Evaluation of physiotherapy intervention for non-specific sub-acute and chronic low back pain

This thesis investigates routine physiotherapy management of patients with subacute and chronic non specific low back pain. In a pragmatic multi-centre trial patients were randomised to receive a course of physiotherapy treatment or advice following a bio-psychosocial model. Disease specific, patient specific and generic measures were used to assess outcome. The 286 patients recruited in the trial had, on average, minimal to moderate low back pain disability. Patients reported enhanced perceptions of benefit in the physiotherapy group but there was no evidence of a long term effect in any other outcomes. There were no differences between the groups in NHS costs although patients in the physiotherapy group incurred significantly higher out of pocket expenses. Further analysis of the outcome data confirmed that the primary outcome measure (Oswestry Disability Index) was the most responsive instrument because it was able to detect deterioration as well as improvement. As the trial demonstrated no additional benefit of physiotherapy over brief advice, it was important to investigate the effectiveness of the latter. A systematic review found limited evidence that brief bio-psychosocial advice was more effective in reducing fear avoidance and improving back beliefs in patients with acute and subacute low back pain compared with traditional medical advice. There was no direct evidence to support the use of brief bio-psychosocial advice (2 sessions or less) for reducing pain or disability. This thesis describes research that has contributed to European guidelines for the management of chronic low back pain and reviews extensively the literature that seeks to evaluate physiotherapy practice. The clinical implication of this research is that for patients with non specific low back pain of mild severity, brief advice is likely to be as effective as prolonged physiotherapy intervention. The extent to which a single session of advice is more effective than no intervention needs further assessment

Evaluation of physiotherapy intervention for non-specific sub-acute and chronic low back pain

This thesis investigates routine physiotherapy management of patients with subacute and chronic non specific low back pain. In a pragmatic multi-centre trial patients were randomised to receive a course of physiotherapy treatment or advice following a bio-psychosocial model. Disease specific, patient specific and generic measures were used to assess outcome. The 286 patients recruited in the trial had, on average, minimal to moderate low back pain disability. Patients reported enhanced perceptions of benefit in the physiotherapy group but there was no evidence of a long term effect in any other outcomes. There were no differences between the groups in NHS costs although patients in the physiotherapy group incurred significantly higher out of pocket expenses. Further analysis of the outcome data confirmed that the primary outcome measure (Oswestry Disability Index) was the most responsive instrument because it was able to detect deterioration as well as improvement. As the trial demonstrated no additional benefit of physiotherapy over brief advice, it was important to investigate the effectiveness of the latter. A systematic review found limited evidence that brief bio-psychosocial advice was more effective in reducing fear avoidance and improving back beliefs in patients with acute and subacute low back pain compared with traditional medical advice. There was no direct evidence to support the use of brief bio-psychosocial advice (2 sessions or less) for reducing pain or disability. This thesis describes research that has contributed to European guidelines for the management of chronic low back pain and reviews extensively the literature that seeks to evaluate physiotherapy practice. The clinical implication of this research is that for patients with non specific low back pain of mild severity, brief advice is likely to be as effective as prolonged physiotherapy intervention. The extent to which a single session of advice is more effective than no intervention needs further assessment.EThOS - Electronic Theses Online ServiceArthritis Research Campaign (Organization)University of WarwickGBUnited Kingdo

Promotional approaches to undergraduate recruitment for marginalised courses and marginalised students

This research challenges the norms of undergraduate recruitment promotion practice responding to political, economic, social and technological drivers in a competitive environment. The practical problem is defined from a marketing practitioner standpoint working with core approaches which do not represent nuanced subject and audience needs, instead leaving them on the margins of the institutional recruitment offer. Marginalised students are represented by those who did not attend private or high-achieving state schools, including, but not restricted to, those identified by widening participation policy. Marginalised subjects are represented by selected arts and humanities courses without overt links to specific professions. These aspects of marginalisation triangulated from an elite institution perspective create a framework for investigating the problems created by core promotional practice, and for developing solutions. The use of a case study supported by design-based research methods allows for practical research outputs in a live environment. Mixed methods are employed to gather data from a small sample of insider sources (nine students and seven tutors) and general public sources (1,923 online reader responses to 31 news articles and forum posts). The insider and public accounts provide an alternative marketing intelligence corpus to normative large-scale quantitative data. This is used to inform design principles incorporated into a prototype package of three promotional resources and a sustainable strategy. The success of the challenge to promotional practice norms materialises not simply through public-facing practical solutions as initially anticipated, but also though the collaborative processes of the enquiry, improving professional relations between marketing administrative and academic staff. The alternative approaches realised through this research can be summarised as a move towards small-scale market intelligence gathering and resource production to meet the nuanced needs of marginalised subjects and audiences, and an alteration to professional practice which acknowledges academics as marketing partners. These outputs are now employed within routine practice within the boundaries of the original study, and have the potential to be generalisable through wider discussions among HE marketing practitioners

