The focus of this PhD project is on symptom centralisation. Its primary objectives were to establish a standard operational definition of centralisation and evaluate its inter-rater reliability in neck pain. Two systematic reviews on the reliability and prognostic value of clinically induced symptom responses in spinal pain (Chapters 2 and 3) showed that although the potential usefulness of centralisation has been demonstrated in low back pain, concern has been expressed about the observed inconsistency in reported definitions, and the scarcity of studies in neck pain. A Delphi survey of experts (Chapter 4) assisted in the development of a uniform operational definition for centralisation and the identification of future research questions. Centralisation was generally defined as the progressive and stable reduction of the most distal presenting pain towards the spine midline in response to standardised spinal loading strategies. The support by the Delphi panel of a broader definition allowed for a multitude of different ways of testing to be included in the assessment procedure which may offer some flexibility to clinicians assessing, classifying and managing different spinal pain presentations across different countries. Although the reliability of identifying centralisation was acceptable, high levels of reliability were not demonstrated (Chapter 5). However, reliability was greater for the pair of physiotherapists with prior experience and formal extensive training in symptom response assessment. Therefore, the optimal type and amount of training for eliciting and interpreting centralisation and the effect of procedural variations on testing the outcomes of individuals who centralise require urgent investigation. The prognostic and management value of centralisation are also unknown. This investigation may pave the way for the standardisation of centralisation as a physical sign and stimulate interest for further study of potential sub-groups and classification of spinal syndromes.

This thesis investigates routine physiotherapy management of patients with subacute and chronic non specific low back pain. In a pragmatic multi-centre trial patients were randomised to receive a course of physiotherapy treatment or advice following a bio-psychosocial model. Disease specific, patient specific and generic measures were used to assess outcome. The 286 patients recruited in the trial had, on average, minimal to moderate low back pain disability. Patients reported enhanced perceptions of benefit in the physiotherapy group but there was no evidence of a long term effect in any other outcomes. There were no differences between the groups in NHS costs although patients in the physiotherapy group incurred significantly higher out of pocket expenses. Further analysis of the outcome data confirmed that the primary outcome measure (Oswestry Disability Index) was the most responsive instrument because it was able to detect deterioration as well as improvement. As the trial demonstrated no additional benefit of physiotherapy over brief advice, it was important to investigate the effectiveness of the latter. A systematic review found limited evidence that brief bio-psychosocial advice was more effective in reducing fear avoidance and improving back beliefs in patients with acute and subacute low back pain compared with traditional medical advice. There was no direct evidence to support the use of brief bio-psychosocial advice (2 sessions or less) for reducing pain or disability. This thesis describes research that has contributed to European guidelines for the management of chronic low back pain and reviews extensively the literature that seeks to evaluate physiotherapy practice. The clinical implication of this research is that for patients with non specific low back pain of mild severity, brief advice is likely to be as effective as prolonged physiotherapy intervention. The extent to which a single session of advice is more effective than no intervention needs further assessment.

The study aimed to establish whether levels of fitness and depression, or changes in those levels, in coronary heart disease patients are associated with survival time. The cohort consisted of 2,714 coronary patients who were followed up for 13 [median 6.4] years after enrolment into a cardiac rehabilitation [CR] programme. All participants underwent fitness testing and psychological assessment at the start of Phase III CR. These tests were repeated approximately 12 weeks later. Fitness levels were categorised into low, medium and high. Depression scores were divided into none, borderline and clinical depression. Primary endpoints were all-cause mortality and cardiovascular mortality. At the end of the study period 16.6% of the cohort had died. The improvement in fitness over the 3 months of physical training was 16.8%. Fitness category improved in 33% of the cohort and deteriorated in less than 1%. Baseline fitness was predictive of all-cause and cardiovascular mortality with adjusted hazard ratios [HR] for low fitness of 2.83 [2.02,3.96] (p<0.001) and 5.40 [3.36,8.69] (p<0.001) respectively. Low fitness at the end of CR was predictive of mortality, HRs 4.23 [2.64,6.79] (p<0.001) and 6.37 [3.37,12.0] respectively (p<0.001). An increase in fitness amongst the least fit at baseline was associated with an 11 % reduction in the risk of cardiovascular mortality [0.80,0.98] for each unit increase in fitness of 1 ml/kg/min. Baseline clinical depression was 4.6%. This had reduced to 1.1% by the exit assessment. Fitness levels were related to depressions scores; the least fit participants were more likely to be depressed. The study showed an association between baseline clinical depression and all-cause and cardiovascular mortality, before adjusting for fitness, HRs 1.60 and 1.79. Initial fitness and baseline depression are associated with prognosis in coronary patients who have attended CR. These findings may help target patients at risk in order to maximise treatments.

