The purpose of this study is to determine whether a community based rehabilitation exercise programme had an effect on pulmonary function, exercise tolerance and Health Related Quality of Life (HRQoL) in patients diagnosed with Pulmonary Tuberculosis (PTB). The prevalence of PTB in South Africa is one of the highest in the African continent. Assessing the effectiveness of the programme could provide further methods in improving compliance to pharmaceutical medication as well as an improvement in the morbidity experienced after diagnosis of PTB.

The increased life expectancy of people living with HIV/AIDS (PLWHA) has meant that the disease has changed status from a terminal to a chronic condition. Along with this shift, increased attention has been given to maximising the quality of the prolonged life. A common, long standing problem impacting quality of life in PLWHA is that of pain. Investigating pain in PLWHA was therefore the core subject under study in the current thesis. The thesis consists of four main components. Firstly, a theoretical framework for pain as a biopsychosocial phenomenon from which current literature on the aetiology and management of pain in this population was reviewed. Secondly, to gain an understanding of whether pain was a problem in the English and/or Afrikaans speaking urban and rural population of PLWHA, a prevalence study was conducted. Thirdly, an investigation assessing the efficacy of the use of a biopsychosocialy informed intervention for the management of pain in this population was conducted. And finally a qualitative study exploring the experiences of adult women living with pain and/or HIV was studied. The findings of the prevalence study showed that urban participants (with a prevalence rate of 42% (CI:34-50%) n=151) were 8.1 (CI:3.7-17.9) times more likely to experience pain than their rural counterparts (with a prevalence rate of 8% ((CI:4-15%) n=96). From this it was concluded that pain is indeed a problem in the urban community, whereas it was not as big a problem in the rural community. This prompted the researchers to conduct the intervention study in the urban population. The intervention study however suffered from a small sample size (N=32 having given consent, but only n=17 attending baseline data collection) which limited analysis. Upon reflection, the small sample was a result in and of itself, and could be considered as an indication that interventions need to be strongly informed by what is deemed (un-)acceptable by the community in which they are run and tested. As such, a conclusion was made that the ‘one-size-fits-all’ approach to the management of pain in HIV/AIDS may not be the solution. With this result from the intervention study, as well as the vastly different pain prevalence rates seen in the prevalence study, a qualitative study was added. Using a purposive sampling technique, seven participants (three from the urban site, and four from the rural site) who were HIV positive, with (n=4) and without (n=3) pain, were interviewed and their responses analysed and compared. With the use of the Morse model, the qualitative study gave insight into how pain and/or HIV influenced the experiences of Afrikaans and/or English speaking women, and also highlighted the role that stigma/support plays in their experiences with pain and HIV. From all three studies it is clear that pain in HIV/AIDS is complex and requires specific community tailored approaches.

Includes abstract. / Includes bibliographical references. / The aim of this randomised clinical trial over 12 weeks was to determine if the gradual transition (accompanied by calf muscle training), from conventional to minimalist running shoes 1) increased the risk of lower limb pain or injury and 2) improved lower limb muscle function (endurance, flexibility and power) in experienced distance runners. In addition, the effects of the transition on runner satisfaction were studied. To determine whether there were significant differences in lower limb injury incidence and pain, calf endurance, lower limb muscle flexibility, lower limb muscle power, footposture index, hallux ROM and participants’ satisfaction with the type of running shoes and performance between an experimental group, that ran in minimalist shoes, and a control group that ran in conventional shoes. (b) To determine whether there were significant differences in lower limb injury incidence and pain, calf endurance, lower limb muscle flexibility, lower limb muscle power, foot posture index, hallux ROM and participants’ satisfaction with the type of running shoes and performance between groups over time.

