A dissertation presented in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban Institute of Technology, 2005. / Following an inversion ankle joint sprain, damage to the proprioceptive organs can occur, which is made worse by lack of proprioceptive retraining and will increase the chances of re-injury (Hoffman and Payne 1995:144 and Anderson, 2002). Pellow and Brantingham (2001) indicated that patients who received multiple manipulations improved more rapidly than patients in the placebo group. Therefore it is proposed that manipulation provokes changes in afferent input that may restore normal proprioceptive input (Slosberg, 1988). However, Pellow and Brantingham (2001) were not able to establish what effect multiple manipulations had, as opposed to a single manipulation, on the proprioception on the foot and ankle complex and how this may influence the clinical outcome of the patient’s treatment. Therefore, it was hypothesized that multiple manipulations of the foot and ankle complex would have a greater effect on chronic ankle instability syndrome than a single treatment in terms of overall improvement subjectively and objectively. In addition to this the following was also hypothesized: • That multiple manipulations of the foot and ankle complex would increase the ROM to a greater extent than single manipulations. • That multiple manipulations would decrease point tenderness more effectively than a single manipulation. / M

MSc(Med), Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Introduction Many patients that have suffered traumatic injuries require admission to Intensive Care Unit (ICU). Mechanical ventilation (MV) is deemed to be the defining event marking many ICU admissions. As many as 30% of admissions, and 90% of all critically ill patients will require at least a short period of MV. There are many risks and complications associated with prolonged MV, such as rate of pneumonia, morbidity and mortality, increased cost, hospital LOS, emotional distress and decreased bed availability. To minimize these risks and complications it is important that patients be weaned and extubated from MV at the earliest possible time. However, just as delayed weaning and extubation carries the risk of complications, premature extubation and subsequent re-intubation should be avoided where possible, as extubation failure leads to an eight-fold higher risk of infection and a twelve-fold increase in mortality. Weaning is the transition from ventilatory support to spontaneous breathing and can often be achieved easily, but may be difficult in up to 25% of patients. Numerous studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs. Purpose To determine if the use of a nurse and therapist-driven weaning protocol to wean and extubate long-term patients with trauma from MV in an open ICU results in decreased total MV days and ICU length of stay (LOS), and to determine time to spontaneous breathing trial (SBT) failure. Methods A weaning protocol was developed by the researcher using clinical guidelines compiled for the American Association for Respiratory Care, American College of Chest Physicians and American College of Critical Care Medicine. A total of 56 mechanically ventilated trauma patients were enrolled in two phases of the study. A prospective cohort of 28 patients (Phase I), weaned according to the protocol, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched to be similar for gender, age, type and severity of injury. Data analyzed for both groups were number of MV days, number of ICU days, self-extubation and need for re-intubation. For Phase I patients, time to SBT failure and reason for failure was recorded. v Results and Discussion With respect to the mean MV days it was found that the two protocol groups did not differ significantly (p = 0.3 ; Phase I = 14.4 days vs Phase II = 16.3 days), although the two day reduction in MV was considered clinically significant in view of the complications associated with additional MV days. The difference of 0.25 days for length of ICU stay between the groups was not statistically significant (p = 0.9; Phase I = 20.8 days vs Phase II = 21 days), and demonstrates that a reduction in MV days may not necessarily result in a reduction of ICU LOS. Rate of re-intubation was similar in the two groups (Phase I = 3/28 vs Phase II = 4/28). Eleven patients (39%) in Phase I failed at least one SBT and four of these patients (36%) failed two SBTs prior to successful extubation. Failure of the first SBT occurred an average of 18 hours after onset of SBT. Injury severity scores for these patients were higher than the average for Phase I (16.1 vs 14.5). Mean MV time in this group was 20.5 days as opposed to 14.4 days in the total Phase I group. This indicates that these patients were more critically ill and that they may require longer SBTs than advocated in many studies. All patients failed SBT due to increased RR. Conclusion In this study of longer-term ventilated patients who had traumatic injury as reason for admission to ICU and mechanical ventilation, the use of a standardized protocol to assist with weaning and extubation from MV demonstrated a clinically significant reduction in total MV time, even though this did not reach statistical significance. The reduction in MV time did not lead to a reduction in ICU LOS, however it reduces the risks of ventilator-associated complications such as VAP. The use of a weaning and extubation protocol did not lead to a higher rate of re-intubation, demonstrating its safety for use in this patient population. This protocol was driven by nurses and physiotherapists, and the role of physiotherapists and nursing staff in weaning and extubation of patients from MV could be greatly expanded in the majority of ICUs in South Africa.

