Development, validation, reliability and predictive capacity of neuro-motor recovery of the Acute Brain Injury Physiotherapy Assessment (ABIPA): A tool for physiotherapists during early management of people following Acquired Brain Injury (ABI).

In the acute stages following ABI, when people are functionally dependent, a specific scale for physiotherapists to monitor incremental changes in neuro-motor function is needed. This thesis represents the development of the acute brain injury physiotherapy assessment (ABIPA), an outcome measure to fill this gap. The first step in the development of the ABIPA was to identify items known to reflect acute neuro-motor impairments for inclusion in the measure and develop scoring criteria along with guidelines for the identified items (Study 1). The final items of the ABIPA were: upper limb and lower limb movement; overall muscle tone in each limb; head and trunk alignment in supine; head and trunk alignment in sitting; head and trunk control in sitting; and overall presentation. Once items were selected and scoring criteria established, the new outcome measure underwent psychometric testing. In Study 1 responsiveness and concurrent validity of the ABIPA were examined together with participants assessed at day 1, 3, 7 and at discharge through their acute hospital admission to capture clinical changes. Concurrent validity of the ABIPA was examined against other commonly used measures; specifically, the Glasgow Coma Scale (GCS), Clinical Outcomes Variable Scale (COVS) and Motor Assessment Scale (MAS). The ABIPA was found to be responsive to change demonstrating greater sensitivity to change (SRM = 0.83) when compared to other assessment measures (SRMs ≤ 0.77) during the early weeks following ABI. Additionally, the ABIPA demonstrated good concurrent validity with commonly used measures to assess acute brain injury, including the GCS (rho = 0.76, p ≤ 0.001, COVS (rho = 0.82, p ≤ 0.001) and MAS (rho = 0.66, p ≤ 0.001). Study 2 of this thesis investigated inter- and intra-tester reliability of physiotherapists using the ABIPA. An observational study using video-recorded ABIPA assessments of seven people with moderate or severe ABI was undertaken with two cohorts of physiotherapists; trained and untrained. Trained physiotherapists attended two one-hour training sessions; an initial instructional session and then a practice session. The untrained physiotherapists were provided with the ABIPA guidelines. Participating physiotherapists scored the video recorded package of ABIPA assessments with intra-tester reliability examined by repeat screenings of the video recorded assessments a minimum of two weeks after the initial session. A high level of inter-tester reliability (α ≥ 0.9) was demonstrated for both trained and untrained physiotherapists. Trained physiotherapists showed good to excellent internal consistency for total ABIPA score and for all individual items except for alignment of the trunk in supine (α = 0.4). Similarly, untrained physiotherapists showed good to excellent internal consistency on the total ABIPA score and all individual items except for alignment of the trunk in supine (α = 0.09) and alignment of the head in supine (α = 0.60). For intra-tester reliability, substantial or perfect agreement was achieved for eight items (Weighted kappa Kw ≥ 0.6), with moderate agreement reached for a further four items (Kw = 0.4 - 0.6), leaving three items (representing 20% of the scale) achieving fair agreement. Items with the lowest agreement were alignment of the head in supine (Kw = 0.289); alignment of the trunk in supine (Kw = 0.387) and tone left upper limb (Kw = 0.366). This was similar for both the trained and untrained physiotherapists. Study 3 of the thesis investigated the underlying factor structure of the ABIPA using an exploratory factor analysis with principal axis factor extraction and varimax rotation. A four-factor solution with a simple structure (factor loadings ≥.30) that explained 69.6% of total variance was suggested. Factor one (alignment and posture) accounted for 36.6% of the variance while factor two (tone) explained 15.8%, factor three (left side movement) explained 9.6% and factor four (right side movement) accounted for 7.5%. Two items were identified with the lowest loading with the four-factor solution, alignment of the head in supine loading to factor three at 0.358 and alignment of the trunk in supine loading to factor two at 0.405. The final study of this thesis examined the association of the ABIPA with long term recovery following ABI by evaluating ABIPA scores at acute hospital admission and ABIPA scores at admission to rehabilitation against: length of stay in the acute hospital setting, length of stay in rehabilitation, discharge destination and secondary measures including the GCS, Mental Status Questionnaire, COVS, Coma Recovery Scale-Revised (CRS-R), Functional Independence Measure (FIM), Disability Rating Scale (DRS) and Carer Strain Index (CSI). ABIPA at acute hospital admission and rehabilitation were inversely related to acute, rehabilitation and total hospital length of stay (rho ≥ -.508; p ≤ 0.044). ABIPA at acute hospital admission demonstrated moderate to good correlations with ABIPA, FIM (motor) and COVS (rho ≥ 0.563, p ≤ 0.023) at long term follow up. ABIPA scores at rehabilitation admission demonstrated moderate to good correlations with GCS and MSQ (rho ≥ 0.564, p ≤ 0.023) and excellent correlations with ABIPA, FIM (motor) and COVS (rho ≥ 0.799, p ≤ 0.001). Overall the ABIPA showed moderate to good relationships with length of stay and long-term neuro-motor recovery from severe ABI. This thesis demonstrates that a new outcome measure with strong psychometric properties has been developed for measurement of acute neuro-motor impairments following severe ABI. Further investigation is required to continue the development paradigm by removing outlying items, establishing a minimal clinically important difference and expanding participant numbers

