Individuals with chronic liver disease experience progressive muscle wasting, weakness, fatigue, and decreased quality of life. Liver transplantation is the only treatment for end-stage liver disease with cirrhosis; however, muscle wasting, strength impairments, activity limitations, and health related quality of life do not return to the level of healthy adults. Currently there is no plan of care for rehabilitation of individuals post-liver transplantation. These individuals are only instructed to gradually increase walking and activity. Walking may increase lower extremity muscle strength; however, walking at a self-selected pace is less effective than resistance exercise. The purpose of this dissertation was to compare the benefits of a home exercise program of targeted lower extremity resistance exercise with benefits of progressive walking in individuals who have undergone liver transplantation. In Chapter 2 we performed a study to validate the ability of several outcome measures to detect changes in strength and activity performance in the population with liver disease and post-liver transplantation. The strength impairment measures of Grip Strength, Heel Rising, and Bridging along with activity limitation measures 30 Second Chair Stand and Six Minute Walk Test (6MWT) were able to differentiate strength and activity performance across levels of liver disease severity including post liver transplantation. Liver disease severity was moderately correlated with the strength impairment measures Bridging and Heel Rising but was not correlated with Grip strength. Liver disease severity was moderately correlated with 6MWT and 30-Second Chair-Stand but was not correlated with the SF-36 physical function scale. Strength impairment measures were strongly correlated with the activity limitation measures. Heel Rising and Bridging were strongly correlated with 30-Second Chair-Standing and 6MWT. Grip strength was moderately correlated with 30-Second Chair-Standing. In Chapter 3 we conducted a randomized controlled trial to assess the benefits of resistance exercise to progressive walking as a treatment plan for improving strength and activity performance in individuals post liver transplantation. We also examined the relationships of the change in muscle strength to the change in activity performance. Both the exercise and walking groups improved in strength and activity performance; however, the group performing the resistance exercise improved more. Bridging, 30 Second Chair Standing, Heel Rising, and 6MWT increased more for the exercise group than the walking group. Additionally, changes in strength were related to the changes in activity performance and health related quality of life. Bridging was correlated with Heel Rising, 30 Second Chair Standing, 6MWT, and the Chronic Liver Disease Questionnaire. In Chapter 4 we discuss the clinical relevance of the results of the studies described in the above chapters. We conclude Bridging, Heel Rising, 30 Second Chair Standing, and 6MWT are valid outcome measures to measure changes in strength and activity performance in the population with liver disease. Individuals post liver transplantation improve in strength and activity performance through progressive walking; however, the addition of resistance exercise to the current treatment plan is necessary for greater improvement. Additionally it is clinically relevant that this population was adherent to a home exercise program. Subjects adherent to the exercise program increased in strength and activity performance greater than subjects who were non-adherent.

京都大学 / 0048 / 新制・課程博士 / 博士(人間健康科学) / 甲第21705号 / 人健博第71号 / 新制||人健||5(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 市橋 則明, 教授 黒木 裕士, 教授 妻木 範行 / 学位規則第4条第1項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

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<p>Syftet med studien var att undersöka hur patienter upplevde en sjukgymnasts metodik i samband med utlärningen av hemträningsprogram de fått ordinerade i rehabiliterande syfte för sina skador. Dessutom undersöktes hur väl sjukgymnastens metodik gällande hemträningsprogram stämde överens med tidigare forsknings rekommendationer, och ifall samband kunde ses mellan patienternas följsamhet och de faktorer som påverkar den. Undersökningen var en modifierad fallstudie och genomfördes med relativt högt strukturerade telefonintervjuer. Undersökningsgruppen bestod av sju patienter som alla hade ordinerats hemträningsprogram ifrån samma sjukgymnast, för olika typer av skador. Resultatet av studien visade på att patienterna upplevde mottagningens metodik som väl fungerande. Sjukgymnastens metodik stämde även väl överens med tidigare forskningsrekommendationer för en hög följsamhet utav träningsprogrammen bland patienterna. Samband mellan patienternas följsamhet och tidigare forsknings rekommendationer visade sig vara starka.</p> / <p>The purpose of this study was to examine how patients experienced the methodology concerning the home exercise programmes they have been prescribed by a physiotherapist in rehabilitation purpose due to their injuries. Furthermore it was examined how well the methodology regarding the home exercise programmes made by the physiotherapist agreed with recommendations according to previous research studies, and if a connection could be drawn to the patients’ determination to comply with the exercise programmes. The study was a modification of a case study and it was conducted by relatively high structured telephone interviews. The target group for the study consisted of seven patients, all which had been prescribed with home exercise programmes by the same physiotherapist due their different injuries. The result of the study implies that the patients experienced the methodology of the physiotherapist reception as well-functioning. The methodology of the physiotherapist was also fall in line with what previous recommendations from scientific studies regards important in order to achieve a high compliance of the exercise programmes among the patients. The connection between the compliance of the patients and recommendations made based on previous studies appears to be highly related.</p>

