Wheelchair rugby originated in 1977 in Canada, as a sport for athletes with tetraplegia (quadriplegia).The game has grown into an intense physical team sport for both female and male with a variety of disabilities involving all four limbs. Athletes are systematically grouped into sport classes according to their ability to move and perform basic functional skills in their specific sport. This allows for fairness. Cerebral palsy (CP) players joined the wheelchair rugby. Because the CPâs disability lies on a total different level, classifiers find it difficult to classify them correctly. The aim of the study as to explore whether the present classification system disadvantages the CP wheelchair rugby players. An explorative descriptive research design was used. Data was gathered by the use of the nominal group technique. The research took place at the 2005 International Wheelchair Amputee Sport championships in Brazil. Seven specialists in the field of wheelchair rugby participated in the study. The findings of the study and the conclusion reached indicated that there is a definite need for a different and more functional approach to bench testing cerebral palsy wheelchair rugby players. A new bench test format should be developed and could then be suggested to the International Wheelchair Rugby Federation for possible future inclusion in the classification manual.

Globally four to nine million cases of newborn asphyxia occur each year. Despite major advances in monitoring technology, obstetric care and knowledge of fetal and neonatal pathologies, asphyxia remains a serious condition causing significant mortality and longterm morbidity. More than a million newborns that survive asphyxia at birth develop longlasting problems such as cerebral palsy, speaking, hearing and visual disabilities. The role of the physiotherapist in the follow up, assessment and early intervention of at risk infants is poorly researched and subject to much debate. The aims of the study were two-fold. The primary aim was to determine the proportion of neurodevelopmental sequelae in infants who suffered moderate to severe neonatal asphyxia. The secondary aim was to describe the population regarding maternal, neonatal and referral risk factors associated with asphyxia. This retrospective descriptive study included a study population of all infants diagnosed with grade II or III neonatal asphyxia admitted to the Pelonomi Hospital neonatal unit. All subjects had to have had a physiotherapy neurodevelopmental assessment between the ages of six weeks and twelve months of age. A total of 40 subjects were included in the study. Five subjects were lost to follow up and five did not meet the inclusion criteria. Information contained in the subjectsâ medical record and physiotherapy file were used to complete a data form. The Data form contained the neurodevelopmental assessment score (NDS), which served as the objective measure for neurodevelopmental outcome. The NDS for the grade II and grade III subjects showed no statistical difference, whilst there was a tendency towards the grade IIIâs having a higher score indicating poorer developmental performance. The results indicated that 32% of the subjects presented with neurodevelopmental sequelae following moderate to severe birth asphyxia. In terms of risk factors this study found that hypertensive disease of pregnancy and intrauterine growth restriction were the most prevalent maternal risk factors. Neonatal risks indicated the majority of subjects had low (< 7) Apgar scores at both five and ten minutes of life. Five infants required mechanical ventilation following initial resuscitation. In 41% of the subjects, mothers resided outside of Bloemfontein at the time of the birth, and 37% of the deliveries occurred at a primary health care facility. Of the subjects 62% were delivered vaginally and 38% via caesarian section. In conclusion the study indicates that developmental sequelae are common in this study population. In some cases developmental delays were observed as early as six weeks of age. Neurological impairments however were only observed from nine months of age. It would therefore be suggested that all moderate to severely asphyxiated infants be followed up routinely and assessed by a physiotherapist for developmental problems from six weeks of age and on. A routine assessment by an occupational and speech therapist is also advised.