Includes bibliographical references. / Chronic non-specific low back pain (NSCLBP) is a common low back condition affecting a large proportion of the population suffering from low back pain (LBP). Exercise therapy is recommended as the first line treatment for NSCLBP but no type of exercise has been found to be more effective than another in improving pain and function outcomes. Low back pain trials have compared heterogeneous exercise types to date. Pilates mat classes are a popular form of exercise taught by therapists. The aim of this study was to compare outcomes of an eight-week supervised Pilates mat programme with those of a similar non-supervised home exercise programme with regard to pain intensity, function, medication use, health related quality of life, adherence, and participant satisfaction with such exercise programmes in treating NSCLBP. A randomised control trial was done to compare the effect of a supervised Pilates at programme with a non-supervised home programme of similar exercises. The programmes were comparable for both the type of exercise and the participation duration of programmes (per week) and included the same fourteen exercises with gradual progressions. The Pilates classes were held twice a week for a 45 minute class and the home programme required doing the exercises for 30 minutes, three times a week, for an eight-week period. All participants were women who had been suffering from NSCLBP for longer than six weeks and who had volunteered to participate, or were referred by a therapist. The participants were screened and randomly allocated to the respective groups: a supervised exercise group (SEG) and a home exercise group (HEG). All the individual sessions and the supervised classes were held at a multi-disciplinary centre, which housed both a private physiotherapy practice and a Pilates studio. Outcome measures were measured at baseline, four weeks, eight weeks and 12 weeks by an assessor who was blinded to group allocation. The primary outcomes of pain and function were measured using the Pain Intensity Numeric Rating Scale (PINRS) and the Roland Morris Disability Questionnaire (RMDQ) respectively. Change in medication was measured as a percentage change in medication; mobility of the pelvis and lumbar spine was measured using the fingertip-to-floor (FTF) test; health-related quality of life was assessed using the EQ-5D questionnaire, and the confidence to perform certain tasks was measured using the pain self-efficacy questionnaire (PSEQ). Additionally, patient satisfaction was measured at eight weeks using the Better Backs Patient Satisfaction Questionnaire, and adherence was measured by calculating a percentage of the maximum adherence.

Background: Specific Learning Disorder (SLD) is described as a neurodevelopmental disorder affecting academic performance and/or activities of daily life including reading, writing or calculation skills during formal years of schooling. There is strong evidence that Developmental Coordination Disorder (DCD), presenting as a disorder affecting motor skills, may be co-morbid with other neurodevelopmental conditions, including SLD. Children with SLD and co-morbid DCD (SLD/DCD) are considered a unique group. Learners with SLD/DCD experience a significant, negative impact on daily tasks such as selfcare, play, leisure and schoolwork. Neuromotor Task Training (NTT), a form of intervention, has been reported to be effective in reducing the activity limitations in children with DCD. However, information regarding the most effective treatment to improve function and behaviour in learners with SLD/DCD, who attend special schools, has not yet been investigated. The aim of this study was to evaluate the efficacy of task-orientated NTT group intervention programme on motor performance, behavioural profile and health related quality of life (HRQOL) of children with SLD/DCD attending a School for Learners with Special Education Needs (LSEN) in Cape Town, South Africa. Method: A quantitative, quasi-experimental design with pre- and post-tests was used. Learners were included if they presented with a primary or secondary diagnosis of SLD plus DCD (scoring at or below the 16th percentile on the Motor Assessment Battery for Children 2nd Edition (MABC-2) and a functional motor problem, as identified by the MABC checklist), aged between 6–10 years and grade 1-4. Learners were allocated to either NTT (n = 18) or Usual Care (n = 18) groups. The Usual Care (UC) group continued with normal activity, but did not receive physiotherapy. The MABC-2, parent and teacher Strengths and Difficulties Questionnaire (SDQ) and self-reported European Quality of Life 5- Dimensions questionnaire for Youth (EQ-5D-Y) were used to assess performance pre- and post - intervention. The NTT program was implemented for nine weeks, with two 45-60 minute sessions per week. Results: There was a significant difference in Total Standard Score (TSS) between NTT and UC groups (p=0.048). In the NTT group, the mean TSS (p < 0.001) and Balance score (p= 0.02) significantly improved over the intervention period. The control group did not show any significant changes over the intervention period while receiving UC. The intervention group did not show any significant changes in Behavioural Profile (SDQ) over the intervention period while receiving NTT, according to v teachers. The results indicate that the intervention group showed a significant change in Behavioural Profile (SDQ) in the Behaviour/Conduct domain (p=0.01) over the intervention period while receiving NTT, according to parents. There was no significant change in HRQOL according to the self-report EQ-5D-Y. Conclusion: The results of this study showed that a task orientated programme (NTT), presented in small groups, has a positive effect on motor performance in learners SLD/DCD.

