Prehabilitation for total knee arthroplasty: A patient-centred approach to maximizing surgical outcomes

The purpose of this dissertation was to investigate the role of prehabilitation in post-operative recovery for patients undergoing total knee arthroplasty (TKA) for osteoarthritis. Study one was a meta-analysis that aimed to consolidate the body of knowledge regarding prehabilitation for TKA patients. Study two compared the Lower Limb Tasks Questionnaire (LLTQ) to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in terms of agreement and responsiveness. Study three investigated the effect of a six-week pre-surgical strength training program on post-operative outcomes (quadriceps strength, mobility, pain, self-reported function, health-related quality of life, arthritis self efficacy) for TKA patients. Finally, study four provided a preliminary insight into the implementation context of prehabilitation for TKA. Study one demonstrated that prehabilitation had no effect on post-operative pain or self-reported function, but had a large effect on length of hospital stay (ES = -0.819; 95% CI: -0.985 - -0.653). Pre-operative exercise had no significant effect on quadriceps strength in the early post-operative phase (hospital discharge to 12 weeks after surgery), but did have a small effect on strength beyond 12 weeks (ES = 0.279; 95% CI: 0.018 – 0.540). Study two found that the LLTQ activities of daily living (ADL) subscale had good agreement with the WOMAC global score [bias = -1.40 (SD = 10.00); 95% limits of agreement = -22.00% to +19.00%.] Conversely, the LLTQ sport/recreation subscale had very poor agreement with WOMAC [bias = -31.00 (SD = 17.00); 95% limits of agreement = -65.00% to +2.40%]. The statistical responsiveness of the WOMAC was superior to that of the LLTQ ADL and sport/recreation subscales (1.17, -0.63, and -0.01, respectively). Study three showed that pre-surgical strength training had a large effect on quadriceps strength, F(3,18) = 0.89, p = 0.47, η2 = 0.13, and walking speed, F(3,18) = 1.47, p = 0.26, η2 = 0.20 before TKA. After TKA, there were no significant differences in any outcome measures between the prehabilitation and control groups. Furthermore, there were no significant correlations between self-reported and objective measures of function. Finally, study four indicated that TKA patients are likely to participate in prehabilitation, particularly exercise-based programs

A qualitative examination of women\u27s self-presentation and social physique anxiety during injury rehabilitation

Objective To understand women\u27s self-presentation experiences in the rehabilitation setting, and their attitudes and preferences toward the social and physical features of the rehabilitation environment. Design Qualitative study. Setting Outpatient physiotherapy clinic. Participants Ten women (age 18 to 64) with high social physique anxiety (Social Physique Anxiety Scale score ≥25) referred for physiotherapy following acute injury. Main outcome measures Semi-structured interviews were conducted prior to commencement of treatment, and again after a third treatment session. Results Participants experienced extensive self-presentational concerns that were intensified due to the nature of the physiotherapy environment. The women reported that their self-presentational anxiety did not diminish over time, and was related to others’ negative perceptions regarding their physical appearance and inability to perform exercises as well as expected. The presence of men or younger women in the clinic was identified as a barrier to appointment attendance, along with open concept clinic settings, which were associated with the most potential for evaluation. Mirrors and windows in the physiotherapy clinic were highlighted as anxiety provoking. The women suggested that they would feel apprehensive about advocating for themselves if they felt uncomfortable with the area in which they were receiving treatment, and instead used avoidance coping strategies (e.g., hiding behind equipment, preventing eye contact) to manage their anxiety. Conclusions Physique-anxious women experience extensive self-presentational concerns in the rehabilitation environment, which could affect treatment adherence. Modifying the treatment setting, providing protective self-presentational strategies such as positive self-talk, and open patient–therapist communication could be implemented to help mitigate these concerns

Utilising a Behaviour Change Model to Improve Implementation of the Activate Injury Prevention Exercise Programme in Schoolboy Rugby Union

The Health Action Process Approach (HAPA) is a behaviour change model showing promise in positively changing youth sport coaches’ injury prevention behaviours. This study incorporated the HAPA model into coach training workshops for Activate, an efficacious rugby injury prevention programme. Primary aims were to investigate the effect of the workshop on schoolboy rugby union coaches’ (1) perceptions towards injury risk and prevention, (2) Activate adoption and adherence. Secondary aims were to (3) assess the differences in post-season HAPA constructs between workshop attendees and non-attendees, (4) explore associations between HAPA constructs and Activate adherence. In the pre-season, all participants (n = 76) completed a baseline survey, with 41 coaches electing to attend a workshop. Participants completed a post-season survey assessing HAPA constructs and Activate adoption and adherence throughout the season. The workshop did not affect coach perceptions of injury risk and prevention. Attendees had significantly greater rates of Activate adoption (95% vs. 54% χ2 = 17.42, p < 0.01) and adherence (median = 2 sessions vs. ≤1 session per week; z = 3.45, p = 0.03) than non-attendees. At post-season, attendees had significantly greater task self-efficacy (z = −3.46, p < 0.05) and intention (z = −4.33, p < 0.05) to use Activate. These results support the delivery of coach workshops that utilise a behaviour change model to maximise programme implementatio