This thesis investigates the role of cervical spine Range of Motion in the recovery from Whiplash Associated Disorders. In clinical practice, Health Care Professionals attach value to measurements of cervical spine Range of Motion for diagnostic, prognostic and treatment evaluation purposes. A systematic literature review found conflicting evidence as to whether cervical spine Range of Motion was a prognostic factor following a whiplash injury. Greater understanding of prognostic factors such as this may facilitate improvements in patient management. A second systematic literature review investigated the reliability and validity of methods for measuring cervical spine Range of Motion. The Cervical Range Of Motion (CROM) device was found to be the most rigorously tested and clinimetrically promising method and was subsequently investigated for intra- and inter-observer reliability in a group of whiplashinjured individuals and found to be substantially reliable. The CROM device was utilised in a longitudinal cohort study of 599 whiplash-injured patients to investigate the prognostic value of cervical spine Range of Motion for neck painrelated disability and patient-reported recovery at short, medium and long-term follow-up. A patient-reported version of cervical spine Range of Motion was also evaluated as a prognostic factor. Although useful for explaining disability at the time of measurement, active, passive and patient-reported forms of cervical spine Range of Motion were not significant prognostic factors for poor outcome when other physical and psychosocial factors were accounted for. The clinical implication of this research is that if patients are experiencing reduced cervical spine Range of Motion a few weeks after their whiplash injury they will not necessarily have a poor outcome in the longer term as is commonly believed at present.

FRIENDS For Life' (Barrett, 2004) is a ten-week programme for children aged 7 - 11 years, based on cognitive behavioural principles, designed to teach coping skills and techniques to manage anxiety and depression. This study describes an evaluation of a universal programme, delivered to a class of Year 5 children in a school in a socio-economically disadvantaged community located in the East of England. A review of literature, combining narrative and systematic approaches, presents what is known about the development of emotional distress and academic self-perceptions in children, underpinned by the principles of Social Cognitive Theory (Bandura, 1986). Evidence for the effectiveness of Cognitive Behavioural Therapy with children is critiqued, with specific attention to the FRIENDS programme delivered as a universal intervention. A quasi-experimental non-equivalent groups design (intervention group and wait-list control) was employed to evaluate the impact of the programme upon children's levels of emotional distress, their academic self-perceptions and teacher ratings of pupil behaviour. Pre and post-test measures comprised the Paediatric Index of Emotional Distress, (O'Connor et al, 2010), the Myself-As-Learner Scale (Burden, 1998) and the Strengths and Difficulties Questionnaire (Goodman, 1997). A change score analysis revealed statistically significant reductions in self-reported levels of emotional distress and teacher-rated hyperactivity for the intervention group in comparison to the control group. Both groups showed significantly improved overall behaviour and prosocial skills. There was no evidence of a significant change between or within groups for academic self-perceptions. The limitations associated with quasi-experimental designs are highlighted, together with the difficulties of operationalising abstract constructs such as 'emotional distress' and 'academic self-concept.' The results are discussed in relation to the theoretical and methodological implications highlighted in previous chapters. Particular attention is paid to the significance of contextual influences operating in concert with the programme components in mediating outcomes. Implications for future research and the role of the Educational Psychologist supporting universal therapeutic programmes in schools are discussed.