Introduction Phantom limb pain (PLP) is described as painful sensations felt in the missing portion of an amputated limb. PLP occurs in up to 85% of amputees, making it the most common painful condition secondary to amputation. PLP interferes with sleep, mobility, and work, general activities of daily living and enjoyment of life. Current pharmacological and non-pharmacological interventions have shown limited efficacy for reducing PLP, perhaps because they do not effectively target the mechanisms that have been proposed to underlie PLP in people who have undergone amputations. Graded motor imagery (GMI) is a cortical mechanisms-based intervention which aims to reduce PLP using a graded sequence of strategies including left/right judgements, imagined movements and mirror therapy. The aim of this thesis was to investigate whether the GMI programme is effective for reducing PLP and disability in people who have undergone amputations. Methods A single blinded randomised controlled trial was conducted at Somerset, Khayelitsha and Victoria hospitals in Cape Town, South Africa. The experimental group underwent a 6-week GMI programme where each phase was carried out for two weeks, during which the patient received treatment for 30 minutes on two separate days of the first week (at least one day apart) and continued with a structured home-exercise programme during the first week until the end of the second week. The control group continued with routine care. Data on the outcomes- PLP severity, pain interference with function and health-related quality of life were collected at baseline, 6 weeks and 3 months by a blinded outcome assessor. Results The study recruited 21 participants from which 11 and 10 were randomly allocated to the experimental and control groups respectively. Within group analysis showed that participants in both the experimental and control groups had improved pain severity scores immediately after treatment and at 3-month follow-up. The between-group analysis showed that the experimental group had significantly greater improvements in pain immediately after treatment (p=0.02). However, there was no difference between groups at 3-months follow-up (p=0.14). To explore clinically meaningful improvements in pain, the Number Needed to Treat (NNT) were calculated using a cut-off of 3 points on a 0-10 scale. The NNT were 2 [95% CI: 1.1 – 6.5] and 3 [95% CI: 1.9 – 7.1] immediately after treatment and at 3-months follow-up respectively. For pain interference with function, within group analysis showed that participants in the experimental group had significant improvements immediately after treatment and at 3-month follow-up. The between-group analysis showed that the experimental group had significantly greater improvements in pain interference with function immediately after treatment (p=0.007) and at 3- month follow-up (p=0.02). The NNT were 1.4 [95% CI: 1 – 1.8] and 1.9 [95% CI: 1.1 – 6.5] immediately after treatment and at 3-months follow-up respectively. For disability, the experimental group had significantly fewer problems with mobility than the control group at 3 months (χ2 = 9.8; p= 0.04). Conclusion The results of the current study provide support for the use of GMI to treat PLP based on the proposition that PLP is driven by cortical mechanisms and that GMI effectively targets these mechanisms. On the basis of the significant pain reduction within the GMI group, the lack of serious adverse effects, and the ease of application, GMI may be a viable treatment for treating PLP in people who have undergone amputations. While more studies using rigorous methodology, including sham treatment, larger sample sizes and a more generalisable sample, are required, the efficacy of GMI coupled with its affordability and low risk, suggest that it is applicable in a resource-constrained primary health setting in South Africa.