With the increasing popularity all over the world of Ironman triathlon events, the need to determine the type, timing and number of injuries sustained by these triathletes on race day is evident. Also to determine the optimum medical staffing requirements and knowledge during these events is of importance. The Ironman South Africa 2011 (IMSA) took place on the 10 of April of that year. On that day 1742 triathletes started the event and a total of 1477 where able to complete the entire race distance in the time period allowed, (completion rate of 84.8%). Of those athletes competing, a total of 183 (male 155)(87.4%) and 28 (female)(11.3%) presented to the medical facility for treatment. The mean age of the triathletes presenting was 38.73(SD±9.82) years and the mean time of presentation to the facility was 12.35(SD±2.33) hours after the start of the event. Injury prevalence showed exercise associated collapse (EAC) to be the most common presentation at 44.8%. The medical support and staffing was established to fit the temporal model of injuries sustained by non elite Ironman triathletes. This allowed increasing medical staffing in the latter stages of the race when a greater number of athletes were expected to present for medical assistance.

Aim: This pilot study compared the efficacy of superficial dry needling (SDN), deep dry needling (DDN), placebo dry needling (PDN) and a common physiotherapy control group (CON) when used in the treatment of myofascial trigger points (MTrPs) in rotator cuff syndrome (RCS) patients. Methodology: A randomised, single-blind, placebo-controlled pilot study (n=20) was conducted comparing the three needling groups to each other and to a common physiotherapy protocol. Participants were selected patients presenting for treatment in a private practice. The objectives of the study were to compare the groups on three levels: Pre trial-Post trial, within individual treatment session (Intra-treatment), and between treatment sessions (Inter-treatment). All groups were treated with the same basic common protocol but three of them had the addition of one each of the needling interventions. A modified Constant-Murley scale, range of motion and power were used as outcomes measures. Ethical permission was obtained from the University of the Witwatersrand. Results: Results were analysed for the four groups using an ANCOVA. DDN had significant improvement over CON over the trial period (p≤0.05) and SDN (p≤0.02). This was particularly due to highly significant intra-treatment effect on internal range of motion at session 3 (p≤0.01) and the highly significant inter-treament effect between session 3 and 4 (p≤0.03). DDN was significantly less effective than the other groups at session 3 (p≤0.01) and session 4 (p≤0.03). External rotation power was also significantly greater for DDN between sessions 2 and 3 (inter-treatment) (p≤0.05). 49% of the MTrPs identified were found within the infraspinatus muscles. Discussion: Twitch-obtaining dry needling (DDN) appears to show greater clinical benefit on the effects of myofascial trigger points than SDN, CON or PDN. The effect appears to correlate with the greater incidence of MTrPs in the infrapinatus muscles whose functions directly relate to the improved parameters. The clinical effect may be related to the effects of the bleeding elicited by intramuscular needling (humoral effects). This is evidenced by the transiently poor effect of DDN immediate following treatment becoming significanly better by the following treatment. Conclusion: The pilot study showed that DDN may be an effective treatment for RCS when used in conjunction with a conventional physiotherapy programme. The elicitation of a local twitch response and associated bleeding may be significant. In future studies, particular attention should be paid to both the infraspinatus muscle and the timing of the intervention and observation intervals.

M.P.H., Faculty of health Sciences, University of the Witwatersrand, 2011 / Background: The hospital as an organisation employs many people who may be at risk for Injuries on Duty (IOD). Although IOD occur across the hospital and impact on staff morale and quality of care, no formal study has been conducted within the public hospitals in South Africa on the profile of employees who have sustained these injuries. This study was aimed at comprehensively describing the IOD and related factors at Klerksdorp/Tshepong/Potchefstroom (K/T/P) Hospital Complex in order to better understand and plan appropriate preventive strategies. Methodology: The study was based on a cross-sectional design involving retrospective record review obtained from the hospital information system. No primary data was collected. The study setting was K/T/P Hospital complex. All records of employees who sustained IOD during the study period were reviewed. Data was collected on relevant variables such as employee profile, type of IOD during the study period. Descriptive statistics was used to analyse the data. Results: The study found that the total number of IOD during this period was 152. The annual prevalence rate was 2.3% (Klerksdorp-Tshepong Hospital Complex) and 2.8% (Potchefstroom Hospital). . The category of employees who experienced injuries were administration (5.3%), support (18.8%), medical (34.9%), nursing (36.2%), professional (4.6%). The types of the injuries sustained were cut (8.6%), fall (19.7%), minor injuries (9.2%), needle prick (49.3%), patient related (1.3%), splash (11.8%). With regard to PEP costs, Klerksdorp Hospital incurred the highest costs of R31 231 34, followed by Potchefstroom Hospital with R23 714 83 and Tshepong Hospital with R19 305 57 during the study period