This thesis provides an empirical investigation of the geneticisation thesis. Geneticisation is one of the most prominent critiques of the social and cultural implications of developments in genetics. It incorporates a set of claims and expectations about the way genetic knowledge and technologies are transforming or will transform ideas about health and illness, and health care practices. This research aims to explore the empirical basis of these claims, by looking at the place of genetic discourses and practices in one specific area. The thesis focuses on familial hypercholesterolaemia (FH), a treatable hereditary cholesterol condition associated with high rates of coronary heart disease (CHD). It asks how much and in what ways patients with FH and professionals involved with the condition construct FH and CHD as genetic conditions. The thesis draws on three main areas of data - biomedical literature concerning CHD and FH; ethnographic work concerning the activities of HEART UK, the main UK health charity involved with inherited lipid disorders and cholesterol; and interviews with patients with FH and with staff and members of HEART UK. The analysis suggests that FH is not understood or managed within a strong genetic frame, and that neither professionals involved in HEART UK, nor patients with FH, provided or contributed to radically new or geneticised accounts of CHD. In short, the research suggests that geneticisation overstates the transformatory potential of genetics, and that factors such as the availability of effective therapeutics, the sites where care takes place, the disciplines involved, and existing lay and professional models of disease are important for the construction of a particular field. Furthermore, in arguing that FH is not associated with a strong specific disease identity or community, the analysis questions the notion of biosociality, suggesting that is may be less relevant to some biological states or conditions than to others.

Over the last 20 years, an increasing number of research studies have shown that ultrasonography can provide a valid and accurate assessment of the median nerve and the pathological changes associated with median nerve disorders. More recently ultrasonographic technology has advanced and it now allows for dynamic imaging of the nerve during physical movement of the hand. However dynamic ultrasonographic imaging is still a relatively new application as is yet to be explored to its full potential in the study of median nerve dynamics and the associated pathological changes. The primary aim of this research is to study median nerve activity during physical hand movement using ultrasonography with 8-16MHz linear array transducer. The objectives are to establish an ultrasonographic technique for the dynamic imaging of the median nerve, along with an analytical method that can quantify its changing size, shape and location during four hand movements. The data obtained from participants with normal median nerve function is compared to values from participants who are either moderately symptomatic or fully symptomatic of a median nerve disorder, to investigate whether the novel method and technique could distinguish between the groups. Three studies were designed to investigate median nerve activity during physical movement using ultrasonography. The aim of the first study was to investigate if the novel quantification method and ultrasonographic technique could measure the changing parameters of the median nerve between the start and end positions of a finger grip, power grip, pinch grip and thumb opposition movement, in non-symptomatic participants who have normal median nerve function. The second study investigated whether the novel quantification method and ultrasonographic technique could distinguish between the non-symptomatic participants and participants who are either moderately symptomatic or fully symptomatic of a median nerve disorder, during each movement. The third study examined the change in size, shape and location of the median nerve at five intervals during the four movements and compared the data obtained from the non-symptomatic group with the values obtained from the moderate and fully symptomatic groups. The findings from the studies show that the dynamic ultrasonographic technique can be used to image the median nerve during physical activity of the hand and that the novel quantification method can be used to measure the change in the parameters of the median nerve during physical hand activity and distinguish significant differences between the non-symptomatic median nerve and those symptomatic of an median nerve disorder.

The general research aim was to examine the process by which the mental health review tribunal decided on the 'dangerousness' of the person before them as a basis for their judgement about release or continued detention. Within the general context of the sociology of law, the research project was concerned with the decision-process as it operated in practice within the established socio-legal framework and its interaction with the concept and causation and social nature of deviance and 'danger'. It was assumed that the formal-structural approach was insufficient to study and explain the decision-process in practice; so the research incorporated the study of the relationship between socio-demographic facts and the tribunal decisions, a study of the way the facts were perceived by the tribunal members, and consideration of the dilemmas and conflicts experienced in practice and innovatory action arising from anomalies in their rules and powers. Various methods of data-collection were adopted in respect of the sample of 150 tribunal hearings held at Rampton Hospital: a) the systematic observation of the hearing, b) the structured interviewing of the legal chairman, and c) structured examination of written records for details of the subject. The findings supported the conclusions that the prescribed rules and powers of the tribunal were insufficient for the task of protecting the individual from unfair detention; and the nature of 'danger' and the social identity of the 'dangerous individual' required a response from the decision-makers beyond objective assessment of observable facts. The decision-process was shown to be a 'human-process' involving emotional and subjective reactions. A more sufficient model of the decision-process in respect of 'danger to self and others' was developed, designed to take account of external restraints and anomalies in the system, and influences which could not be explained in strictly 'objective' terms.