Development and Initial Validation of Novel Multi-Planar Neck Strength Assessment and Neuromuscular Training Protocols

Concussions are a serious health concern in today’s active society. There are many contributing factors to concussions but one that is starting to draw significant attention is the potential role the neck muscles play in mitigating concussive forces. There is evidence that stronger neck muscles may decrease an individual’s concussion risk. In order to fully define this role, an appropriate outcome measure for assessing neck strength is required. Once this is established, methods of training to improve neck strength can be evaluated for their effect on neck strength and subsequently effect on concussion risk. This thesis included three studies. Chapter 2 was a within session and between session test-retest agreement of a novel multi-planar neck-strength and upper kinetic chain assessment protocol using a hand-held dynamometer in a healthy adult population. Chapter 3 examined this protocol to determine its preliminary validity. Due to the lack of an accepted ‘gold standard’ for neck strength assessment, the validity was examined using three a priori hypotheses; face validity, known groups validity and convergent validity using EMG muscle activity. Chapter 4 is a pilot study investigating the effects of a training program using a novel neuromuscular neck-training device that has theoretical rationale on how to improve neck function to decrease concussion risk. This investigation demonstrated the device to be safe and potentially effective at improving axial rotation strength. This study provided promising results to justify further fully powered studies with the device. The final chapter provides a summary of this thesis and provides direction and guidance for future research into further defining the role of the neck muscles in concussion

Physical Therapy Following Shoulder Rotator Cuff Repair

ABSTRACT Introduction Rotator cuff (RC) tears are one of the common causes of pain and disability in the upper extremity. Currently there are no fixed guidelines for choosing testing positions for shoulder range of motion measurement. Optimal rehabilitation following RC repair is yet to be defined. Purpose and Method The purpose was to inform about postoperative Physical therapy following rotator cuff repair, with the following objectives: To systematically review the content of clinical research, which addresses various physical therapy programs. To describe validity and responsiveness of different testing positions for goniometric measurement of shoulder active external rotation. To pilot test study procedures and estimating effects of a land-based and an aquatic exercise program. Results Fourteen studies were included in the systematic review. ROM measurements in sitting and supine positions correlated moderately (r= 0.40 - 0.53). The sitting position showed greater sensitivity to change with estimates of standardized response mean (SRM) and effect size (ES) (SRM: 0.66, 1.05 and ES: 0.50, 1.02) as compared to the supine position (SRM: 0.39, 0.74 and ES: 0.37, 0.76) at 3 and 12 months postoperatively, respectively. A total of 12 patients with a 67% recruitment rate, participated. Clinic visit adherence was 95%. No one was lost to follow-up. Both land-based and land plus aquatic exercise groups showed improved flexion AROM over time (Mean change= 21°, Standard Deviation (SD)= 25° and Mean change= 22°, SD= 33° respectively). For future studies, for having 80% power (α= 0.05, β= 0.20), and to detect 20% between-group difference, a total of 33 patients per group would be needed. Conclusions The systematic review found that exercise therapy including adjunctive interventions has small to moderate effect. 29% of the patients could not undergo active shoulder external rotation testing in supine, all patients could be tested in sitting. The sitting position has higher responsiveness than the supine position. Both land-based and aquatic exercise programs are shown to be feasible. To achieve power, we recommend future studies with larger sample size. Keywords Physical therapy, rotator cuff tear, land-based exercises, aquatic exercises, systematic review, pilot study

Aerospace medicine and biology: A continuing bibliography with indexes (supplement 339)

This bibliography lists 105 reports, articles and other documents introduced into the NASA Scientific and Technical Information System during July 1990. Subject coverage includes: aerospace medicine and psychology, life support systems and controlled environments, safety equipment, exobiology and extraterrestrial life, and flight crew behavior and performance