Introduction The number of South Africans aged 60 years and older is increasing. The National Development Plan (NDP) aims to raise average life expectancy to 70 years by 2030. In response to similar global trends, the World Health Organization (WHO) developed the global Active Ageing Policy Framework (AAPF) to inform the actions taken by countries to address the needs of older persons, acknowledging the different contexts and cultures. The WHO recommended that the framework should have been evaluated to test its applicability and use in member countries by the first half of the twenty-first century. In South Africa, Senior Service Centres for Older persons were set up in communities to provide services to enhance the achievement of the goals of the AAPF. Unfortunately, little information is available on how the framework has been applied to inform services offered in African countries, including South Africa. This study explored services provided by Service Centres for Older Persons in the Western Cape using the WHO framework on Active Ageing as a guide to the services. The study was conducted in two phases. Aims In the first phase, the study explored the characteristics of Service Centres – the organisational structures, the types of services offered, the profile of the managers, and their perception of the needs of the members of the centres. In the second phase, the study explored the profile of the members of these centres by determining their socio-demographic profile, health and psychosocial characteristics. Methodology In phase 1, forty-one service centres were selected by stratified random sampling to proportionally represent the five districts and the Cape Metropole in the province. Only 35 service centres consented to take part in the study. In phase 2, a sample of convenience was recruited from 3 051 registered members at the 35 service centres. Only 625 members consented to participate. A cross sectional, descriptive research design was utilised to collect data on the characteristics of the service centres from the managers, using a modified self-developed questionnaire. To explore the profile of members of the service centres, a self-developed questionnaire and two standardised questionnaires namely, World Health Organization Quality of Life-BREF (WHOQOL-BREF) and World Health Organization Disability Assessment Schedule II (WHODAS II), were administered. Data analysis Descriptive statistics were used to analyse the responses to the closed-ended questions in phases 1 and 2 of the study, and data presented as frequencies. Similarly, responses to the open-ended questions were summarised and themes were identified. In phase 1, quantitative and qualitative responses were analysed according to the WHO Active Ageing Framework. In phase 2, the data generated were analysed according to the WHO International Classification of Functioning, Disability and Health Framework (ICF) model. Results Services offered to members at the centres in the six categories of determinants of the AAPF included the following: • Health and social care systems – Limited screening programs were provided as part of health promotion and disease prevention services. • Behavioural – Physical activity/exercise programmes were most common, but no programs addressed healthy eating habits, tobacco and alcohol abuse, or adherence to medication use. • Personal factors – Services were provided to enhance members’ cognitive skills. • Physical environment – No services were offered on falls prevention. • Social environment – Different types of social support programmes were offered, including meeting education and literacy needs of members through the provision of Adult Basic Education Training (ABET). • Economic – Some centres offered members opportunities for formal work and volunteering, while some provided income generation activities. Most of the managers had high school education but expressed the need for training to manage these centres. The managers perceived the needs of the members would relate to health care, social support, inactivity, isolation and safety among others. The summary of the profile of the 625 members of the centres are presented in the domains of the ICF model: • Personal factors – The members were predominantly widowed women with a mean age of 74.1 ±7.51 years (range 60–100 years). Most members displayed good lifestyle habits and engaged in various leisure and physical activities. Members were also satisfied with themselves, their health, bodily appearance and quality of life and reported a variety of aspirations for their future with and without possible future-orientated behaviours. • Health conditions – Hypertension, arthritis and diabetes were the most common health problems reported by members for which they took medication. Falls were not common among members although the majority feared falling. • Body structure and function – Most members expressed good cognitive function, could concentrate and follow conversations, and reported no hearing, visual or bladder problems. Members also reported good postural balance. • Activities and participation – Members were satisfied with their abilities to do daily activities, participate in the community, and learn new tasks. • Environmental factors – Most members resided with their children or family for various reasons, including needing care for themselves or to provide care to their children and/or extended families. Discussion and conclusion Using the WHO AAPF as a guide, it was found that services provided by Service Centres for Older Persons in the Western Cape, although varied, were deficient at most service centres. The managers responsible for providing these programmes were women with limited skills who needed more education and training to be able to manage the centres appropriately. The members of service centres, despite presenting with health challenges and multi-morbidities, indicated aspirations for the future. In view of the goals of the National Development Plan (NDP) to increase life expectancy of older persons to 70 years by 2030, a more comprehensive exploration of the profile of older persons will assist the managers of the Service Centres to respond more appropriately to the diversity of needs and interests of members.