Research had two aims: firstly, to explore the clinical observation that dependent drug users are often apparently unwilling, or are unable to reflect in any depth on experience, including thinking about mental states in self and other. Secondly, to consider the intrapsychic elements that exist alongside, and which may motivate drug addiction (including heavy and dependent alcohol use). 34 drug users were interviewed using the Adult Attachment Interview, and interviews coded for Reflective Function (RF), an objective measure of the capacity to mentalize. Low RF was identified across the sample. Data from Adult Attachment Interviews also revealed that a climate of violence and/or cruelty, deprivation and a lack of basic care nearly always precede chronic drug or alcohol addiction. I suggest that as a result of this the individuals interviewed had minimised thinking about their own & others’ states of mind. Ten of the sample were then interviewed twice more using a research interview based on the clinical psychotherapeutic interview, which explored internal dynamics and object relational aspects of participants’ narratives. The data obtained revealed the presence of two kinds of internal object relating in a very specific way. A cruel, bullying, depriving object was found to dominate, and to severely restrict access to, a much weaker, though potentially helpful internal object. There was an over-reliance on the dominant bad object which was felt at one time to have saved the addict from unbearable psychic pain, but had then demanded he turn forever away from human help, denying the need for this or indeed any vulnerability or ‘weakness’. Whilst intoxication was initially found both to help the addict sustain this position, and to obliterate psychic pain, ongoing addiction actually cemented the dynamic described, and further inhibited access to helpful, human objects.

Metabolic syndrome (MetS) is defined as the clustering of medical conditions (that is impaired fasting glucose (IFG) or type 2 diabetes mellitus (T2DM), hypertension (HTN), obesity and dyslipidaemia) that increase an individual's risk of developing diabetes or cardiovascular diseases (CVD). In the United Arab Emirates (UAE), the prevalence of MetS and its features are among the highest in the world. However, research that explores the health needs of patients with MetS within the socio-cultural context of the UAE is lacking. This study aimed to explore patient and professional perceptions of MetS and its management in the UAE. A qualitative approach that drew on the broad principles of grounded theory was undertaken to meet the aims of the study. Following ethical approval, semi-structured interviews were conducted with 29 patients with MetS and 27 health care professionals (HCP) involved in the management of patients with MetS (10 physicians, 11 pharmacists, 4 dieticians and 2 health educators). This was followed by one focus group discussion with nine pharmacists for further exploration of identified themes. Interviews were audio-recoded and transcribed verbatim. NVivo aided the organisation of data. Thematic analysis based on the principles of grounded theory was conducted. This study was able to identify a number of factors that influenced patients' perceptions of their health and attitude towards their treatment plan. All patients interviewed were unfamiliar with the MetS concept and claimed to have never been informed by their physicians about their MetS diagnosis. Patients' awareness of the high prevalence of MetS features in the UAE, the asymptomatic nature of the cardiometabolic risk factors (CRFs) and the availability of treatment resulted in downplaying of MetS risk. Not all HCPs were familiar with the MetS concept or definition. Factors such as the complexity of the MetS name and the absence of the MetS diagnosis from the list of reimbursed medical conditions discouraged physicians from informing patients of their MetS diagnosis and limited the clinical utility of the MetS concept respectively. The study found that a number of socio-cultural factors hindered successful implementation of lifestyle interventions. Such factors included family restrictions of outdoor exercising by women, lack of culturally sensitive health clubs, food-centric activities and eating habits. Patients' beliefs about medicine and medicine brands affected their medicine-taking habits and altered their adherence. HCPs believed that a population-focused health approach would result in behavioural change. They also emphasised the key role of the public health policy to prevent MetS and promote a healthy lifestyle. Patients acknowledged the importance of adhering to lifestyle interventions to control their clustering risk factors. However, they believed that their lack of motivation, willpower, and limited physical mobility, due to coexisting health condition, were detrimental to adherence to lifestyle interventions. This study provides important new information for understanding the dynamics of patients' health behaviour and attitude towards MetS treatment in the UAE. It also demonstrates how aspects of the health policy and professionals' clinical practice limit the clinical utilisation of the MetS concept. Efforts to promote healthy behaviour and enhance the prevention and management of MetS in the UAE need to be stepped up and be tailored to patients' personal, social and cultural needs.