Effectiveness of the <i>Activate </i>injury prevention exercise programme to prevent injury in schoolboy rugby union

Objective The efficacious Activate injury prevention exercise programme has been shown to prevent injuries in English schoolboy rugby union. There is now a need to assess the implementation and effectiveness of Activate in the applie setting. Methods This quasi-experimental study used a 24-hour time-loss injury definition to calculate incidence (/1000 hours) and burden (days lost/1000 hours) for individuals whose teams adopted Activate (used Activate during season) versus non-adopters. The dose-response relationship of varying levels of Activate adherence (median Activate sessions per week) was also assessed. Player-level rugby exposure, sessional Activate adoption and injury reports were recorded by school gatekeepers. Rate ratios (RR), adjusted by cluster (team), were calculated using backwards stepwise Poisson regression to compare rates between adoption and adherence groups. Results Individuals in teams adopting Activate had a 23% lower match injury incidence (RR 0.77, 95% CI 0.55 to 1.07), 59% lower training injury incidence (RR 0.41, 95% CI 0.17 to 0.97) and 26% lower match injury burden (95% CI 0.46 to 1.20) than individuals on non-adopting teams. Individuals with high Activate adherence (>= 3 sessions per week) had a 67% lower training injury incidence (RR 0.33, 95% CI 0.12 to 0.91) and a 32% lower match injury incidence (RR 0.68, 95% CI 0.50 to 0.92) than individuals with low adherence (<1 session per week). While 65% of teams adopted Activate during the season, only one team used Activate three times per week, using whole phases and programme progressions. Conclusion Activate is effective at preventing injury in English schoolboy rugby. Attention should focus on factors influencing programme uptake and implementation, ensuring Activate can have maximal benefit

Feasibility and acceptability of a new shoulder-specific warm-up programme to prevent injuries in community youth rugby union as compared to the FIFA 11+

Injury prevention exercise programmes (IPEPs) are efficacious, though there is no IPEP specifically designed to reduce shoulder injuries in rugby. This study aimed to determine the feasibility and acceptability of the Rugby Active Shoulder Injury Prevention (RASIP) programme. Three community rugby union clubs participated in a 12-week pilot study (players, n = 51; coaches, n = 7). Two teams were randomly allocated to the RASIP programme and one to the FIFA 11+ (IPEP) intervention. Feasibility was examined by players’ adherence to the IPEP, and acceptability was described by players’ and coaches’ perceptions of the IPEP. On average, more players were exposed to 11+ training sessions (100%) than the RASIP programme (19 out of 36 players, 53%). Higher percentage of exercises was completed over the season in the 11+ (97%) than the RASIP programme (58%). Across both groups, there were different approaches followed in delivering the allocated intervention. The coach-led, prescriptively followed 11+ IPEP was better at achieving higher adherence with exercises. Coaches were concerned of not having enough time in their sessions to include the IPEP. This pilot study has shown that the intervention is feasible to deliver and is acceptable with improvements recommended by community stakeholders, coaches and players in a community youth rugby setting

Barriers and facilitators to implementing the Activate injury prevention exercise programme – A qualitative study of schoolboy rugby coaches

The rugby-specific Activate injury prevention exercise programme was deemed efficacious in a randomised controlled trial and subsequently disseminated nationwide by the Rugby Football Union (English rugby union governing body) in 2017. However, no assessment has been made of the factors influencing Activate implementation in an applied setting. Consequently, this study sought to assess the barriers and facilitators to coaches implementing Activate in English schoolboy rugby. This qualitative study adopted a framework approach, using four a-priori themes influencing injury prevention implementation: awareness, motivational determinants, volitional determinants and socio-environmental factors. A purposive sample of schoolboy rugby coaches were recruited from schools nationwide, participating in semi-structured, one-on-one interviews (n = 10). Transcripts were thematically coded. Participants had positive perceptions towards Activate, although only six adopted the programme. Participants reported that players were generally unaware of the programme, with some suggesting this was not an issue as coaches made the decision to adopt Activate. Participants focused heavily upon the use of resources to develop coaches' awareness, knowledge and confidence. No participant implemented Activate as initially designed, influenced by time and engagement, instead incorporating it within training drills rather than as a block at the beginning of the session. Participants adapted the programme to make it suitable for multiple sports. Some participants reported asking players to deliver Activate, despite their lack of awareness, raising concerns around implementation. Participants heavily adapted Activate delivery to suit their contexts. How this affects the effectiveness of Activate to reduce injury risk is unknown and should be investigated. Player-specific dissemination strategies should be considered if these individuals act as delivery-agents