Myofascial pain syndrome is characterized by sensory, motor and autonomic symptoms, and a myofascial trigger point (MTrP) is considered the principal clinical feature. Clinicians recognise myofascial pain syndrome as an important clinical entity but many basic and clinical issues need further research. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Authors also suggest that MTrPs are located in the innervation zone (IZ) of muscles. The aim of this thesis was to describe both the location of MTrP and the IZ’ locations in the upper trapezius muscle. The hypothesis was that distance between the IZ and the MTrP in upper trapezius muscle is equal to zero. This thesis includes two preliminary studies. The first one address the reliability of surface electromyography (EMG) in locating the IZ in upper trapezius muscle, and the second one address the reliability of a manual palpation protocol in locating the MTrP in upper trapezius muscle. The intrarater reliability of surface EMG in locating the IZ was almost perfect; with Kappa = 0.90 for operator A and Kappa = 0.92 for operator B. Also the interrater reliability showed an almost perfect agreement, with Kappa = 0.82. Both the operators conducted 900 estimations of IZ’ location through visual analysis of the EMG signals. The reliability of an experienced physiotherapist using a manual palpation protocol in locating the MTrP in the upper trapezius was established. An anatomical landmark system was defined and MTrP’ location established using X and Y values. The ICC values were 0.62 for X and 0.81 for Y. Twenty-four subjects with MTrP in upper trapezius were enrolled for this latter study. MTrP’ and IZ’ locations were described in 48 subjects. MTrPs were located in well-defined areas of the upper trapezius, showing a typical location with a mean distance from the IZ of 10.4 ± 5.8 mm. MTrPs in the upper trapezius are proximally located to the IZ but not overlapped by it (p = 0.6). These results extend the body of knowledge regarding the phenomenon of MTrP iperalgesia.

Evidence suggests that the walking ability of people with cerebral palsy (CP) often deteriorates in early adulthood. This is especially problematic as the health care for young people with disabilities changes considerably over the course of the transition from paediatric to adult health care services. This suggests the importance of providing young people with the appropriate tools for managing their disability on a largely independent basis if they hope to reduce or delay this physical decline. One such strategy is the introduction of young people to an exercise programme which may be carried out independently of the health care system. Therefore, the main aim of this thesis was to investigate the feasibility and effectiveness of an 18-week pragmatic community exercise programme in adolescents and young adults with CP. Acknowledging the importance of assessing the effects of exercise studies using outcome measures (OMs) which are reliable, valid and responsive to change, a secondary aim of this thesis was to synthesise the psychometric evidence for the measures of gait quality and walking performance currently used for adolescents and young people with CP through a systematic review. Additional psychometric evidence for measures commonly used to assess the efficacy of exercise interventions was provided by a test-retest reliability study as part of this thesis. A standardised quality checklist (COSMIN) was used in the systematic review (Study 1) to measure methodological quality. The strength of the evidence was rated using standardised guidelines. The synthesis of best evidence was scored according to the Cochrane criteria, which indicated that the reliability (inter-rater) of the Functional Mobility Scale was characterised by a ‘strong’ level of evidence. The evidence for the responsiveness for all OMs included in this review was rated as ‘unknown’. Only one study reported on measurement error when reporting on reliability. In Study 2, test-retest reliability (Intraclass Correlation Coefficient (ICC) and Minimal Detectable Change) was calculated for physical function, habitual physical activity (HPA), quality of life (QoL) and self-esteem measures in a group of adolescents and young adults with CP (n=8) and their age-matched peers (n=14). The ICCs for physical function and HPA OMs ranged from moderate to good but were poor for the measures of QoL and self-esteem. The RCT (Study 3) showed no statistically significant improvement following the exercise programme in any of the OMs at 6 weeks (experimental n=9, control n=7). A small effect size (d=0.54) in favour of the experimental group was found for the Canadian Occupational Performance Measure (COPM). Considering the experimental group only, a statistically significant improvement was found for the COPM at 12 weeks (n=7, p=0.02) compared to the baseline. Feasibility issues were also identified. This study was limited by its small sample size. This thesis contributes to the evidence base on pragmatic community exercise programmes for adolescents and young adults with CP and confirms the test-retest reliability (consistency) of physical function and HPA OMs commonly used to assess the efficacy of exercise interventions in CP.

Bibliography: leaves 63-71.

