Chapter one of this thesis offered a general insight on the anterior cruciate ligament (ACL) injury and the outcome measures of ACL rehabilitation while chapter two was a systematic review on the effects of “accelerated rehabilitation” after ACL reconstruction surgery. The review concluded that 5 out of 10 randomised control trial studies had demonstrated moderate relative effect sizes in terms of improved knee laxity, neuromuscular performance, range of motion and some patient-reported outcome measures following accelerated rehabilitation for patients with ACL reconstruction. Chapter three was a systematic review in which the genetic influence on responsiveness to strength conditioning and the outcomes of knee after ACL reconstruction were investigated. The findings revealed that intra-genotypic responses to strength conditioning were heterogeneous and that duration, intensity and frequency of strength conditioning were factors that contributed to the differential responses of genotypes in regulating gains in strength. Chapter four (study one) was a randomised control trial in which the effects of quantified accelerated conditioning rehabilitation, anthropometric and orthopaedic-related factors on the outcomes of knee performance were investigated following ACL reconstruction. Participants (n= 40) were prescribed either accelerated rehabilitation in the first 12 weeks post-surgery (n=20) or contemporary (n=20) ACL rehabilitation. Participants were assessed in four different testing occasions; pre-surgery (0), 6, 12 and 24 weeks post-surgery. The findings revealed there was significant group by leg by time interaction using ANOVA and repeated measures on the latter two factors with superior scores in the accelerated group for the change scores of some sub-sections of KOOS. When controlling for body mass, waiting time and unstructured physical activity, scores associated with objective neuromuscular measures showed significant interaction (group by time by leg) from pre-surgery to 12 weeks post-surgery with superior scores favouring the accelerated group. This showed that the accelerated rehabilitation offered advantages over the contemporary practice coincident with enhanced conditioning and that orthopaedic-related factors were influential in determining the outcomes of ACL rehabilitation. Chapter five (study two) explored the correlation amongst the objective and subjective functional and objective neuromuscular outcome measures. Participants from study one (n=40) took part in this study. While there was no correlation between the change scores of the objective functional (single leg hop) and the subjective functional (KOOS, K-SES, Lyhsholm, IKDC) outcome measures, the absolute scores associated with sub-sections of KOOS had shown the most consistent correlation with objective measures (KOOS and sensorimotor performance [SMP] of the quadriceps;-0.46, peak force of the quadriceps; -0.34, and anterior tibio-femoral displacement [ATFD]; -0.32). Change scores for SMP and KOOS and for the single leg hop and Lysholm showed the highest correlation in the hierarchy of objectively-measured determinants of knee functional performance. Overall, there was a lack of robust and significant linkage amongst the functional and objective neuromuscular outcome measures. Chapter six (study three) investigated the influence of angiotensin converting enzyme (ACE) I/D gene polymorphisms on the responsiveness of function and physical performance to rehabilitation training following ACL reconstruction. Participants (n=40) from the previous two studies participated in this study that involved obtaining blood samples for DNA and genotyping for ACE I/D polymorphism. The findings revealed that one (peak force for quadriceps) out of 5 objective functional and neuromuscular measures had shown significant interaction (ACE genotype by time by leg) in response to rehabilitative training favouring the D allele over the I allele group. It was concluded from this exploratory trial that there was some evidence to suggest that planning for ACLR rehabilitative care might be optimised by using the conditioning-response characteristics associated with the individual.s genotype of the ACE I/D. There was a 15% of variance in the peak force (quadriceps at 12 to 24 weeks post-surgery) favouring the D allele group, indicating that strength training could be possibly prescribed routinely earlier to patients carrying the D allele. The last chapter of the thesis (chapter seven) was a general discussion that synthesised the findings of all the three studies of the thesis including their limitations and future directions.