In summary, the biomechanical stimulations can augment osteotendinous healing processes by facilitating better fibrocartilagious transitional zone regeneration as well as the restoration of proprioceptions, and the early application showed the more beneficial effects. However, further experimental and clinical studies are still needed to explore the optimal timing, intensity, frequency, and duration of the proposed postoperative biomechanical stimulation protocols. / LIPUS is a "non-contact" biomechanical stimulation, which can provide a direct mechanical stimulation through cavitation and acoustic microstreaming effects to improve tissue healing in a less-than-rigid biomechanical environment. So the mechanical stimulation induced from LIPUS could be applied immediately after surgery without worrying about the mechanical strain exceed the structural property at the osteotendinous healing interface in the early phase of repair. In this part of study, we also examined the effects of the regime of biomechanical stimulations applying immediately after repair on the osteotendinous healing interface. By using the same healing junction model, forty-two female New Zealand white rabbits were randomly divided into two groups; daily mechanical stimulation was applied immediately after surgery lasting up to post-operative 12 weeks on the healing interface in the treatment group. The regime of mechanical stimulations included by LIPUS was 20 minutes, 5 days per week for 4 weeks, followed by cyclic mechanical stimulation generated from quadriceps muscles induced by FES for 8 weeks. Results showed that early application of biomechanical stimulations on the osteotendinous healing interface were significantly better radiologically, histologically and biomechanically than that of not any or later application of the biomechanical stimulations during the osteotendinous healing processes when assessing at the same healing time point. In addition, the early application of biomechanical stimulations showed the better functional recovery in terms of the restoration of the proprioceptions, which an increased numbers of sensory nerve endings labeled by calcitonin gene-relate peptide (CGRP) was detected in the whole osteotendinous healing complex. / Sports or trauma injuries around osteotendinous junctions are common; treatments usually require surgical reattachment of the involved tendon to bone. Restoration of osteotendinous junction after repair is slow and difficult due to regenerating the intermitted fibrocartilage zone to connect two different characteristic tissues, tendon to bone. Although the factors influencing fibrocartilage zone regeneration and remodeling during osteotendinous repair are poorly understood, however, is believed that the mechanical environment plays an important role in such healing process. In present study, the effects of mechanical stimulation on osteotendinous healing process were examined, in the way of mechanical stimulations induced by biophysical stimulations, surface functional electric stimulation (FES) and low intensity pulsed ultrasound (LIPUS), applying on the patellar tendon to patellar bone healing interface in an established partial patellectomy model in rabbits. / The mechanotransductive stimulation linked to the transmission of forces across osteotendinous junction can be generated from its muscle contraction induced by FES. In the partial patellectomy model, thirty-five female New Zealand white rabbits were randomly divided into two groups with initial immobilization for 6 weeks, daily FES was applied to quadriceps muscles for 30 minutes, 5 days per week for 6 weeks in treatment group and compared with non-treatment control group at postoperative week 6, 12 and 18, radiologically, histologically and biomechanically. Results showed that FES-induced cyclic mechanical stimulation significantly increased new bone formation and its bone mineral density. An elevated expression of tenascin C and TGFbeta1; an increased proteoglycant stainability; mature fibrocartilage zone formation with better resumptions of biomechanical properties also observed on the osteotendinous healing interface, indicating that the post-operative programmed cyclic mechanical stimulation generated from its muscle contraction has beneficial effects on osteotendinous healing processes by facilitating the fibrocartilagious transitional zone regeneration. / by Wang Wen. / Advisers: Kai Ming Chan; Ling Qin. / Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1550. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 159-175). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

Establishment of animal model for studying treatment efficacy of low-intensity pulsed ultrasound stimulations for accelerating bone-tendon repair. Standard partial patellectomy was conducted in the 18-week old rabbits that were then divided into the LIPUS treatment and control groups. The animals were followed for 2, 4, 8, and 16 weeks for various tissue analyses. LIPUS was applied to the experimental animals from postoperative day 3 to 16 weeks. We demonstrated that the healing process of PPT junction was initiated through endochondral ossification. The results showed that the size and length of newly formed bone, and its bone mineral content (BMC), but not its bone mineral density (BMD) were correlated with the failure load, ultimate strength and energy at failure. Using radiographic, biomechanical, histomorphologic and biomechanical methods, it was found that LIPUS had significant accelerating effect on PPT junction repair. We validated our study hypothesis in that LIPUS enhances bone-tendon junction healing by stimulating angiogenesis, chondrogenesis and osteogenesis. / Establishment of in vitro model for mechanism study on effects of low-intensity pulsed ultrasound stimulations. An in vitro model of osteoblast-like cell line (SaOS-2 cells) was studied using cDNA microarray to explore the molecular mechanism mediated by LIPUS. This microarray analysis revealed a total of 165 genes that were regulated at 4 and 24 hours by LIPUS treatment in osteoblastic-like cells. These genes belonged to more than ten protein families based on their function and were involved in some signal transduction pathways. This study has validated the hypothesis that LIPUS can regulate a number of critical genes transient expressions in osteoblast cell line Saos-2. / Keywords. partial patellectomy model; bone-tendon junction repair; low intensity pulsed ultrasound stimulations (LIPUS); gene expression; complementary DNA microarray; rabbit. / This study explored the intact morphology, regular healing and the augmented healing under the effects of low intensity pulsed ultrasound stimulations (LIPUS) on the patella-patella tendon (PPT) junction in a rabbit partial patellectomy model. To probe its possible mechanism, the key genes involved in regulating osteogenesis mediated by LIPUS were identified using the state-of-the-art methods---complementary DNA microarray. / Lu Hongbin. / "June 2006." / Advisers: Ling Qin; Kwok Sui Leung. / Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1548. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 259-288). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

