Doctoral Degrees (Physiotherapy)

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Biomechanical analysis of specific motor impairments contributing to early functional decline in adults living with HIV-1 infection : a sub-study to the Cape Winelands HAART to HEART (Prevalence)/EndoAfrica study
(Stellenbosch : Stellenbosch University, 2019-04) Berner, Karina; Louw, Q. A.; Morris, L. D.; Baumeister, J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health & Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY : Background: HIV-1 infection has become a chronic condition. Although people living with HIV-1 infection (PLHIV) now have near-normal life expectancies, walking-related impairments remain concerning as they occur early and may lead to falls. A poor understanding remains of how movement patterns are affected due to a lack of biomechanical studies. Three-dimensional (3D) motion analysis can provide insight into movement patterns and assist in identifying a valid performance-based screening test for detecting early motor impairments in PLHIV. Aim: The aim of this research was to investigate gait and balance impairments existing in PLHIV using 3D motion analysis. It further aimed to correlate 3D analysis findings (via a gait summary score), as well as self-reported function and history and fear of falling, to physical performance tests which may be considered in clinical practice to screen for early functional decline in PLHIV. Methods: The research was divided into three parts: Part I presented a systematic review describing objective gait and balance impairments in PLHIV. Results contributed to the theoretical groundwork for study conceptualisation and aided in selecting clinically relevant biomechanical outcomes and performance-based tests. Part II comprised validity and reliability testing of a portable 3D gait analysis (3DGA) system, newly obtained by the motion laboratory, in 16 healthy student volunteers, as well as in eight consecutively recruited PLHIV and eight community-matched seronegative participants (SNP). The studies determined the psychometric properties of specific 3DGA outcomes to aid appropriate data interpretation in the next phase. Part III comprised the main observational study to cross-sectionally describe key biomechanical characteristics in 50 PLHIV relative to 50 community-matched SNP (consecutively sampled). The study was conducted in a clinical setting, and performancebased tests were assessed in addition to the 3D motion analysis. Gait analysis results, fallrelated outcomes and self-reported function were correlated to clinical test performance to identify the most valid performance-based screening test. Main results: The systematic review (Part I) revealed some agreement that PLHIV walk slower and have increased centre of pressure (COP) excursions and postural reflex latencies, particularly under challenging conditions. No included studies used 3DGA. The validity and reliability studies (Part II) demonstrated that, with regular recalibration, the 3DGA system reliably measures gait biomechanics in SNP and PLHIV, except for four discrete angles. The system/model highly compares to the reference model after accounting for modelling differences. The field study (Part III) revealed that the gait of PLHIV (median age: 36.61 years) was significantly slowed and rigid relative to SNP (median age: 31.10 years). This pattern manifested when walking at a usual pace or when performing a dual task. Dual task walking further revealed joint range of motion (ROM) changes at the hip and knee in a distal-to-proximal pattern-shift. PLHIV also demonstrated increased COP excursion in dual task single-leg stance. PLHIV were significantly slower in completing the Five-Times Sit-To-Stand (5STS) Test. Slowed sit-tostand was significantly related to gait rigidity, worse self-reported function, and fear of falling. Conclusion: Relatively young PLHIV present with biomechanical gait and balance impairments that resemble patterns noted in elders, especially under dual task conditions. The 5STS test is recommended as a valid clinical screening test. These findings improve understanding of movement impairments in PLHIV and highlight the need for early screening. Further research is needed to determine whether the 5STS test predicts falls, and whether the impairments noted in PLHIV are reversible. Early identification and rehabilitation can reduce healthcare utilisation needs in PLHIV.