The aim of this thesis is to inform clinicians and researchers of the reliability and responsiveness of the most commonly used outcome measures in prosthetic rehabilitation in the UK. In addition, this thesis supports the call for more studies of high methodological quality to provide evidence of the psychometric properties of outcome measures of physical function in lower limb amputees. A survey (study I) of Allied Health Professionals established that the outcome measures used most often during prosthetic rehabilitation in the UK were: the Timed Up and Go (TUG), a timed walk test, the Locomotor Capability Index (LCI) and its modified version (LCI-5), the Socket Comfort Score (SCS) and the Special Interest Group in Amputee Medicine (SIGAM) Mobility Grades. A standardised quality checklist (COSMIN) was used in a systematic review (study II) to measure the methodological quality and strength of evidence of the published literature that reported on the psychometric properties of outcome measures used to measure physical function during prosthetic rehabilitation. The review found mixed methodological quality ratings and many studies with small sample sizes rendering the strength of the evidence indeterminate. A limited number of studies commented on limits of agreement and measurement error when reporting on reliability. Even fewer studies reported on responsiveness with only one reporting minimally clinically important difference (MCID) values. Values for consistency, agreement and measurement error, were calculated for the top five commonly used outcome measures as identified from the survey, using a test-retest study design with a period of 7 days between tests (study III). Minimum detectable change (MDC) values were calculated for the SIGAM, LCI-5, TUG and 2MWT. The EQ-5D-5LTM, a measure of the global health of the respondent, was also included as knowledge of its psychometric properties in a population of pwLLA is unknown. However, reliability could not be confirmed for the EQ-5D-5L or the SCS in this population. A longitudinal study (study IV), based during the early rehabilitation period (mean 84 days) following provision of a primary prosthesis, gathered data to calculate indices of responsiveness for the same six outcome measures. Effect sizes were presented for five measures: SIGAM, LCI-5, TUG, 2MWT, SCS and EQ-5D-5L. Minimal clinically important difference values were also presented for the first time for all the outcome measures in this population. A patient reported change questionnaire was used as the anchor in a Receiver Operator Characteristic (ROC) curve analysis to establish the MCID values.

Background: Bilateral task training (BT) may improve upper limb (UL) recovery on the affected as well as non-affected side in longstanding stroke however for acute stroke its effects on physical and psychosocial outcomes compared to unilateral training (UT) has not been clearly established. Furthermore, clinical and demographic factors that influence UL training responses and predict UL recovery are also unclear for acute stroke. PrimaryAims: To compare effects of BT and UT on: • ipsilesional and contralesional UL outcomes • anxiety, depression and health related quality of life (HRQOL) Secondary Aims: To investigate: • which clinical and demographic factors influence contralesional training responses • predictors of UL activity limitation over time for the sample as a whole • UL dysfunction as a predictor of HRQOL six months after stroke for the sample as a whole Design: Single-blinded randomised controlled trial, with outcome assessment at baseline (T1), after 6 weeks training (T2), and 18 week follow-up (T3). Participants: 106 in-patients randomised to receive BT (n=56) or UT (n=50) 2 to 4 weeks after stroke onset. Intervention: Supervised BT or UT for 20 minutes on 5 weekdays, over 6 weeks, using a standardised programme developed for the study. Outcome Measures: UL outcomes: Action Research Arm Test (ARAT), Rivermead Motor Assessment (UL scale), Nine-Hole Peg Test (9HPT). Secondary measures: Modified Barthel Index, Hospital Anxiety and Depression Scale, and Nottingham Health Profile. Assessment was conducted by a blinded assessor. Results: Between the two groups, there were no significant differences at T1 or T2 on any contralesional UL measure or on any psychosocial measure (p>0.05). At T3, 9HPT (p=0.03) and ARAT pinch section scores (p=0.04) in the UT group were significantly higher. None of the selected clinical or demographic factors significantly influenced training responses. BT significantly improved ipsilesional dexterity between T1 and T2 (p=0.04). For the sample as a whole, early ARAT and MBI scores significantly predicted contralesional ARAT scores at T2 and T3. Anxiety, depression and UL impairment significantly predicted overall HRQOL at T3. Conclusions: BT was no more effective than UT for the affected arm – in fact UT was more effective for dexterity. BT was more effective than UT, however, for short-term recovery of ipsilesional dexterity. Future studies should determine optimal BT characteristics for contraand ipsilesional recovery in stroke populations with differing levels of severity. Knowledge of predictors of UL activity limitation and HRQOL will enable therapists to target rehabilitation at factors that most influence these important outcomes.