Background: Osteoarthritis (OA) is one of the leading causes of disability worldwide. A major challenge facing those with severe OA is long waiting lists delaying access to joint replacements. Patients are known to wait more than five years for a joint replacement in the Western Cape of South Africa (SA). The main complaint in this population is pain and its consequences including activity limitations, participation restrictions and reduced quality of life. Hip or knee OA is not merely joint degeneration but a condition requiring holistic management, even while waiting for surgery. Most of the literature in this field is available from high income countries exploring the effects of interventions during short waiting periods. Thus research is warranted in a low income country such as SA, in those waiting for long periods to explore the effects of a six-week physiotherapist-led exercise and education intervention. Methods: A single blinded randomised controlled trial, aligned with CONSORT guidelines, was performed at Tygerberg Hospital in the Western Cape, SA. The experimental group attended a six-week group-based physiotherapist-led intervention including education, exercise and relaxation. The control group continued to receive usual care. The primary outcome measure was pain with secondary measures of disability, function, quality of life and self-efficacy. Measures were obtained at six weeks, 12 weeks and six months by a blinded physiotherapist. An open ended questionnaire was completed by the participants in the experimental group at month six. Analysis was by intention to treat. Two-way analysis of variance and post-hoc Tukey comparisons were used for parametric data, Pearson Chi squared calculations for categorical data. Effect sizes were established for significant differences between groups. Results: The study recruited 42 participants from the waiting list for a hip or knee arthroplasty. Mean waiting time was 3.6 ± 2.5 years. Compared to the control group, the experimental group had significant improvements with large effect sizes at month six for pain interference (3.49 ± 2.63 vs. 6.09 ± 2.43; p=0.02, ES=1.15) and function (15m fastest speed walk) (15.09 ± 6.04s vs 20.10 ± 8.79s; p=0.03, ES=0.88). Furthermore, the experimental group displayed significant (p < 0.01) and sustained improvements at month six in pain severity, disability and function (15m normal speed walk, sit-stand, 6-minute walk). Subgroup analysis showed participants with knee OA responded better to the intervention than those with OA of the hip or combined hip and knee OA. Participants enjoyed the intervention reporting improved knowledge, function and activity, pain relief and improvement in psychosocial aspects. Conclusions: A six-week physiotherapist-led exercise and education intervention brought about significant long term improvements in pain interference and functional walking ability in patients with osteoarthritis, awaiting a joint replacement compared with a control group. Such a programme also appears to have significant and sustained improvements in pain severity and disability. Further research with longer follow up is recommended to determine if results are sustained.

