Although rare, distal biceps tears are common in middle-aged men in their 4th and 5th decades of life. The evidence surrounding prognosis, complications and rehabilitation interventions for distal biceps ruptures are of poor quality and therefore, many questions remain to be answered. This thesis includes four manuscripts describing studies that aim to improve our understanding of the rehabilitation of surgical and non-surgical management of distal biceps tendon rupture, prognostic factors associated with surgical repair and the outcomes for non-surgical management. The first manuscript is a scoping review of rehabilitation procedures described in the literature for the management of distal biceps ruptures. Overall, rehabilitation descriptions for distal biceps ruptures are poor for both post-surgical and non-surgical management. The findings suggest heterogeneity, both on the reporting and the content of rehabilitation delivered as a stand-alone intervention or post-operatively. The second manuscript is a cross-sectional study evaluating potential factors associated with reduced function post double incision surgical repair. The findings suggest that having a smoking history and weaker biceps flexion strength are associated with a poor prognosis and accounted for 50.4% of the variability in functional scores. These findings support existing studies that indicate a smoking history is associated with less favourable pain, function and disability outcomes follow distal biceps repair. The third manuscript is a prospective study evaluating prognostic factors associated with reduced function for those undergoing double incision surgical repair. These findings suggest that the majority of persons undergoing a distal biceps repair using a two-incision approach have minimal complications and good functional outcomes. In addition, having surgery on the non-dominant hand and having a weaker grip strength at baseline accounted for 43.4% of the variability of functional scores. The fourth manuscript describes two cases of non-surgical management of a complete distal biceps rupture. Despite the common belief that surgical repair for biceps rupture results in superior elbow flexion and supination strength, these cases demonstrated that full recover of strength and function is possible through rehabilitation alone. This study contributes to the evidence-base by questioning the need for surgical repair for all cases of distal biceps ruptures. / Dissertation / Doctor of Philosophy (PhD) / The biceps tendon is prone to rupture where it inserts into the elbow. While not a common injury, it does occur more often in middle aged men following a forceful movement. Most of the research regarding the prognosis and management of distal biceps ruptures is of poor quality and imprecise due to small sample sizes. This thesis examined management in a set of studies. A scoping review indicated that rehabilitation descriptions for distal bicep ruptures were of very poor quality for both surgical and non-surgical management for this condition. A cross-sectional analysis of 60 patients revealed that having a smoking history and weaker flexion strength was associated with poor outcomes after distal biceps repairs. A prospective cohort study of 34 patients found that having surgery on the non-dominant arm and weaker grip strength was associated with poor outcomes 6-12 months after surgical repair. Given the excellent outcomes after surgery and presumption of the need for surgery as standard practice, there has been little attention to the role of conservative management. We evaluated two cases where patients refused surgery and were able to recover full strength and functional abilities using a comprehensive rehabilitation program. This thesis confirms that excellent outcomes occur after this injury and raises the need for future trials comparing surgery and rehabilitation as treatment options. The fact that this injury often occurs in healthy men may partially explain the excellent outcomes with surgery or rehabilitation.

Background: Play is the child’s natural world. According to psychoanalytical studies, play has an important role in children’s development, and the absence of play during a child’s life could lead to severe pathological implications. Based on this theory and being aware that physiotherapy treatment programs could be long lasting, tiresome and lacking motivation for children, this literature review presents a perspective regarding the integration of play within physiotherapy programs and examines the physical and emotional outcomes during this integration. Aim: To investigate the outcomes of integrating play in physiotherapy for children with chronic health conditions. Method: The research strategy for this review was a thorough search of peer-reviewed articles in the databases CINAHL and AMED which include articles from the fields of allied and complementary medicine, as well as the database Scope Med. Participants were children with chronic health conditions, ranging from 2-18 years old. In the term ‘play’ virtual reality and video game activities were included due to the lack of research. In addition, articles from a previous literature review conducted by the author were also included in the present paper. Results: The focus of researchers on children with CP and the lack of evidence for children with other health conditions, the persistence of physiotherapists to assess mainly physical outcomes and not emotional needs of children, and the measurement tools used for this purpose are presented. Conclusions: For children with chronic health conditions who attend physiotherapy sessions, play could serve as a mediate and an appropriate developmental approach in order to achieve physical and emotional changes. There is a need for physiotherapists to balance physical and emotional needs, and have a more ‘human’ relationship, rather than a ‘bodily’ - strict professional relationship with children. Although the information presented in this review is not considered as sufficient to draw conclusions, it could serve as a first step for researchers to study this integration in greater depth, and to focus on children with conditions other than CP.

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