This thesis is based on six studies which address questions around the use of accelerometers to measure physical activity and sedentary behaviour of pre-school children: are shorter epochs more accurate? Which epochs are most accurate? Are there advantages to using triaxial accelerometers? Which cut-points are most accurate? Are different generations of Actigraph accelerometers comparable? What is the recommended wear time to provide a reliable estimate of habitual physical activity and sedentary behaviour? Analysis of 7-10 day accelerometry data, collected from 31 pre-school children (mean (SD) age 5.9 (0.7) y), suggests that shorter epochs (15 s) result in significantly greater estimates of time spent in moderate-to-vigorous physical activity (MVPA) in comparison to 60-s epochs (p <0.05). When compared against a direct observation method, Children’s Activity Rating Scale (CARS), with 32 pre-school children (4.4 (0.8) y) during 1 hour of free-play, 15-s epochs were more accurate than 60-s epochs. Comparison of the triaxial RT3 against a uniaxial accelerometer, suggests no advantage of the RT3 accelerometer. The Puyau et al. (2002) cut-points had the ‘best’ agreement with estimates of sedentary behaviour, light intensity and MVPA against the CARS. Different generations of accelerometers were not comparable, however, application of a correction factor to the GT1M data (7164 = GT1M/0.91) may improve comparability of total physical activity. Finally, analysis of 7 day accelerometry data from 112 pre-school children (3.7 (0.7) y) suggests that 3 days of 7 hours provides a reliable estimate of habitual physical activity and that inclusion of weekend days is not necessary. This thesis highlights the implications that methodological decisions can have over apparent estimates of physical activity and sedentary behaviour and has made recommendations for accelerometry use. Ideally, there needs to be a move towards consensus, as, only by adopting standardised approaches to accelerometry use, will comparison between study outcomes become meaningful.

This thesis addresses current issues regarding assessment of physical activity (PA) and physical function (PF) status of haemodialysis (HD) patients, specifically: What is the recommended wear time to provide a reliable accelerometer estimate of habitual PA and sedentary behaviour? Can similar outcomes from different accelerometers be used interchangeably? Do subjectively and objectively estimated PA outcomes agree closely enough to be pooled? Which PF assessments are potentially most ‘useful’? This thesis also explores potential risk factors of arterial stiffness, a strong predictor of mortality in this population. A PA reliability study involving 70 maintenance HD patients (55.9 ± 15.7 years) over a seven-day monitoring period indicated one dialysis day and two non-diaysis days with a minimum of eight hours wear per day would provide reliable estimates of PA and sedentary behaviour regardless of accelerometer employed, and allowed 90% sample retention. Concordance studies indicated broad agreement for similar outcomes obtained via ActivPAL and Actigraph GT3X accelerometers but they were not interchangeable. ActivPAL is recommended for monitoring steps taken and time seated, Actigraph activity count output for total/overall PA. Questionnaire and accelerometer estimated PA outcomes may not be used interchangeably or pooled. More of the shared variance of physical performance was explained by clinical, demographic and habitual PA factors than for self-reported functional status thus recommending the former. Age, blood pressure and HD vintage were determinants of arterial stiffness, however PA and cardiorespiratory fitness did not appear to be risk factors in this sample. This thesis makes clear recommendations regarding implementation of PA and PF assessment methods, and illustrates their application on sample retention, as well as characterising and potentially identifying individuals at risk of poor outcomes. Emergence of HD vintage as a risk factor for arterial stiffness underscores the need for further research into adjunctive lifestyle interventions to manage health threats in this population.

Rehabilitation following Anterior Cruciate Ligament (ACL) Reconstruction (ACLR) benefits most patients electing ACLR surgery. Contemporary practice offers limited adaptation of the service to the needs of individual patients. This thesis focuses on a Randomised Control Trial (RCT) that evaluated the effects of a novel formulation of patient-centred musculoskeletal rehabilitation involving the Performance Profiling Technique (Butler and Hardy, 1992). Performance Profile Management (PPM), a programme of rehabilitation, was adapted to incorporate patient-physiotherapist negotiation and agreement on decisions for subsequent rehabilitation and treatment strategies. Therefore, the primary aim of the research was primarily to assess the efficacy of individually-tailored, self-managed rehabilitative care (PPM) in comparison to contemporary (CON) clinical practice. The latter would facilitate an understanding of patient needs and verify the circumstances in which rehabilitation might be enhanced by allowing individuals to play a key role in designing their treatment and recovery. A secondary clinical aim was to evaluate the strength of relationships amongst Patient-Based Outcome Measures (P-BOMs) and Clinician-Based Outcome Measures (C-BOMs). Currently, it is unknown which combination of outcome measures (P-BOMs or C-BOMs) delivers an optimum global assessment of functional and physical performance capabilities during patients’ post-surgical rehabilitation. A clinically-relevant and significant association amongst P-BOMs and C-BOMs might indicate correct scaling of patients’ own capability perceptions with those measured using objective assessment methods (C-BOMs) and endorse the utility for the clinical use of P-BOMs.