Cardiovascular disease risk factors among school attending adolescents in rural Nigeria
(Stellenbosch : Stellenbosch University, 2016-03) Oduniaya, Nse Ayooluwa; Louw, Quinette; Grimmer, Karen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Background: The prevalence of Cardiovascular Disease (CVD) is increasing in Nigeria, particularly hypertensive heart disease among the working class population. Unfortunately, resources for effective management of CVD at acute stage are sparse and expensive for the average Nigerian making preventive measure the best option for Nigeria. CVD risk factors have been identified in adolescents in many countries but information on CVD risk factors among Nigerian adolescents, especially rural adolescents, are sparse. This study aimed to develop culturally appropriate lifestyle CVD risk factors questionnaire for adolescents in Nigeria and to investigate CVD risk factors and its associates among 15-18 years school attending adolescents in rural Nigeria. Methods: The study was conducted in rural south west Nigeria, one of the six geopolitical zones of Nigeria. The people living in this area are Yoruba speaking population of Nigeria. The study was conducted in four phases. Phase 1: development of a composite lifestyle CVD risk factors questionnaire through systematic review, expert panel and target population. Phase 2: Cross cultural validation of composite measure developed to facilitate its use among rural adolescents. Phase 3: Pilot study to assess the logistics of the study and to test the reliability of the newly developed questionnaire. Phase 4: investigation into CVD risk factors among adolescents. CVD risk factors such as smoking, alcohol, Physical inactivity, and poor diet using the newly developed questionnaire were assessed. Blood pressure, BMI and waist hip ratio were also assessed using standardized protocol. Data was analyzed qualitatively and quantitatively. Content validation of the questionnaire was done qualitatively using expert consensus and adolescents’ feedback. Reliability was tested using ICC (Intraclass Correlation), Kappa and paired t test. CVD risk factors data was analyzed descriptively first, then with Pearson correlation and multiple regressions to determine associations among risk factors at 95% confidence interval (0.05 level of significance). Result: European countries showed high prevalence of smoking among adolescents in the systematic review. The prevalence of dyslipidemia ranged from 2.5% of total cholesterol (TC) in rural Iran adolescents to 48.9% high Triglyceride (TG) in rural Mexican adolescents. Overweight and obesity prevalence ranged from 0.6% prevalence in an age (10 y) of a study to 48.7%. Studies from the United States showed a decreasing trend in pre hypertension and hypertension, overweight and obesity. The newly developed composite lifestyle CVD risk factors questionnaire for adolescents had moderate to good reliability. Intraclass correlation (ICC) ranged from 0.3 - 0.7 and 0.3-0.8 in English and Yoruba versions’ subscales respectively. Kappa statistics showed moderate to strong agreement in priority questions in English and Yoruba versions. Investigation into the CVD risk factors showed high prevalence and clustering of CVD risk factors; 7.1% adolescents were smokers, 10.2% drank excessive alcohol, 27.9% had low physical activity level, 59.8% consumed high cholesterol diet, 6.1%, consumed low vegetable 8.1% consume low fruit 65.5% had high salt intake, 33.1% had pre hypertension ( systolic), 5.5% had pre hypertension (diastolic) 3.2% had hypertension (systolic) 0.8% had hypertension (diastolic). Smoking and drinking were significantly higher in males and physical activity was significantly higher in females. Smoking and drinking were significantly associated in both males and females and the odd of drinking and smoking was more elevated in girls. Systolic pre- hypertension was associated with age and high BMI in boys and was associated with only high BMI in girls. Conclusion: Nigerian rural adolescents are at risk of future adult CVD. There is an urgent need to put measures in place to prevent future epidemic of CVD in adulthood. CVD prevention program for boys and girls should be tailored to address gender specific CVD risk factors.