Includes abstract. / Includes bibliographical references. / Traditionally, non-specific low back pain (NSLBP) has been described as an important public health issue among adults but a rare phenomenon in the young. However, recent epidemiological studies have provided evidence that NSLBP affects all age groups. In adolescents, the literature has shown that the prevalence has increased tremendously during the past two decades. The reasons for this remain unclear. In addition, there is substantial evidence to suggest some adolescents will experience severe episodes of recurrent NSLBP associated with adverse consequences such as long-term chronicity into adulthood, reduced health-related quality of life, and school absenteeism. In-spite of such evidence, no studies have been conducted in Zimbabwe to investigate the subjective presence of NSLBP symptoms among school-aged adolescents and to screen adolescents in schools affected by the condition in an attempt to identify the associated risk factors. The aim of the study was to estimate the prevalence (lifetime and point) and the one-year prevalence of recurrent NSLBP. In addition, the study aimed at identifying the individual risk factors associated with the report of recurrent NSLBP. A further aim was to compare the health-related quality of life between adolescents with recurrent NSLBP and those without.

Includes abstract. / Includes bibliographical references. / Cerebral palsy is a disabling and permanent condition which requires sustained rehabilitation over a long period of time. There is much debate as to which model of service delivery is most appropriate for children with cerebral palsy and their mothers. The aim of this study was to compare the efficacy and effectiveness of two models of service delivery currently offered in Harare, Zimbabwe. One of these is a hospital-based and the other a community-based service. A quasi-experimental study was done to determine the efficacy of two service delivery models from the perspective of caregivers and functional gains in children. Questionnaires were distributed to caregivers of children with CP at baseline and after three months. The caregivers were 46 in total, with twenty caregivers having children receiving rehabilitation services under an outreach program and 26 receiving services as outpatients at a central hospital. The caregivers’ health- related quality of life was assessed using the EQ-5D, the burden of care was measured using the Caregiver Strain Index, satisfaction with physiotherapy was assessed using the modified Medrisk satisfaction with physiotherapy services questionnaire and compliance was measured as an index of the met appointments from the scheduled appointments. Additionally, motor functional changes in children with CP were assessed at baseline and after three months using the Gross Motor Function Measurement (GMFM-88). Children receiving community based treatment children were significantly older than children in the hospital based group. However, the two groups were comparable in terms of sociodemographics of both children and caregivers at baseline. The correlation between age and change in score was tested and found to be non-significant (r=-.103, p=.497). Spearman’s rho indicated that as the level of severity increased in terms of GMFCS level, so the amount of improvement decreased (rho=-568, p<;.000). However, as age was significantly different between the two groups and there were more severely affected children in the community based treatment group, regression analysis was done to establish which factors predicted the amount of change in the GMFM Score. Dummy variables were created for the categorical variable of the group and the ordinal variable of GMFCS was dichotomised into level 3 and above and level 4 and below. The resulting model accounted for25% of the variance (adjusted R²= .25) after the score of one child was removed after residual analysis indicated that he/she had improved more than two standard deviations from the mean residual. The results indicate that, once age and category were controlled for, children in the community based treatment group improved 3.5 points more than children receiving hospital based services. Children who were more severely disabled showed 4.7 points less improvement, and for each month of age, children showed .04 less improvement, although this was not significant.

The thesis set out to document the process of developing and testing a non-pharmacological biopsychosocial intervention programme which included exercise and health education for women with musculoskeletal conditions attending a clinic in a poorly resourced area of the Free State Province in South Africa. To inform the development of an appropriate intervention, several sub-studies were undertaken. Systematic reviews on the use of exercise and health education in adults were undertaken, one on the impact of these interventions on adults with chronic diseases of lifestyle (diabetes mellitus type II, hypertension) and the risk factor obesity, and the other on the impact on adults with musculoskeletal conditions. The selected research tools, which were chosen based on the framework of the International Classification of Functioning, Disability and Health (ICF) were subjected to a rigorous translation process. A facility-based descriptive observational cross-sectional study was undertaken to determine the prevalence and nature of musculoskeletal conditions amongst women between the ages of 40 and 64 years attending a community clinic. The gathered information was then used to modify and adapt existing non-pharmacological programmes and develop an intervention programme tailor made for these patients. Finally, an experimental randomised controlled trial was undertaken to determine the effectiveness of usual care against a non-pharmacological intervention utilising a workbook for the women identified in the survey.

