Introduction: Hypermobility syndrome (HMS) is a common cause of morbidity in children, with the knee most frequently affected by its symptoms. Impaired joint proprioception has been reported in adults with HMS. Muscle weakness, problems with school activities and abnormal gait patterns have been observed in children with this condition. It has also been suggested that activities of daily living and physical and sporting activities may be limited in children with HMS due to pain. To date, the factors associated with HMS in children have not been well reported. The relationships between impairments, function and quality of life (QoL) have not been investigated in children with this condition. The purpose of this study was to identify the range of neuromuscular performance, functional range of motion (ROM) and QoL indices, and investigate the relationships between these features in children with HMS. A purpose-built motorised device was developed and validated for the assessment of knee joint proprioception as an integral part of the research programme. The test-retest repeatability of various outcome measures used for the present study was also investigated in healthy children and those with HMS. Methods: A cross-sectional study was conducted. Twenty nine children with HMS and 37 healthy children (aged 8 – 15 years) were investigated for neuromuscular indices, functional ROM and QoL. Knee joint kinaesthesia (JK) and position sense (JPS) were examined using a motorised device, muscle torque was tested with a digital myometer, passive ROM was measured with a universal goniometer and functional ROM was assessed using the VICON camera system. Pain intensity and QoL were measured using the Coloured Analogue Scale and the Paediatric Quality of life Inventory respectively. Mann-Whitney U tests and independent t-tests were performed to determine the differences between the two groups. The relationships between pain and each of the following: neuromuscular impairments, functional ROM and QoL were examined in children with HMS. The correlation between Beighton scores and each outcome was also evaluated in children with HMS. Results: Knee JK and JPS were significantly poorer (both p < 0.001) in children with HMS compared with the controls. Significantly reduced (p < 0.001) knee muscle torque was also observed in children with HMS. Pain intensity and passive knee ROM were significantly higher (both p < 0.001) in children with HMS. They also demonstrated significantly increased knee extension, reduced knee flexion in loading response and during maximal knee flexion of walking (all p <0.001). Moreover, the overall QoL perception and all the domains were significantly poorer (p range < 0.001 to 0.008) in children with HMS than the controls. No relationship (r range = -0.065 to 0.271; p range = 0.106 to 0.985) was found between pain, neuromuscular impairments and functional ROM in children with HMS. However, a significantly strong negative relationship (r = -0.65; p = <0.001) was established between pain and QoL in children with HMS. In addition, no relationship (r range = -0.014 to 0.315; p range = 0.112 to 0.895) was observed between Beighton scores and neuromuscular impairments, functional ROM and QoL in children with HMS. Conclusions: Children with HMS, compared with their healthy counterparts had knee joint proprioception and knee muscle torque deficits, increased passive knee ROM and pain intensity. Abnormal walking patterns (increased knee extension, reduced knee flexion in both mid stance and maximum knee flexion in swing phase during walking) were also found in children with HMS. They also presented with poorer QoL in comparison with the controls. Clinicians are to be aware of these identified features and should develop appropriate treatment intervention programmes for children with this condition.

This internet-based qualitative study aimed to explore the subjective experience of having Repetitive Strain Injury (RSI) using an ‘insider’s perspective’ (Schneider and Conrad, 1983). A purposive sample of RSI sufferers was recruited from an online support group covering diverse experiences across different age groups, gender, occupations, health care use and both clinically recognised RSI conditions and diffuse nonspecific RSI. Data triangulation involving documentary analysis of 468 archived email postings and 5 asynchronous online focus groups (n=57) was used to illuminate different aspects of RSI sufferers’ experiences. Data from each method was thematically analysed and the findings integrated. Firstly, methodologically the internet medium was found to be a valuable additional tool for accessing illness experiences. Further, the essence of the RSI experience was conceptualised as a major life change and uncertainty affecting people’s employment, social participation and ability to perform routine daily activities such as caring for themselves, family members and the home. Also changed were their identities, financial circumstances and relationships both in and outside of work. RSI was found in the study to bear the hallmarks of a chronic pain condition with attendant implications for management and diagnosis. The significance and meaning of a medical diagnosis was found to extend far beyond establishing ‘what was wrong’; it became a quest for evidence to support the reality of their suffering and a means of defending threats to their integrity and identity. The implications of these findings are discussed in the context of current chronic pain management which places less emphasis on finding a diagnosis on the premise that regardless of aetiology, the problems encountered are similar across different chronic pain conditions, and it is more useful to restore functioning and reduce disability. However, this study shows that the significance of a diagnosis should not be under- estimated since for the individual with RSI, it carries multiple meanings and profound consequences for their daily lives.