Physical assessment to improve the identification of modifiable physiological fall risk factors in healthy community-dwelling older adults

As the population aged >60 years grows, the number of people falling and subsequent injury increases. Falls have a devastating effect on older adults living in the community in terms of morbidity, mortality, and loss of independence. In general, a positive answer to falls screening questions, or opportunistic identification of fall risk through primary care pathways, establishes an older adult as being at risk of a fall and warrants further investigation using multifactorial fall risk assessments (MFRA). At the MFRA stage, standardised fall risk assessment tools are directed at identifying the presence of physiological impairments and risk of falling in older adults. Although these tools identify which intervention domain a person needs, information from these assessments does not inform the health professional of the underlying causes of poor physical function and performance. Therefore, the purpose of this project was to develop an assessment tool that may potentially identify modifiable fall risk factors in this population. A conceptual framework for objectively measuring modifiable physical impairments and a novel assessment procedure (Performance Deficit Test for Community-dwelling older adults (PDT-Com)) were introduced (Chapter 2). This was followed by a brief description of the scoring criteria of the PDT-Com assessment and discussion of the validity of its contents (Chapters 3 and 4). Chapter 5 reviewed current literature on falls prevention guidelines and assessment procedures which identified a need to better detect modifiable risk factors. The first study was a systematic review examining the objective measurement of lower-extremity muscle strength in community-dwelling older adults (Chapter 6). The second study was another systematic review (Chapter 7) examining current assessment tools which are used to identify modifiable functional status and fall risk factors in this population. The results further supported the need for a newly designed assessment tool that can objectively measure modifiable physical impairments to better inform the contents of an exercise intervention. The first experimental study (Chapter 7) was carried out to determine reference values of strength for ten lower-extremity muscle actions using hand-held dynamometry in a small cohort of community-dwelling older adults. These data were used to develop an objective scoring system. A second experimental study (Chapter 8) investigated intra- and inter-rater reliability of the PDT-Com in community-dwelling older adults. Assessment of movement competency is reliable and can confidently be applied by suitably trained individuals when a standardised procedure is used. A final experimental study examined the effect and feasibility of a three-month home and group exercise intervention directed by initial assessment using the PDT-Com. For the experimental group, a corrective exercise programme was prescribed based on each person’s PDT-Com score. The mean total PDT-Com scores for the exercise group were significantly improved compared to baseline scores. Conversely, mean PDT-Com scores in the control group marginally decreased over time from baseline scores. Between groups differences in mean PDT-Com scores were observed between groups suggesting that those subjects receiving an individualised exercise programme improved their physical function compared to the control group. This new assessment tool is a promising but untested approach to reducing falls and falls-related injury through the identification, and possible causes, of modifiable fall risk factors at the MFRA stage. A physiological assessment paradigm serves to promote a primary preventative approach to the management of falls in active community-dwelling older adults

Biomechanical analysis using FEA and experiments of metal plate and bone strut repair of a femur midshaft segmental defect

© 2018 Jason Coquim et al. This investigation assessed the biomechanical performance of the metal plate and bone strut technique for fixing recalcitrant nonunions of femur midshaft segmental defects, which has not been systematically done before. A finite element (FE) model was developed and then validated by experiments with the femur in 15 deg of adduction at a subclinical hip force of 1 kN. Then, FE analysis was done with the femur in 15 deg of adduction at a hip force of 3 kN representing about 4 x body weight for a 75 kg person to examine clinically relevant cases, such as an intact femur plus 8 different combinations of a lateral metal plate of fixed length, a medial bone strut of varying length, and varying numbers and locations of screws to secure the plate and strut around a midshaft defect. Using the traditional “high stiffness” femur-implant construct criterion, the repair technique using both a lateral plate and a medial strut fixed with the maximum possible number of screws would be the most desirable since it had the highest stiffness (1948 N/mm); moreover, this produced a peak femur cortical Von Mises stress (92 MPa) which was below the ultimate tensile strength of cortical bone. Conversely, using the more modern “low stiffness” femur-implant construct criterion, the repair technique using only a lateral plate but no medial strut provided the lowest stiffness (606 N/mm), which could potentially permit more in-line interfragmentary motion (i.e., perpendicular to the fracture gap, but in the direction of the femur shaft long axis) to enhance callus formation for secondary-type fracture healing; however, this also generated a peak femur cortical Von Mises stress (171 MPa) which was above the ultimate tensile strength of cortical bone