Background: Road traffic injuries are the leading cause of death in children and young adults. Children are at increased risk of fatalities and serious injury due to the differences in their body segment proportions affecting their body kinetics in a vehicle accident. Serious injury and death can be reduced by the appropriate use of car restraint systems (CRS). Children with special health care needs (CSHCN), particularly children with poor postural control, may need adaptive seating to improve postural support and sitting ability within the vehicle due to their additional physical needs. Standard CRS might be unsafe or inappropriate for children with physical disabilities. Research Aims: The thesis aimed to understand the current CRS usage as well as the parents' experiences and perspectives of transportation of CSHCN in the Western Cape, and to determine the postural support needs of CSHCN and the suitability of different CRS designs to meet these needs during transportation. This was achieved through a survey study, followed by a cross-sectional study. Assessing the use of car restraint systems in children with special health care needs; a Western Cape based survey study Objectives: To determine the modes of transport and the prevalence of the use of postural support systems by CSHCN. Along with describing the current use of seatbelts, standard or specialised CRS and exploring the challenges faced by parents of CSHCN during transportation. Methods: A descriptive quantitative survey was performed amongst a convenience sample of all parents of CSHCN between the age of 4 – 18 years enrolled at three special needs schools in the Western Cape, South Africa. Parents had to be able to read and understand English or Afrikaans to be eligible for enrolment in the study. Focus group discussions were conducted to validate the self-designed questionnaire. Results: Parents of 268 children were enrolled in the study (median (IQR) age 11.52 (14.63- 8.86) years; 58.96% male). The most common diagnosis was cerebral palsy (CP) (29.10%), and most children were transported to school with public transport, including school bus (73.13%). The mode of transport was linked to the distance travelled and affordability, and each had its own challenges. The main challenges of parents using private transport were transporting the wheelchair (10.82%) and the unavailability of demarcated disability parking bays (7.46%). When using public transport parents identified their child's poor sitting balance (6.34%) and lack of space within the vehicle (5.60%) as the greatest challenges. The majority of children (58.96%) came from low-to-middle income households (< R6500 per month), significantly impacting the use of a CRS, with more children from higher income families being transported in a CRS (X²= 48.14, p< 0.001). Difficulties with sitting balance was reported in 25.75% of the children and was significantly association to the parents understanding of their child's sitting balance (X²= 17.72, p< 0.001). Parents who felt that their child had difficulty with their sitting balance were more likely to use a CRS. Furthermore, a significant association between currently using a CRS and child's weight was observed (X²= 11.54, p=0.021), as children who weighed more were less likely to still be using a CRS. Most parents (54.48%, n=146) did not know South Africa's current legislation on CRS, which was significantly associated with a lower CRS usage (X²= 19.84, p< 0.001). Half of the parents (n= 139, 51.87%) were not willing to spend money on a CRS as they felt that a car seat was not necessary for their child. The amount parents were willing to spend on a CRS was significantly associated with having ever made use of a CRS (X2=43.38, p< 0.001). Conclusions: Parents of CSHCN reported many challenges in transporting their child depending on the mode of transportation. CRS usage was associated with parent perception on the child's sitting abilities, lower weight, knowledge of legislation and a higher household income. Despite these, CRS usage amongst CSHCN is lower than expected as (48.88% – 55.22%) children that are still within the age and weight range to use a CRS as required by law did not report CRS usage. This could link in with the affordability of the CRS and failure to know the legislation on CRS by parents. This study highlights the need for national campaigns to promote and educate citizens on road safety and CRS legislation. Due to the lack of financial resources in low to middle income countries, it is vital that an affordable CRS is made available or is subsidized by the government where families are unable to afford the cost themselves, particularly for use in public transport. Effectiveness of currently available car restraint systems to maintain correct seating position during transportation for children with special