No description available.

The current study aimed to investigate influences of rigid Ankle Foot Orthoses (AFOs) on gait in children with Cerebral Palsy (CP), immediate effects of tuning of AFO-FC (AFO-Footwear Combination) on gait of children with CP, short-term effects of tuning of AFO-FC on gait, muscle and joint characteristics and quality of life in children with CP, and the feasibility of conducting a larger trial. The study included 11 healthy children and 8 children with CP. Outcome measurements included sagittal plane kinematics and kinetics derived using 3D motion analysis, Gait Deviation Index (GDI), physical examination, and quality of life using the PedsQL™ questionnaire. Data from healthy children demonstrated influences of shoes on gait parameters and the role of the ankle joint in adapting to various wedges and rockers during gait. When studying children with CP, beneficial effects of rigid AFO-FC on gait parameters were evident; these were thought to relate to the appropriateness of the AFO-FC and familiarisation with the prescription. Immediate effects of tuning varied according to gait patterns previously demonstrated with non-tuned AFO-FC; benefits to knee kinematics and kinetics were largely seen in legs with extended knee gait, followed by jump knee gait, and with poorest responses in legs with crouch knee gait. Short-term effects of tuning were evident when comparing measurements taken before and after two-to-four months of wearing the tuned AFO-FC. Barefoot walking demonstrated significantly improved walking speed. Stride-length improved when comparing tuned AFO-FC at baseline with the tuned AFO-FC following the intervention period. No short-term changes were seen in PedsQL™ scores, muscle and joint characteristics, and GDI. Feasibility issues were also identified. It was concluded from this exploratory trial that tuning of AFO-FC improved gait for children with CP, although initial gait pattern affected the amount of benefit. This was evident immediately after tuning and some parameters improved further after short-term intervention. A randomised controlled trial is required; power analysis indicates the need for a larger sample of 18 in each group to detect change in GDI with a medium effect size and at a power of 0.8 and p <0.05.

Signal detection theory (SDT) measures (discriminability and response bias) have been proposed to be valid for determining pain perception changes. The construct validity of SDT measures applied to pain perception studies has been questioned on three grounds: interpretation, methodology and theory. Multiple interpretations are possible for the combinations of discriminability and response bias change when the magnitude-rating scale is used for pain perception studies. This is resolved by utilising the confidence-rating scale. The problem of comparability of results between the two scales is bridged by Irwin & Whitehead’s (1991) common analytical framework. The results of this thesis supported the framework’s prediction that both scales are comparable. Therefore, the confidencerating scale was used for all studies within this thesis for interpretational clarity. Response bias data were not analysed in this thesis due to data artefacts created by correction methods for zero proportions in response categories. Methodologically, the construct validity of discriminability is influenced by the research design and procedures. Therefore, the following procedures were adopted to address weaknesses in previous studies. The one-interval confidence-rating task was used with a six-category confidence-rating scale and post-trial feedback. Based on a methodological study conducted within this thesis, the trial number was pragmatically reduced from 40 trials to 17 trials per stimulus intensity. This trial number reduction would not alter the mean and variance of the data sufficiently to influence the outcome of inferential statistical testing performed. Due to the novel use of the Quantitative Sensory Testing machine for the signal detection study procedures, accuracy and precision study on the machine was performed. This thesis found that the accuracy, repeatability and reproducibility of the machine in generating noxious thermal stimuli is excellent for the purposes of this thesis. Machine error is eliminated as a major source of variance for the thesis results. Theoretically, critics have challenged the construct validity of discriminability as an indicator of pain perception alteration. This thesis examined this issue in two separate contexts: 1) discriminability change as a correlate of local anaesthesia and, 2) discriminability as a correlate of psychological factors (depression and anxiety) in chronic low back pain (CLBP) sufferers. The results failed to establish the construct validity of discriminability for both contexts. However, the higher discriminability in CLBP sufferers compared to healthy individuals is in contrast to past research and warrant further investigation. This thesis addressed the construct validity issues through theoretical, methodological and interpretational modifications. A more robust analysis of the construct validity issue was facilitated. Caution is recommended on the use of discriminability as a pain perception measure until the construct validity issue has been satisfactorily resolved.