Recent literatures of the Holocaust: negotiations with (post) memory and the archive

Abstract The primary aim of this dissertation is to investigate the manner in which certain examples of post-Holocaust second and third generation literature negotiate questions of memory, history and the archive, when writing about the Holocaust from a specific spatial and temporal remove. This is undertaken via close readings of three texts, namely: Maus by Art Spiegelman, Austerlitz by Sebald and Everything is Illuminated by Jonathan Safran Foer. Each text required a slightly different theoretical approach and exhibits a different set of subject positions, however they all share the characteristics of generic blurring, self-conscious narration and intertextuality and use these to dramatise their own provisionality. I make specific use of Marianne Hirsch’s term postmemory alongside various theories of the archive including Derrida’s Archive Fever in order to describe these texts’ relation to a remote past. In particular I analysed Maus in terms of postmemory, while considering Spiegelman’s complex visual palimpsest as an archive. Austerlitz was analysed via conceptions of the uncanny and a Derridian elaboration of the concept of the spectre. With specific reference to the inclusion of photographs in the text I show how the spectre of the Holocaust comes to haunt the text, allowing the author to reference it indirectly. Everything is Illuminated, which I believe is an under-theorised text, was analysed in terms of its epistolary structure and its engagement with silence and absence in order to analyse the expression of postmemory from the additional temporal remove of the third generation. Using Hal Foster’s view of the archival impulse expressed in certain art forms I conclude that these texts exhibit an archival approach to the events of the past. I argue that in highlighting its own provisionality each text avoids expressing an authoritative version of the past, and thus avoids the destruction of the heterogeneity of the archival trace

Promotional approaches to undergraduate recruitment for marginalised courses and marginalised students

This research challenges the norms of undergraduate recruitment promotion practice responding to political, economic, social and technological drivers in a competitive environment. The practical problem is defined from a marketing practitioner standpoint working with core approaches which do not represent nuanced subject and audience needs, instead leaving them on the margins of the institutional recruitment offer. Marginalised students are represented by those who did not attend private or high-achieving state schools, including, but not restricted to, those identified by widening participation policy. Marginalised subjects are represented by selected arts and humanities courses without overt links to specific professions. These aspects of marginalisation triangulated from an elite institution perspective create a framework for investigating the problems created by core promotional practice, and for developing solutions. The use of a case study supported by design-based research methods allows for practical research outputs in a live environment. Mixed methods are employed to gather data from a small sample of insider sources (nine students and seven tutors) and general public sources (1,923 online reader responses to 31 news articles and forum posts). The insider and public accounts provide an alternative marketing intelligence corpus to normative large-scale quantitative data. This is used to inform design principles incorporated into a prototype package of three promotional resources and a sustainable strategy. The success of the challenge to promotional practice norms materialises not simply through public-facing practical solutions as initially anticipated, but also though the collaborative processes of the enquiry, improving professional relations between marketing administrative and academic staff. The alternative approaches realised through this research can be summarised as a move towards small-scale market intelligence gathering and resource production to meet the nuanced needs of marginalised subjects and audiences, and an alteration to professional practice which acknowledges academics as marketing partners. These outputs are now employed within routine practice within the boundaries of the original study, and have the potential to be generalisable through wider discussions among HE marketing practitioners

Factors Affecting the Observed Densities of Ringed Seals, Phoca hispida, in the Alaskan Beaufort Sea, 1996-99