The development of a contextualised evidence-based clinical practice guideline for the primary health care of chronic musculoskeletal pain in the Western Cape
(Stellenbosch : Stellenbosch University, 2017-03) Ernstzen, Dawn Verna; Louw, Q. A.; Hillier, S. L.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health & Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY : Background: Chronic musculoskeletal pain (CMSP) is a global healthcare concern, and is a major cause of disability and morbidity in sub-Saharan Africa. The implementation of high-quality, evidence-based clinical practice guidelines can enable quality healthcare for CMSP. Clinical guidelines for CMSP developed in developed nations may not be appropriate in developing countries with resource-constrained environments, due to differences in socio-cultural, societal and policy contexts. The contextualisation of clinical guidelines may be an option to provide guidance in resource-constrained environments. Aim: The overall aim of the research project was to develop a contextualised evidence-based, multimodal clinical practice guideline for the primary health care of chronic musculoskeletal pain in adults in the Western Cape Province of South Africa (SA). Method: The research was conducted in three parts: Part 1 comprised two qualitative descriptive studies to explore contextual factors that play a role in the health care of CMSP in three community centres. Three community health centres were strategically selected to represent a rural, a semi-urban and an urban-township setting. Study one used semi-structured interviews with patients to discover patients’ perspectives of CMSP and its healthcare management. In study two, semi-structured interviews were conducted with a diverse group of healthcare practitioners’ to explore their perspectives on the contextual barriers and facilitators regarding the healthcare of CMSP. Interviews were recorded, transcribed and analysed using inductive content analysis. Part 2 entailed study three, a systematic review conducted to identify current, high-quality clinical guidelines on the primary health care of CMSP. Guidelines that met the inclusion criteria were assessed using the Appraisal of Guidelines Research and Evaluation, Version II. Evidence-based recommendations were extracted from high-quality guidelines and synthesised for the contextualisation process. Part 3 of the project entailed the validation and contextualisation of the clinical recommendations. In study four, a multi-disciplinary panel of experts validated the clinical recommendations for the South African context using a modified Delphi approach. The panel developed context points relevant to the recommendations during a consensus meeting. In study five, potential end-users reviewed the applicability and acceptability of the contextualised clinical practice guidelines through a survey. Results: Twenty patients with CMSP and 21 practitioners participated in Part one. The findings indicated that CMSP influenced patients in multiple ways. Participants largely agreed on the context factors that influence CMSP care, namely the personal characteristics of the patient and practitioner, the social and environmental circumstances within which the patient lives, the healthcare interventions received and healthcare system factors. These contextual factors formed the foundation of the relevant facilitators and barriers to CMSP care in the context investigated. Twelve clinical guidelines on the primary healthcare management of CMSP were identified through the systematic review. Six of these clinical guidelines were of high quality, and 156 recommendations were extracted from them. The recommendations were synthesised using a structured process. The end-result was a core set of 43 multimodal evidence-based, clinical recommendations. Seventeen multi-disciplinary panel members validated the recommendations for the South African context, nominated an extra recommendation and positioned the recommendations within the context of application for primary healthcare. The contextualized guideline was reviewed by a diverse group of 18 end-users who confirmed the clinical guideline to be largely applicable and acceptable for the intended context. Conclusion: The end-product of the project was a contextualised, evidence-based and multimodal clinical guideline for the primary healthcare of CMSP in the Western Cape province of South Africa. The findings indicate that modifications in practice patterns, healthcare system organization and governance will contribute to the successful implementation of the guideline. A inter-/multi-disciplinary approach, with the outcome of the patient as self-manager within a supportive environment, is underscored. Further research avenues include the development of a multilevel implementation plan and a pragmatic trial to investigate the feasibility of the contextualised clinical guideline in the South African context.
The effect of a back pain campaign on back beliefs, coping strategies and participant activation for nurses in Lusaka, Zambia