Recent health surveys have found that many young women do not participate in sufficient physical activity to produce health benefits. Consequently, they are at risk of developing cardiovascular disease, diabetes and osteoporosis in later life. The transition between secondary and higher education is associated with particular risks in relation to declining activity participation. There is clearly a need to explore the aetiology and impact of activity behaviour change in this context. A literature review identified several gaps relating to the validity of physical activity measurement, mental health benefits associated with participation and factors influencing changes in activity choices over time. Three studies were designed to address these issues in a female undergraduate population at Queen Margaret University College in Edinburgh. A theory is proposed to explain relationships between many of the variables explored. Study One aimed to validate the Scottish Physical Activity Questionnaire (SPAQ) against an estimate of time in moderate and vigorous activity derived from heart rate monitoring data. Women were monitored for three days of the seven-day recall period (N=23). Self-report and heart rate estimates of time in activity differed significantly (t test: p=0.008) and correlated poorly (r=0.03). The questionnaire was modified as a result of analysis and testing was repeated in a sample of 21 women. Modified SPAQ for students and heart rate estimates of time in activity did not differ significantly (p=0.119) and demonstrated improved correlations (r=0.59). Stage of Behaviour Change classifications also demonstrated hierarchical agreement with subjective and heart rate estimates of time in activity. Study Two aimed to establish baseline levels of exercise and moderate lifestyle physical activity in female undergraduates and to explore associations with psychological well-being over time. A large longitudinal survey was carried out using the modified SPAQ for students and psychometric measurement tools. The first survey time-point occurred at the start of the academic year and according to Stage of Behaviour Change classification 51% of participants were not active enough to achieve health benefits (n=425). The second survey was carried out two months later. Significant correlations were found between self-esteem scores and Stage of Behaviour Change classification in relation to moderate lifestyle PA (r=0.29), but not vigorous exercise. The low response to survey two (n=89) necessitated a change in methodology, implemented in the final study. Study Three aimed to explore changes in activity over the first academic year, influences on activity-related decisions and the effects of these choices on psychological well-being. Sixteen participants from the previous study sample were interviewed in a qualitative study design. Content analysis indicated that individuals frequently decreased their activity participation on entry to higher education, but some re-incorporated activity into their lifestyles over subsequent months. Many influences on activity patterns were discussed, including the negative impact of transition periods such as the summer vacation. Data analysis led to the development of the "Narrative Integration Theory," which describes motivation to participate in physical activity as being influenced by the immediate affective reaction to the experience. This is reciprocally related to interacting personal, cultural, environmental and social influences and their integration into a sense of identity. Positive experiences are required to alter negative perceptions and to build feelings of competence in relation to activity participation. This thesis provides further understanding of the challenges to activity behaviour experienced by female students. Decisions relating to uptake of activity and continued participation are frequently made with conscious processing and reflect complex issues relating to personal identity and self-evaluations.

Background: Many people living with chronic stroke are not involved in any form of ongoing rehabilitation, despite having ongoing impairments and limitations in activity and participation. The approach to structuring practice of functional tasks, as part of ongoing rehabilitation, can incorporate diverse techniques. Current texts advocate that physiotherapists construct stroke rehabilitation programmes that incorporate Motor Learning principles, however the evidence to support this is limited. No evidence related to stroke exists as to whether functional tasks should be practised in their entirety (whole practice) or in component parts (part practice). The primary aim of the work reported in this thesis was to investigate the effects of a home exercise programme based on Motor Learning principles of part practice (PP) or whole practice (WP) of selected functional tasks for people at least six months after a stroke. Methodology: A single blind, randomised controlled trial was undertaken, with participants allocated to either a part practice experimental group (PP), a whole practice experimental group (WP) or a control (Con) group. Both experimental groups followed a four week exercise intervention programme of functional tasks based on PP or WP. Outcome measures were undertaken at baseline, at the end of a four week intervention (wk 4), at short-term follow-up (wk 4.5) and at long-term follow-up (wk 16). Outcome measures utilised were the Barthel Index (BI), Motor Assessment Scale (MAS), Timed Up and Go over 2 metres (TUG2m), Step Test, Frenchay Arm Test (FAT), Hospital Anxiety and Depression Scale (HADS), Frenchay Activities Index (FAI)and the Stroke Impact Scale (SIS). Differences between the groups at each measurement point were examined using a Kruskal Wallis test. Differences within each group over time were analysed using a Friedman’s Anova, followed up by a Wilcoxon’s Signed Ranks test using a Bonferroni correction where a significant difference was found. Results: Sixty four people with late-stage stroke were recruited and provided informed consent. Data were available for analysis for 60 participants (median time since stroke 21 months). No statistically significant differences were found between the three groups at any point for any of the dependent outcome variables. A number of statistically significant within group changes were found in all groups. Most statistically significant changes were demonstrated by PP including on the BI from baseline to wk 4.5; on the MAS from baseline to weeks 4, 4.5 and 16; on the Step Test from baseline to weeks 4, 4.5 and 16 and on the FAT from baseline to week 4. On more global measures the PP group reported statistically significant improvements on the SIS in the domains of strength, mood and mobility from baseline to wk 4; and in the SIS participation domain from baseline to wk 16; as well as a statistically significant within group improvements on FAI from baseline to wk 4. Conclusions: People with late-stage stroke demonstrated capacity for improvements in a number of measures of impairment, activity, participation and mood. The PP group demonstrated improvements, over time, in more of the outcome measures relating to physical ability than either WP or Con groups. Implications for clinical practice and further research are discussed.