A "Job Coach" model was developed based on sports medicine and rehabilitation principles for athletes, and individual placement and supported employment for people with psychiatric disabilities. This is a biopsychosocial model, emphasising workplace-based intervention. / Background. Occupational musculoskeletal soft tissue injuries represent a major source of work disability. There has been a gradual rise in the occurrence of occupational musculoskeletal injuries of the upper extremity, including both acute injuries and more chronic health problems. Return to work following an occupational injury is a multifactoral process, although traditional clinic-based rehabilitation programmes do not appreciate the importance of contextual factors. / Conclusion. Workplace work hardening programmes are a further development of work rehabilitation programmes. The therapeutic use of actual work facilities and the work environment can effectively facilitate the successful return to work process of the injured worker. More importantly, many of the psychosocial problems associated with separation from the work routine, peer group and/or the employer are minimised by the presence of the Job Coach. The results of this study confirm that workplace-based rehabilitation intervention is more effective than conventional clinic-based rehabilitation programmes in terms of prevention of further work disability, improvement in functional capabilities and decrease in perceived pain and disability. / Keywords. Job coach, workplace-based rehabilitation, rotator cuff injury, work disability, return to work intervention. / Methodology. A randomised controlled trial was conducted on 94 workers recruited from Workers' Compensation insurers. These workers had all sustained occupational rotator cuff injury and had lost more than 90 workdays. The workers were randomly assigned into control or experimental groups. The control group received a traditional work hardening programme and the experimental group received a workplace work hardening programme using the Job Coach model. The return to work outcomes of the two groups were compared. Areas of comparison included return to work rate after training, job retention ability and impact on earning capacity. Other outcome measures included change in active range of motion of the shoulder joint, eight basic functional capacities and the worker's perception of shoulder pain and disability based on the Shoulder Pain and Disability Index (SPADI). / Results. After one-month of the training programme, a higher return to work rate was obtained in the experimental group compared to the control group (71.4% against 37%, chi2=11.095, p=0.001). For job retention ability, 93.5% of the workers in the experimental group were still at work compared to 72.9% of workers in the control group (chi 2=7.031, p=0.008). No obvious salary change was noted between the two groups. / The SPADI was statistically significantly lower in the experimental group than in the control group (p=0.032), meaning that workers in the experimental group had fewer shoulder problems after training. Other significant improvements were noted in active shoulder flexion (p=0.001), arm lift strength (p=0.01), high-near lift strength (p=0.014), dynamic carrying strength (p=0.007) and overhead work tolerance (p=0.032), all of which were found to be statistically significantly higher in the experimental group than in the control group. / Cheng Shu-kei. / "July 2006." / Adviser: Leung Kim Hung. / Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1568. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 216-238). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

Ke Changshu. / "March 2001." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2001. / Includes bibliographical references (p. 142-174). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

ABSTRACT This study explored the clinical reasoning expert therapists use in relation to splinting the affected hand following neurological injury. An exploratory, descriptive, qualitative methodology was used in three focus groups with occupational therapists, experienced in neurorehabilitation. Data was analysed based on priori themes, specifically 1. The Model of Practice Development (Higgs and Titchen 2001b) - most value was placed on Procedural knowledge or clinical experience; reflection on protocols, working with and learning from others and having clear outcomes. Undergraduate training and current literature is insufficient to provide guidelines for practice. 2. The Three Track Model of Clinical Reasoning (Fleming 1991) –splinting was used to improve range of motion, maintain muscle length and affect muscle tone. Effectiveness of the splints depended on the patient’s response and the therapists’ ability to adapt to preferences and goals. Interactive reasoning was essential in understanding the South African context. The study provided guidelines for a newly qualified therapist.