health care needs Objectives: To determine the characteristics of CSHCN who require specialised CRS for their postural support needs, through assessment of their sitting ability and whether these needs are met by different CRS. Methods: Participants in the earlier survey study were invited to take part in a crosssectional and pre-post design study. A screening tool for identifying sitting balance problems was developed and found to be reliable for inter- and intra-rater reliability (k>0.700, p0.879). This tool was used to identify CSHCN who had difficulty sitting independently on different types of seats. These participants underwent a standardised sitting balance assessment, using the Level of Sitting Scale (LSS), to identify eligible participants with postural support needs. Participants were excluded if they recently had surgery or had an unstable health condition which could alter their sitting balance. The ability of two standard CRS (Car Seat and Booster seat), two Specialised CRS (one locally and one internationally produced), and Seatbelt only to provide adequate postural support was investigated. Head and trunk postures were analysed and categorised, by deviation from the midline, by photographs taken from different viewpoints. Results: There were 78 CSHCN enrolled in the study (mean (SD) age 11.50 (3.70) years; 65.75% male), the most common diagnosis was CP (63.48%), the majority of participants did not require any support to maintain sitting balance and were categorised as levels 5-8 of the LSS (78.08%). According to the World Health Organisation anthropometric guidelines 54.79% (n=40) of the participants should still use a CRS, either a Booster Seat (42.47%, n=31) or a Car Seat (12.33%, n=9). The head or torso fully supported and between the side supports of the CRS was the most common posture in all the viewpoints of the different CRS except for the lateral head viewpoint of the CRS Car Seat (50.00%; n=4), the Booster Seat (60.00%; n=18), and the International Specialised CRS (60.61%; n=20), as well as the anterior torso viewpoint of the Seatbelt only (50.75%; n=34). The CRS that resulted in the largest proportion of unacceptable posture deviations from the standard position were the Seatbelt only (20.90%, n=56) and the Booster Seat (18.33%, n=22). Out of position (OOP) postures were observed in all the devices for the anterior and lateral head positions (3.03% - 20.00%). The Booster Seat, the Local Specialised CRS and the Seatbelt only devices had participants with OOP postures in all four viewpoints. A key observation in the current study is the lack of torso support for the majority of CSHCN in the anterior torso viewpoint of the Seatbelt Only CRS (55.22%, n=37), indicating that the use of a Seatbelt only does not provide adequate postural support for all CSHCN despite them meeting WHO anthropometric requirements. No significant association was found between the pre- and post-test postural analysis scores of the Seatbelt only (X2=2.14, p=0.144) which could be as a result of the large postural deviations pre-testing (41.79%, n=28) remained post-testing. However, there was a significant association between the preand post-test scores of the anterior head viewpoint of the Booster seat (X2= 7.94, p=0.005), indicating lateral head deviation. The post-test postural analysis score of the Booster Seat anterior head viewpoint was significantly associated with a deviated posture (X2= 7.94, p=0.005). Other OOP observations included postures that could not be categorised by head and trunk deviation from the midline including head or torso rotation, abnormal limb placement, body extension and slouching. Overall performance scores are a sum of the number of viewpoints where the CSHCN posture worsens post-test. an indication of the number of CSHCN whose posture worsened post-test in each of the viewpoints of the CRS. Although there was no correlation between the LSS score and the overall performance score of any CRS device which would indicate if the CSHCN balance influences CRS performance, the Booster Seat (80.00%, n=24) and the Seatbelt only (55.23%, n=37) devices had the greatest number of participants with a poor overall performance. The viewpoints which had the worst performance scores were the anterior and lateral head of the Booster Seat (46.67%, n=14 and 43.33%, n=13 respectively) and both viewpoints had majority of participants worsen their scores. All CRS performed adequately in the lateral torso viewpoint, indicating sufficient support of the torso in the sagittal plane. Conclusions: The postural support needs of CHSCN are unique and depend on the child's anthropometry and the severity of their disability. The currently available CRS designs may not provide the postural support needed for many CSHCN. Postural deviations of the head, torso and limbs were observed which could be