After knee surgery, the development of leg strength and size to its original levels are important requirements in the recovery. The major aim in the rehabilitation of a meniscectomy is to return the injured limb to its original size by a program of active exercises. Failure to do this may result in limited activity and re-injury to the knee joint A program of electrical stimulation has been found to be effective in controlling muscle atrophy during the time of denervation in animals and humans (in animals - Schimrizk et a 1976; Herbison et al, 1973, 1971; Stillwell et al, 1962 and Guttman and Guttman, 1942; in humans - Osbourne, 1951 and Jackson and Seddon, 1945). At the present time no studies have been done to determine if electrical stimulation will be effective in controlling muscle atrophy in normally innervated muscles during the period of immobilization. The purpose of this investigation was to determine the effects of a 10-12 day program of electrical stimulation on the control of muscle atrophy and strength loss during the period of immobilization. A subproblem of this investigation was to determine the relationship between muscle atrophy and strength loss. The subjects for this study were eighteen patients undergoing a meniscectomy operation (mean age 22.7 yrs.). Subjects were rated according to strength per body weight and assigned to a control or an experimental group. The experimental group participated in a five session program of electrical stimulation in addition to a standard physiotherapy program. The control group participated only in the standard physiotherapy program. The electrical stimulation consisted of five sessions each lasting ten minutes. Ninety muscle contractions were made during the ten minute session. The sessions were held on weekdays within a 10-12 day period of the operation. The first session was held 48 hours after the operation. In the first two sessions the leg was stimulated at the immobilized angle and in the remaining three sessions the leg was stimulated at 115 degrees of extention. All subjects were tested one day prior to the operation and at the end of the 10-12 day period for thigh volume and maximal isometric leg strength. The following hypotheses were tested for significance at the .05 level. 1. The use of electrical stimulation in addition to the standard physiotherapy program will show less muscle atrophy as compared to the standard physiotherapy program. 2. The use of electrical stimulation in addition to the standard physiotherapy program will maintain a higher level of original isometric strength as compared to the standard physiotherapy program. 3. There is a positive linear relationship between muscle atrophy and strength loss. Analysis of variance revealed that hypothesis #1 is supported at the .01 level and hypothesis #2 is not supported at the .05 level of significance. The Pearson Product Moment Correlation showed that hypothesis #3 is supported when the two groups were combined and for the control group only at the .01 level of significance, but not for the treatment group only, at the .05 level. / Education, Faculty of / Curriculum and Pedagogy (EDCP), Department of / Graduate

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BACKGROUND: The Canadian healthcare system is subject to national standards that may be challenging to meet, given the evolution and integration of technology in healthcare in disciplines like functional neurosurgery, utilizing therapies such as deep brain stimulation (DBS), whereby implanted devices have provided benefit for patients with movement disorders. A comprehensive assessment of the need for this service to match with the delivery of DBS has not been performed. This thesis comprises a series of studies that aim to address this knowledge gap through the quadruple aim of health service research. METHODS: The first study is a systematic review and meta-analysis including economic evaluations comparing DBS for movement disorders with medical management only. The second is a mixed methods survey of Canadian stakeholders for DBS. The final study is a nationwide retrospective cohort study of DBS patients from 2019-2022 to determine factors that may influence access. RESULTS: Through analysis of 14 economic evaluations, DBS appears to be a cost-effective treatment when considered across the remaining lifespan of the patient with positive incremental net benefit for DBS with a mean difference of 40,504.81USD (95% CI 2,422.42; 78,587.19). Additionally, 220 responses from all DBS stakeholder groups revealed that costs associated with travel, waitlists, lack of specific resources, poor understanding of movement disorders and DBS indications, and referral pathways were barriers to accessing DBS. Finally, preliminary results identified 162 DBS patients. Potential factors that may increase access to DBS were indication (Parkinson’s disease), higher socioeconomic status, and race. CONCLUSIONS: While DBS is a cost-effective therapy for patients with movement disorders, the current delivery of this service needs significant improvement. This includes improved education, streamlined referral pathways, and policy change at a governmental level, with further investigation to determine regions of the country where need for DBS far exceeds current access. / Dissertation / Candidate in Philosophy / Movement disorders are progressive, debilitating neurologic conditions that severely impact the quality, speed and fluency of movement as a result of basal ganglia dysfunction. Medical therapies remain the mainstay of treatment, however high quality evidence supports the use of deep brain stimulation (DBS) to relieve these symptoms in well-selected patients. Given the upfront cost of surgery associated with DBS, and the comprehensive evaluations at tertiary care centres (including a multidisciplinary team with neurologists, neurosurgeons, neuropsychologists, psychiatrists, and electrophysiologists), this is a limited resource, particularly in overburdened publicly funded healthcare systems. There have been no previous attempts to comprehensively analyze access to DBS in Canada’s public healthcare system through investigation of need for these services, matched access, and investigation of barriers to access. This thesis comprises 5 chapters that inform this knowledge gap through the quadruple aim of health service research (patient perspective, health care provider perspective, cost, and population level data), aiming for equitable access to care in Canada. Chapter 1 is an introduction providing the rationale for conducting each of the included studies. Chapter 2 reports on an evaluation of cost, titled Economic Evaluations Comparing Deep Brain Stimulation to Best Medical Therapy for Movement Disorders: A Meta-Analysis. Chapter 3 presents an evaluation of healthcare provider and patient perspective, titled Mixed Methods Survey of Stakeholders to Identify Barriers to Accessing Deep Brain Stimulation for Movement Disorders in Canada. Chapter 4 is a retrospective cohort study providing population level data assessing patients who have received DBS in Canada, titled Canadian Access to Deep Brain Stimulation for Movement Disorders: A Nationwide Retrospective Study. Finally, Chapter 5 discusses the conclusion, limitations, and implications of the research presented in this PhD thesis.