Syftet med studien var att undersöka hur patienter upplevde en sjukgymnasts metodik i samband med utlärningen av hemträningsprogram de fått ordinerade i rehabiliterande syfte för sina skador. Dessutom undersöktes hur väl sjukgymnastens metodik gällande hemträningsprogram stämde överens med tidigare forsknings rekommendationer, och ifall samband kunde ses mellan patienternas följsamhet och de faktorer som påverkar den. Undersökningen var en modifierad fallstudie och genomfördes med relativt högt strukturerade telefonintervjuer. Undersökningsgruppen bestod av sju patienter som alla hade ordinerats hemträningsprogram ifrån samma sjukgymnast, för olika typer av skador. Resultatet av studien visade på att patienterna upplevde mottagningens metodik som väl fungerande. Sjukgymnastens metodik stämde även väl överens med tidigare forskningsrekommendationer för en hög följsamhet utav träningsprogrammen bland patienterna. Samband mellan patienternas följsamhet och tidigare forsknings rekommendationer visade sig vara starka. / The purpose of this study was to examine how patients experienced the methodology concerning the home exercise programmes they have been prescribed by a physiotherapist in rehabilitation purpose due to their injuries. Furthermore it was examined how well the methodology regarding the home exercise programmes made by the physiotherapist agreed with recommendations according to previous research studies, and if a connection could be drawn to the patients’ determination to comply with the exercise programmes. The study was a modification of a case study and it was conducted by relatively high structured telephone interviews. The target group for the study consisted of seven patients, all which had been prescribed with home exercise programmes by the same physiotherapist due their different injuries. The result of the study implies that the patients experienced the methodology of the physiotherapist reception as well-functioning. The methodology of the physiotherapist was also fall in line with what previous recommendations from scientific studies regards important in order to achieve a high compliance of the exercise programmes among the patients. The connection between the compliance of the patients and recommendations made based on previous studies appears to be highly related.

Introduction: The participation profile of patients with chronic obstructive pulmonary disease (COPD) in pulmonary rehabilitation (PR) and the effectiveness of a video-based home exercise programme (VBHEP) were investigated using various research methods. Methods: The content analysis of the Move-On-Up exercise video against NICE guidelines and published research was performed. The video was evaluated for its suitability for use in VBHEP through focus groups involving UK population of patients with COPD and respiratory clinicians. Using the data from the content analysis and the focus groups, questionnaire items were synthesised for a national survey of both patients and clinicians. A study examined the relationship between participation in outpatient PR and patient measures of depression (Brief Assessment Depression Card), social support (Duke Social Support Index), multidimensional health locus of control (MHLC) and COPD severity (Medical Research Council dyspnea score). A randomised control trial (RCT) evaluated the effect of combining VBHEP and conventional outpatient PR on walking ability and PR benefit maintenance. The intervention arm received VBHEP concurrently with outpatient PR, while the control arm received only outpatient PR. Outcome measures included: the endurance shuttle walk test (ESWT), quality of life (QoL) (St George's Respiratory Questionnaire- SGRQ), MHLC and a modified Follick's activity diary. Measures were taken before PR, at the fourth and eighth weeks of PR and at six months post-PR. Focus groups were conducted between six and 20 months post-PR to evaluate patients' experience of and adherence to the use of VBHEP. Results: Critical review of 46 RCTs aided evaluation of the video demonstrating that the video content was consistent with both NICE recommendations and published research. The six focus groups that were part of the initial evaluation of the video involved 14 patients and 14 clinicians. The national survey generated responses from 60 patients and 62 clinicians; between 79 and 100% of respondents in each domain of the questionnaire indicated that the video is suitable for use. Fifty-one patients completed the study investigating the profile of patients participating in PR. The results indicated that depression has a moderate and negative statistically significant association with the uptake of PR (p < 0.05). Fifty-seven patients participated in the RCT [mean age 66.51 years (SD 9.96), mean FEV1% predicted 54.51% (SD 10.47)]. The results indicated that the use of VBHEP with outpatient PR has no significant additive effect in improving or maintaining the benefits of walking ability following PR (p<0.05). Seven patients participated in the follow-up focus groups where findings suggested that patients were still participating in VBHEP up to 20 months after it was first prescribed, though the frequency of its use appeared to diminish after PR ended. Conclusion: The Move-On-Up exercise video is suitable for VBHEP in patients with COPD. Patients with COPD and depression are less likely to take up a referral to PR compared to those without depression. The use of VBHEP concurrently with PR has no additive effect in improving or maintaining benefits of walking ability following PR. Adverse social circumstances and disease severity reduce the duration of participation in VBHEP.