With the rising obesity and the increasing age of the population, a large proportion of patients who undergo Total Knee Arthroplasty (TKA) are obese. Knowing the health risks associated with obesity, it is important to determine if the outcomes of a TKA is compromised in obese patients. Significant discrepancies in the findings of previous studies assessing the effect of body mass index (BMI) on TKA outcomes were observed in a literature review, thus making it difficult to confirm an effect of obesity measured as BMI on the outcomes after TKA. This thesis comprises two studies which further explored the effects of BMI and other body composition measures on the outcome of TKA. 1. The aim of a retrospective epidemiological study was to assess the effect of BMI on patient reported outcomes after TKA. 2. The aim of the prospective cohort study was to assess the effect of body composition, measured by waist circumference (WC), waist to hip ratio (WHR), bioelectrical impedance analysis (BIA), ultrasonography (US) and BMI, on patient reported outcomes after TKA. It was concluded from these two studies that group division of obesity based on the classification of BMI greater or less than 30 kg/m2 could not identify an effect of obesity on outcomes. However, on using BMI as a continuous variable, an adverse effect of BMI on knee function and overall physical health was evident for higher BMI ranges. Body composition measures of BIA and US did not detect an effect of obesity for any outcomes. Effect of obesity detected by BMI and WC was similar. The negative association of BMI and outcomes observed was very weak across BMI ranges of 25-30 kg/m2and a significant association was achieved due to poorer patient reported physical function (indicated by Short Form 12 and Oxford Knee Score questionnaires) in some cases with very high BMI values (> 40 kg/m2). In addition to this finding, the lack of group difference when outcomes were evaluated across a BMI of 30 kg/m2in the two studies and the disparity between studies in the results when using a BMI classification of 30 kg/m2 supported the conclusion that a BMI classification across a cut-off value of 30 kg/m2 does not predict a poor result in obese after TKA. However, because of the limited number of highly obese (> 35kg/m2) participants in both studies of the thesis and often in previous studies, no definite conclusions regarding the effect of higher obesity levels on the outcome of TKR can be drawn from the studies in this thesis. Adequately powered future studies with more morbidly obese participants could give more definitive answers to the effect of BMI and other measures of body composition on outcomes following TKA.