Bakgrund: Psykisk ohälsa är ett allvarligt folkhälsoproblem och en stor bidragande orsak till olika sjukdomar i dagens samhälle. Fysioterapi kan vara en effektiv behandlingsmetod vid psykisk ohälsa Syfte: Syftet med studien var att sammanställa en litteraturöversiktöver studier som undersökt fysiska aktivitetsformer och dess effekt på symtom och hormoner relaterade till psykisk ohälsa.Metod: Litteratursökningen gjordes i PuBMed, PEDro och SweMed+ med sökorden physical therapy modalities, exerciseochstress, psychological. Sökningen resulterade i elva artiklar. Behandlingsmetoderna som studerats är olika former av fysisk aktivitet, fysisk träning och österländsk intervention i form av yoga, qi-gong och andningsövningar. Resultat: Artiklar som tog upp fysisk aktivitet reducerade stressnivån hos försökspersonerna, dock var den inte signifikant (alla p-värden&gt;0.15). Artiklar där fysisk träning ingick visade på en signifikant reducering av ångestkänslighet samt en signifikant kortisolåterhämtning i jämförelse med kontrollgrupperna (p=0.001). Qi-gong visade på en signifikant förbättring gällande depression (p=0.010),ångest (p=0.016) stress (0.009) samt minskning av kortisol i salivet (p=0.012) i jämförelse med kontrollgrupperna. Yoga visade en signifikant minskning av arbetsrelaterad stress (p=0.02) i jämförelse med kontrollgrupperna,Diskussion: Samtliga studier visar att de olika behandlingsformerna ger positiva effekter på tillståndet i någon grad. En trend kunde ses att de senaste tio årens forskning riktat in sig mer på österländska interventioner. Konklusion:Österländsk intervention gav ett generellt högre bevisvärde i jämförelse med de andra interventionerna. Framtida forskning bör använda sig av standardiserade utfallsmått för att underlätta jämförelse mellan studier. Mer vetenskapliga studier med ett längre tidsperspektiv behövs för att se vilka långsiktiga effekter som finns.

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Bakgrund: Applikationer för mobiltelefoner kan användas för understödjande av fysisk aktivitet och träning. En hälsorelaterad applikation med funktioner som kartläggning eller feedback och påminnelse kan användas för att främja fysisk aktivitet och träning men också fungera som ett arbetsverktyg för fysioterapeuter för samma syfte.   Syfte: Syftet med studien är att undersöka fysioterapeuters och användares erfarenheter av att använda hälsofrämjande applikationer för fysisk aktivitet och träning.   Metod: Studien genomfördes med en kvalitativ design i form av en intervjustudie med en induktiv ansats. Urvalet bestod av tre fysioterapeuter och tre användare där analysen av data genomfördes med en kvalitativ innehållsanalys.   Resultat: Intervjuerna resulterade i fem kategorier och 13 underkategorier berörande fysioterapeuter och användares erfarenheter av användandet applikationer för fysisk aktivitet och träning Kategorierna blev: applikationen ger feedback, applikationen underlättar kartläggning, känslomässiga reaktioner av applikationen, upplevda hinder med applikationen för en beteendeförändring och ökad motivation för fysisk träning och aktivitet.   Slutsatser: Deltagarna i studien var överlag positiva till användandet av applikationer. Deltagarnas erfarenheter av applikationer pekar på att applikationer fungerar som ett bra hjälpmedel för att främja fysisk aktivitet och träning, samt fungerar också som ett hälsofrämjande arbetsverktyg för fysioterapeuter. Resultatet visade också på stress och frustration vid ouppnådda hälsomål.   Nyckelord: Applikationer, ehälsa, fysioterapi, fysisk aktivitet, hälsofrämjande