Chronic low back pain (CLBP) is defined as pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without sciatica, that lasts for at least twelve weeks.1 It is the leading cause of disability and loss of productivity in the United States.2 There is conflicting evidence on what is the most effective nonpharmacological treatment for CLBP. Many studies have shown that any general exercise routine is effective for improving symptoms, but the literature provides conflicting evidence about what specific type of exercise is best.3 A few studies have demonstrated decreased pain and disability with supervised directional preference exercise routines compared to non-directional preference routines. The objective of this study was to determine the effectiveness of a home directional preference exercise/stretch program for reducing disability in mechanical CLBP in patients in a residency clinic and to expand on the limited evidence of directional preference exercise effectiveness. Unlike other directional preference interventional studies, this program’s simplicity and convenience of performing at home potentially could increase patient compliance and therefore effectiveness. Patients were screened at a routine clinic visit and considered eligible if they had a known diagnosis of CLBP. They were excluded if they were in an acute exacerbation. Participating patients were categorized on directional range of motion preference based on their physical exam, either flexion or extension, whichever improved their pain. They were given a simple routine with instructions and pictures consisting of three exercises and stretches that emphasized their specific directional preference. Subjects performed three sets of each routine two to three days per week. Degree of disability score was measured at initial visit by completing the gold standard disability index questionnaire, the Oswestry Disability Index (ODI). Degree of disability was reassessed with ODI at a follow-up assessment four to eight weeks later with five follow-up questions regarding compliance and acute exacerbation. Patients were excluded if they were in an acute exacerbation. Pre-interventional disability scores were then compared to post-interventional disability scores. Twelve total patients enrolled in the program. Seven were lost to follow up. Five completed the study at the proper follow up interval; however, one was in an acute exacerbation so was excluded. Of the four patients included, two had extension and two had flexion preference. Three out of four patients had decreased disability scores at follow up. Total post-intervention score on ODI improved by an average of 10 points compared to pre-intervention score for the patients who improved. The most improved post-interventional ODI score category was walking and changing degree of pain. Seventy-five percent of the patients who completed the study had an improvement in their CLBP disability score. However, due to a small sample size and study power, the results are not statistically significant. Therefore, a conclusion cannot be appropriately drawn about the effectiveness of performing a home directional preference exercise/stretch program for reducing disability in mechanical CLBP in patients at a residency clinic. Nevertheless, the results are promising and deserve further investigation with a larger sample size.

Physical activity is a well-known protective factor against poorer mental health outcomes. Feelings of depression, social isolation, and stress have increased since the onset of the COVID-19 pandemic. Public health measures implemented to mitigate the spread of the virus have had some unintended consequences on older adults’ physical and mental health. Researchers and government officials recommend physical activity to minimize the negative psychological and physiological impacts of COVID-19. However, older adults have generally shown less moderate-to-vigorous physical activity and positive behavioural adaptations during the COVID-19 pandemic, highlighting a need for physical activity programs and strategies targeted for older adults. Filling this gap, the current study developed and implemented a remote exercise training program for older adults. Employing a measurement burst design with repeated ecological momentary assessments, the current longitudinal randomized control study examined the dynamic relationships of physical activity, depressive symptoms, social isolation, and COVID-19 related stress in older adults. The results from multilevel model analyses showed: (1) the exercise training program was effective in increasing physical activity; (2) sex, age, and group assignment were significant predictors of physical activity; (3) physical activity did not reduce depressive symptoms over time; (4) social isolation is directly associated with depressive symptoms; and (5) COVID-19 stress is inversely associated with depressive symptoms. At-home physical activity programming could be an effective way to increase physical activity among older adults; thus, more research into at-home physical activity programs is needed. / Graduate

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