Aim: This thesis set out to make an original contribution to knowledge with regard to methods of assessing muscle size and architecture in the CKD and ESRD population, and to assess the ability to improve the muscle size and architecture, and symptoms of uraemia, by implementing an anabolic intervention (resistance exercise training) in the CKD population. Outcome measures: Ultrasound was shown to have high validity (against gold standard MRI measures; ICCs: VLACSA 0.96, VL depth 0.99, fat depth 0.98) and intra-rater reliability (ICCs: VL depth 0.98, total muscle depth 0.97, fat depth 0.99; MDC: VL depth 0.14cm, total muscle depth 0.19cm, fat depth 0.22cm) in measuring regional body composition at the mid-VL site in the CKD population. There were significant (p<0.01) correlations between US-derived measures of (mid-VL) muscle size and architecture with strength and function (larger muscle mass and/or pennation angle positively correlated with higher strength and/or functional performance). Patient-reported uraemic symptoms were worse (p<0.01) in those with reduced strength and/or function. Intervention results: An anabolic (resistance training) intervention (12-weeks, randomized to once [RT1 n=7] or three times [RT3 n=10] per week, 80%1RM) brought about significant improvements over time (p<0.01) in all measures of muscle size and architecture (VL depth, total muscle depth, VLACSA, pennation angle). Interaction effects (group*time) were only seen in pennation angle (p<0.05) and VLACSA (p<0.01) where RT3 gains were greater than RT1 from week 8 onwards. All measures of strength, function, and uraemic symptoms improved over time (p<0.01) with no interaction effects (no difference from greater training frequency/ volume). Clinical and research implications: The intervention results suggest implementing a RT form of “prehabilitation” in early stage (CKD3) patients just once per week is sufficient to bring about statistically and clinically important changes in strength and function that benefit the patient through reduced frequency and/or intrusiveness of uraemic symptoms (improved health-related quality of life), with minimal time-commitment. Further research should examine if there is additional benefit to the significantly greater increases in VLACSA and pennation angle observed in RT3, with regards to long-term maintenance of functional improvements, and whether an RT1 or RT3 programme delays the progression of CKD, the need for RRT, and patient mortality.

Rehabilitation programme following anterior cruciate ligament (ACL) reconstruction is multifaceted and may be influenced by a variety of factors. The role of the environment for care and the levels of supervision from physiotherapists on the outcomes of ACL rehabilitation, have not received robust attention in the literature. In this thesis, two trials were carried out to investigate the role of these factors on the outcomes of ACL rehabilitation. In the first trial, a total of 76 patients [hospital-based rehabilitation group, n = 48 (age: mean ± sd: 31.5 ± 12.1 yr, height: 1.74 ± 0.06 m, body mass: 78.2 ± 10.8 kg, waiting time: 37.3 ± 33.7 months) and community-based rehabilitation group, n = 28 (age: mean ± sd: 34.5 ± 9.9 yr, height: 1.71 ± 0.07 m, body mass: 75.2 ± 12.4 kg, waiting time: 31.1 ± 26.7 months)] self-selected themselves into the hospital- and the community-based rehabilitation programmes. The patients in both the hospital- and the community-based rehabilitation programmes were assessed by selected patient-reported outcome measures (PROMs) included IKDC, KOOS, K-SES, VAS and Lysholm at four different occasions (pre-surgery and at the 6th, 12th and 24th weeks post-surgically). Significant differences at early phase of rehabilitation (up to 12th week post-surgery) on PROMs of function, favouring the outcomes of the hospital-based rehabilitation programme compared to the community-based rehabilitation programme, were observed. However, no differences between the outcomes of the latter two programmes were observed across 24 weeks rehabilitation programme following ACL reconstruction. This suggested that community-care had offered a similar environment to the hospital for achieving the outcomes of rehabilitation. In the second trial, the patients in the hospital-based rehabilitation programme (n=48) were iii further randomly allocated to the fully-supervised and the minimally-supervised rehabilitation groups [ fully-supervised rehabilitation group, n=24 (age: mean ± sd: 32.2 ± 11.1 yr, height: 1.73 ± 0.07 m, body mass: 75.8 ± 10.7 kg, waiting time: 35.8 ± 29.4 months), minimally-supervised rehabilitation group, n=24 (age: mean ± sd: 31.0 ± 13.2 yr, height: 1.75 ± 0.06 m, body mass: 80.6 ± 10.7 kg, waiting time: 28.8 ± 25.1 months)]. The patients in both the fully-supervised and the minimally-supervised rehabilitation groups were assessed on four different occasions (pre-surgery and at the 6th, 12th and 24th week post-surgery) on estimates of function (single-leg hop), physical performance (peak force, rate of force development, sensorimotor performance and electromechanical delay) and musculoskeletal performance (anterior tibio-femoral displacement) alongside the selected PROMs. Significant differences during the early phase of rehabilitation (up to 12th week post-surgery), favouring outcomes of the fully-supervised rehabilitation programme on some aspects and the outcomes of the minimally-supervised rehabilitation programme on other aspects, were observed. However, similar knee function across 24 weeks rehabilitation was observed on the selected objective measures and PROMs amongst the outcomes of the latter two rehabilitation programmes. This indicated that the outcomes of ACL rehabilitation had not influenced by the levels of supervision from the physiotherapists. In short, the environment and the levels of supervision from rehabilitation team were less likely to influence the final outcomes of ACL rehabilitation.