Aerial surveys were conducted during late May and early June 1996-99 in the central Beaufort Sea of Alaska, using strip-transect methods. The purpose of these surveys was to quantify and model the effects of environmental covariates on ringed seal counts and to provide density estimates that would be useful for evaluating trends in seal abundance. Total survey effort included 40-88 transect lines per year covering 1198-2701 km². Observed densities ranged from 0.81 seals/km² in 1996 to 1.17 seals/km² in 1999. We examined the effects of habitat, weather, and time of day on observed seal densities, using univariate chi-square goodness-of-fit tests. We also used a multivariate generalized linear model to estimate the relationship between seal counts and covariates. Three habitat-related variables - water depth, location relative to the fast ice edge, and ice deformation - had substantial and consistent effects. The highest densities occurred at depths between 5 and 35 m. Densities were also highest in relatively flat ice and near the fast ice edge, declining both shoreward and seaward of that edge. Univariate analysis suggested that observed densities were generally highest at about 1200 h Alaska daylight time, but time was not a significant variable in the generalized linear models. Analyses of the effects of weather factors on seal counts were inconclusive. This was likely at least partially because temperature and wind speed were measured at survey altitude, rather than on the ice surface, and surveys were conducted only in weather considered suitable for hauling out. The final multivariate model did not account for a substantial proportion of the variation in seal counts. We think this result was largely due to date-related variation in the proportion of seals hauling out, an issue our surveys were not suited to address.De 1996 à 1999, à la fin de mai et au début de juin, on a effectué des relevés aériens dans la partie centrale de la mer de Beaufort alaskienne, en utilisant des méthodes d'échantillonnage en bande. Ces relevés avaient pour but de quantifier et de modéliser les effets de covariables environnementales sur le comptage des phoques annelés, et de fournir des estimations de densité qui pourraient servir à évaluer les tendances dans l'abondance des phoques. Le travail de relevé a porté chaque année sur un total allant de 40 à 88 lignes-transects, couvrant une superficie de 1198 à 2701 km². Les densités observées allaient de 0,81 phoque par km² en 1996 à 1,17 phoque par km² en 1999. On a étudié les effets de l'habitat, du climat et du moment de la journée sur les densités de phoques observées, à l'aide de tests d'adéquation chi carré à une variable. On a également eu recours à un modèle linéaire généralisé à plusieurs variables pour évaluer le rapport entre les comptages de phoques et les covariables. Trois variables reliées à l'habitat - profondeur de l'eau, position par rapport à la lisière de la banquise côtière et déformation de la glace - avaient des effets importants et constants. Les plus fortes densités se produisaient à des profondeurs de 5 à 35 m. Elles se retrouvaient également sur la glace relativement plane et près de la lisière de la banquise côtière, diminuant à la fois en direction du rivage et en direction de la mer depuis la lisière. L'analyse à une variable suggère que les densités observées étaient généralement plus fortes à environ 12 h (heure avancée de l'Alaska), mais le moment de la journée ne constituait pas une variable d'importance dans les modèles linéaires généralisés. Les analyses de l'impact des facteurs météorologiques sur les comptages de phoques n'ont pas donné de résultats concluants. Ceci était probablement dû au moins en partie au fait que la température et la vitesse du vent étaient mesurées à l'altitude où se faisaient les relevés plutôt qu'à la surface de la glace, et les relevés n'étaient effectués que par temps jugé approprié pour que les phoques montent sur la glace. Le modèle final à plusieurs variables ne représentait pas une proportion substantielle de la variation dans les comptages de phoques. Ce résultat, selon nous, était dû en grande partie à une fluctuation reliée à la date dans la proportion de phoques qui montaient sur la glace, question que nos relevés n'étaient pas conçus pour aborder

Characterization of FANCL variants observed in patient cancer cells

Fanconi Anemia (FA) is a rare genetic disorder characterized by developmental defects, bone marrow failure and high predisposition to cancer. The FA DNA repair pathway is required in humans to coordinate repair of DNA interstrand crosslinks. The central event in the activation of the pathway is the monoubiquitination of FANCD2 and FANCI by the E2-E3 pair, Ube2T-FANCL, with the central UBC-RWD (URD) domain of FANCL recognising the substrates. Whole genome sequencing studies of cancer cells from patients identified point mutations in the FANCL URD domain. We analysed 17 such variants of FANCL, including known substrate binding mutants (W212A, W214A and L248A, F252A, L254A, I265A), a FA mutation (R221C) and 14 cancer-associated mutations (F110S, I136V, L149V, L154S, A192G, E215Q, E217K, R221W, T224K, M247V, F252L, N270K, V287G, E289Q) through recombinant expression analysis, thermal shift assay, interaction with FANCD2, in vitro ubiquitination activity, and cellular sensitivity to an interstrand crosslinking agent. We find that the FANCL mutations I136V, L154S, W212A and L214A, R221W, R221C, and V287G are destabilising, with N270K and E289Q destabilising the C-terminal helices of the URD domain. The hydrophobic patch mutant (L248A, F252A, L254A, I265A), along with mutations E217K, T224K, and M247V, cause defects in the catalytic function of FANCL. This highlights the C-terminal lobe of the FANCL URD domain as important for the activity and function of FANCL. These mutations which affect the fold and activity of FANCL may contribute to tumorigenesis in these non-FA cancer patients, and this implicates FA genes in general cancer progression

"Horses for Courses" Comment on "Translating Evidence Into Healthcare Policy and Practice: Single Versus Multi-Faceted Implementation Strategies – Is There a Simple Answer to a Complex Question?"

This commentary considers the vexed question of whether or not we should be spending time and resources on using multifaceted interventions to undertake implementation of evidence in healthcare. A review of systematic reviews has suggested that simple interventions may be just as effective as those taking a multifaceted approach. Taking cognisance of the Promoting Action on Research Implementation in Health Services (PARIHS) framework this commentary takes account of the evidence, context and facilitation factors in undertaking implementation. It concludes that a ‘horses for courses’ approach is necessary meaning that the specific implementation approach should be selected to fit the implementation task in hand whether it be a single or multifaceted approach and reviewed on an individual basis