Background: Childhood obesity, a rising problem world-wide and within South Africa, has been negatively linked with both physical fitness (PF) and health-related quality of life (HRQoL). The school environment is the ideal setting for children to obtain the skills and knowledge to increase physical activity (PA) levels and healthy diets. PA and school-based nutrition intervention programmes have been shown to have positive effects on diet and PA behaviours in children. However, there is minimal literature reporting on the effectiveness of school-based interventions in a South African setting. Aim: The primary aim of the first phase of the study was to provide a contextual background regarding the provision of PA in school-based PE programmes within a small sample of schools from which the learners in the intervention study were drawn. The primary aim of the second phase of the study was to determine the effect of a teacher-based intervention programme after six weeks for primary schools with less than the mandated amount or no specific amount of PE on learner's HRQoL, Body Mass Index (BMI) and PF. Methodology: Ten schools were randomly selected from the circuit lists within the Port Elizabeth Education District. Ten staff members from the selected schools completed the School Environment Questionnaire in order to provide a situational analysis regarding the provision of PA in school-based PE programmes. A sample of 300 learners (aged nine to eleven) from four randomly selected schools participated in the pre-testing measures in order to establish the weight status (using BMI and waist circumference (WC)), HRQoL (using the EQ-5D-Y), and PF (using the Eurofit test battery). Class teachers, from schools with less than the mandated amount of PE or no specific amount of PE, who were part of the experimental group, implemented the intervention. In order to implement the intervention, they received training and were given a PE programme booklet. The PE intervention programme was in line with the Curriculum and Assessment Policy Statement teaching plan for life skills, and was based on targeting the deficiencies found in the pre-testing fitness measurements. Post-testing measures, using the same learners, were conducted six weeks later. The obtained results were analysed using STATISTICA version 12. Results: Phase one of the study revealed that PE was provided at all schools. The curriculum was followed by 90% of schools, but only 30% had teachers with PE qualifications. PE policies and practices were being developed and/or implemented in 70% of schools, and 50% had no specific amount of time mandated to PE, or less than the mandated amount. Soccer was offered at all schools, and 80% of schools had access to an outdoor sports field and an outdoor paved area. Phase two of the study found that the control and experimental groups were not equivalent at baseline with regard to gender distribution, BMI Z-scores and interpretations, the EQ-5D-Y "looking after myself" variable, and the sit-up test. No positive significant differences were noted in BMI Z-scores, WC, HRQoL, or PF components in the experimental group after the six-week intervention. Discussion: The average duration of PE at 70% of the participating schools was longer than the national average, despite half of the schools not implementing the mandated amount of PE. Gaps in the curriculum content and unqualified PE teachers may have prevented learners from developing the necessary skills associated with PE, including the various components of PF. The six-week teacher-based intervention was found to be ineffective. Similar results were seen in other South African studies. Insignificant intervention findings may be the result of poor intervention implementation or compliance, time constraints experienced by participating teachers, and the short six-week duration of the intervention. Teachers mainly commented on the enjoyment of the intervention programme by the learners. Conclusion: This study concludes that the effects of the six week teacher-based intervention, on primary school learners' HRQoL, BMI, and PF, was insignificant. Nevertheless, all schools provided PE, despite half of the schools not implementing the amount mandated. This study provides a platform for future studies in the attempt to reduce the occurrence of obesity in school children; thereby reducing its increasing national burden on health and the economy.

Includes abstract. / Includes bibliographical references (leaves 139-151). / Low Back Pain (LBP) is a major health problem in many countries at considerable cost to the economy but there is little information available regarding LBP in South Africa. The prevalence and impact is likely to be similar to elsewhere. As South Africa has a small health budget and many health problems to attend to, a cost effective approach to the management of LBP would seem essential. Education, information and advice have been shown to be effective in treating some aspects of LBP and a leaflet is a low-cost method of providing these. Apparently if a leaflet is designed according to the needs of a specific population. it has the potential to be more effective within that group. It has been suggested that the use of such leaflets should be investigated before more expensive treatment. This study therefore aimed to develop an information leaflet about LBP that was appropriate for a resource poor community in Cape Town. The impact of this leaflet was then examined in a second stage of the project. Stage One: Pamphlet development. Stage One: To compile a lifestyle profile of people seeking help for LBP in a resource poor community and to use this profile. together with information about perceived needs of these people regarding LBP. to develop an information leaflet. Method Stage One: Sample: Adults (over the age of 18 years) of a resource poor community who attended the community health centre to consult the doctor for an episode of ALBP, and who agreed to participate in the study, were interviewed about their lifestyle and their perceived needs regarding information to help them manage their LBP. Instrumentation: The Lifestyle Questionnaire consisted of 116 questions, which were based on information obtained from the literature review and the 20-year experience of physiotherapy of the researcher.