dangerous in the event of an accident. This study was not able to determine specific characteristics of CSHCN that require specialised CRS, as there was no association between the LSS and the overall performance score for any of the CRS devices. However, devices that offer less head and torso lateral support, or do not offer additional harness support such as the Seatbelt Only and the Booster Seat showed the largest proportion of OOP postures in CSHCN. Thesis Conclusion: This thesis highlights the complex transportation needs of CSHCN in South Africa and how the different CRS can influence posture. Additional observational research is required to determine the CRS usage in the CSHCN population to compare to the prevalence of CRS usage found in this survey study. Future research could incorporate other specialised CRS designs, particularly ones that are suitable for CSHCN beyond standard CRS weight and height limits or those with severe physical limitations that could not be tested during this study's simulated course. Practitioners prescribing and advising parents on CRS devices for the safe transportation of CSHCN should integrate thorough patient assessment and knowledge of manufacturer CRS design specifications to promote CRS usage. Policies should consider and accommodate for the challenges faced by CSHCN and their families in accessing, affording and utilising transport services. Advocacy and education programs should be combined with legislation enforcement to support improved implementation of CRS usage amongst all children, regardless of their disability status. For effective implementation for CSHCN, CRS should be affordable, accessible, functional and accommodate growth and postural support needs.

Includes bibliographical references / Purpose: Cardio-respiratory physiotherapy for patients undergoing abdominal surgery has been found to be beneficial in improving lung function post-operatively and in the prevention and treatment of post-operative pulmonary complications (PPCs). The Blow Bottle, a Positive Expiratory Pressure (PEP) therapy device, is commonly used as an adjunct to physiotherapy. The Blow Bottle is low cost and can be easily made by the physiotherapist using readily available materials in the hospital setting. However, evidence to support the use of Blow Bottles in the post-operative management of abdominal surgery is minimal, with few studies reporting significant positive effects especially when compared to conventional cardio-respiratory physiotherapy techniques. Methodology: A randomized control was implemented in a public tertiary institution within the Western Cape. Patients admitted for open abdominal surgery via midline incision were eligible for the trial. Participants were randomly allocated to either the control group (CG) receiving conventional post-operative cardio-respiratory physiotherapy, or the intervention group (IG) who received the additional use of the Blow Bottle. Lung function and the development of post-operative pulmonary complications were the primary outcome s of this study. Lung Function was evaluated by means of spirometry testing and interpretation of Forced Expiratory Volume in 1 second (FEV 1) and Forced Vital Capacity (FVC). The development of post-operative pulmonary complications were diagnosed using the criteria by Mackay et al. (2005) where changes from pre-operative findings of auscultation; temperature, X-ray and sputum are evaluated post-operatively and recorded using the Adapted Abdominal Physiotherapy Outcomes Data Sheet (A-APODS). Results: A total of 19 participants were enrolled in the study, n=11 (CG) and n=8 (IG), predominantly female (n=14) and admitted for cancer related abdominal surgery (n=9). There was a statistically significant (p<0.05) marked reduction in post-operative lung function from baseline across groups, 62% in FEV 1 and 47% in FVC on the first post-operative day. The FEV 1 and FVC were similar across both the control and intervention groups for the first three post-operative days. On auscultation majority of participants had decreased breath sounds on the first post-operative day. However, no one participant developed a PPC across the duration of the study as diagnosed using the criteria by Mackay et al. (2005). Conclusion: Whether the additional use of the Blow Bottle is more beneficial than conventional post-operative cardio-physiotherapy alone is inconclusive due to the incremental drop out of participants from the study and small sample size. In this study there was however a significant reduction in lung function post-operatively. This mandates the need for further research investigating the abdominal surgical field and the use of devices to improve lung function, such as the Blow Bottle, as literature is scant and outdated, and sorely lacking in the resource constraint South African hospital settings.