundaries, conditioning the relationship between patient and masseuse as well as the masseuse and medical practitioner. Focus on practice also yields insights into broader socio-economic and political concerns about disability, productivity and military efficiency. It situates the evolution of massage, practically and professionally, as part of the wider development of rehabilitation within society and medicine during this period. By contextualising the early professionalisation of massage in this way, this thesis offers new perspectives on the complex interplay between the development of physiotherapy, society and medicine.

This research explores the meaning of learning as a process of social participation in clinical practice. The study focused on six first‐year student physiotherapists during a period of early clinical experience on a work integrated learning programme. The programme was unique at the time of the study in that it placed students in clinical settings from the first week of their undergraduate experience. The research applied a case study design and qualitative data were gathered from each student via on‐line learning journals, reflection lines and pre/post experience interviews. Data were analysed, between and within cases, to develop a sense of progressive narrative through the experiences made significant by each participant over the course of the clinical experience. An abductive logic was applied to develop a more theoretical explanation of learning as participation in clinical practice for each participant. The study concludes that these individuals adopted an agentic approach and recognised the benefit to their learning of proactively seeking opportunities to get involved in practice. Interaction with a range of co‐participants was valued, for a variety of reasons. Students were more willing to discuss their own deficits and ask questions of junior clinicians. Interactions with senior clinicians were more likely to challenge and extend the students' practice. Interactions with non‐physiotherapy colleagues in the multidisciplinary team were valued for the different perspectives they offered. Students valued participation in situations where they could assume greater responsibility, as long as their efforts were recognised by the clinical educator. Participants did not always see value in “routine” practice where there was little opportunity to be involved in decision making or discussion, describing their involvement as being “an extra pair of hands”. Participants described their performance of secondary Discourses of practice in the construction of their respective identities, which I describe as productive worker, trustworthy student, engaged student and junior professional. These Discourses supported participants' bids for recognition and progressive involvement in communities of clinical practice. However, where the participant identity was associated too strongly with a particular Discourse the educator could restrict access to learning opportunities. Participants dis‐identified themselves from Discourses that conflicted with individual habitus and conveyed lack of care or unethical behaviour. Where power relations challenged the possibility of overt rejection, participants were strategic and excluded these Discourses from their future, rather than current repertoires. At the start of their early clinical experience, participants expressed a desire to “learn by doing” and “learn on the job”. These cases demonstrate that even at an early stage of experience, participants were contributing to the productivity of the workplace and they felt valued when their contributions were recognised. These cases demonstrate that mutual relations support participation but require ongoing negotiation. Considering mutuality as a mechanism for participation in early clinical experience can support analysis of the ways in which social relations support both learning and work objectives. Mutuality as a mechanism for participation requires the learner and educator to recognise these dual objectives. Changing conditions of practice can threaten mutuality. Where a threat occurs, it is countered by adaptive practices that continue to support mutuality in terms of engagement, repertoire and enterprise with the community of clinical practice.