(Stellenbosch : Stellenbosch University, 2021-03) Nkhata, Loveness A.; Louw, Quinette .A.; Ernstzen, Dawn V.; Brink, Yolandi; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health & Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY : Introduction: The prevalence of back pain in nurses globally is high and ranges from 55-84%. In Africa, the prevalence of back pain reported in different studies among nurses ranges from 33%-73.5%. While, in Zambia the reported prevalence for back pain among nurses is 58.3%. Nurses are exposed to labour intensive, repetitive tasks which are often performed in stressful postures. Furthermore, the high occurrence of back pain in nurses is of major concern because it decreases working efficiency and affects the safety of the patients and healthcare outcomes. Aim: The overall aim of this study was to design and assess the effects of a cross-culturally validated back pain campaign on back beliefs, coping strategies and participant activation for nurses in Lusaka, Zambia. Research setting: The research was done in Lusaka at Chawama, Chingwere, Chilenje, Chelstone and Kayama first level hospitals. The hospitals provide various health services and public health programmes at community level. The hospitals were purposefully selected as study sites because of the substantial number of nurses working at the centres and their similarity in operation level and system compared to the other centers. Methodology: Three studies, with different methodologies based on the principle of evidence-based practice (EBP), were carried out as follows: Study 1: A systematic review of self-management education campaigns on back pain, with the aim to retrieve and synthesise the content, mode, and duration of published evidence based on lower back pain (LBP) campaigns, and to describe the outcomes and the effectiveness of the campaigns. Study 2: Cross-cultural validation and formulation of key evidence-based back pain messages for nurses in Zambia. The aim was to ascertain which local contextual factors could influence the understanding, feasibility and uptake of evidence-based messages reported in published campaigns. In addition, it was aimed to design the campaign based on the information obtained in Study 1 and ascertain content validation with experts. Study 3: A pre-post quasi-experimental study to evaluate the effectiveness of a cross-cultural validated back pain campaign for nurses in Lusaka, Zambia, regarding on-participant activation and back beliefs as key outcomes. Results: Articles reviewed (Study 1) had back campaigns conducted in the general population. It was reported that participant activation, awareness, and satisfaction about back pain improved in the general population as an overall effect of the campaigns. Messages delivered during the campaigns were cited as having been helpful in decreasing effects of pain disability and in improving work outcomes by influencing population attitudes and beliefs. Fourteen back pain messages were retrieved, synthesised (Study 1) and cross-culturally validated for implementation among nurses in Zambia (Study 2). All the back pain messages except for one (“back pain is rarely caused by a dangerous illness”) were adapted for use among nurses in Lusaka, Zambia. Effects of the back pain campaign on back beliefs and participant activation for self-management of back pain among nurses in Lusaka, Zambia, showed no significant differences, even though positive trends were observed in many outcomes such as the participant activation measures, where positive trends were recorded in all the 11 items when more people agreed with the statements after the campaign (Study 3). Positive trends were also observed in participants’ coping strategies, use of pain medication, frequency of doctor visits and number of sick-leave days. Conclusion: The back campaign had an influence on the attitudes towards back care goals albeit, not significant, and promoting healthy behaviours. In addition, the campaign demonstrated an effective approach that could decongest the healthcare system and minimise healthcare costs because of the reductions in the number of sick-leave days, frequency of doctor visits and use of pain medication during back pain experiences. Recommendation: The back pain campaign was an effective strategy to advance self-management of back pain in the nursing profession. Their work-setting is also a good arena for implementing practical strategies aimed at promoting health and minimising the effects of back pain experiences.
The implementation and evaluation of a best practice physiotherapy protocol in a surgical ICU
(Stellenbosch : University of Stellenbosch, 2010) Hanekom, Susan; Louw, Q. A.; Coetzee, Andre; University of Stellenbosch. Faculty of Health Sciences. Dept. of Interdisciplinary Sciences
ENGLISH ABSTRACT: Introduction: It is increasingly being recognized that how intensive care services are delivered may have a greater impact on patient outcome than the individual therapies. Uncertainty regarding the optimal physiotherapy service provision model in a surgical intensive care unit (ICU) exists. Methodology: The aims of this study were to 1) develop an evidence-based physiotherapy protocol; 2) validate the content of the protocol; and 3) conduct an explorative intervention trial to compare usual care to the estimated effects of providing a physiotherapy service guided by an evidence-based physiotherapy protocol by a dedicated physiotherapist. A systematic review process was used to synthesize the evidence in eight subject areas. The GRADE system was used to formulate best practice recommendations and algorithm statements. Forty-two experts from a variety of disciplines were invited to participate in a Delphi process. Finally, the evidence-based physiotherapy protocol was implemented in a surgical ICU over four three-week intervention periods by a group of research therapists. The outcomes measured included ventilator time, ventilation proportions, failed extubation proportions, length of ICU and hospital stay, mortality, functional capacity, functional ability and cost (using nursing workload as proxy). Results: Fifty-three research reports in eight subject areas were identified, 23 draft best-practice recommendations and 198 algorithm statements were formulated. The draft protocol consisted of five clinical management algorithms. Fifteen international research experts and twelve national academics in the field of critical care agreed to participate in the Delphi process. Consensus was reached on the formulation of 87% (20/23) recommendations and the rating of 66% (130/198) statements. The risk of an adverse event during the protocol care intervention period was 6:1000 treatment sessions (p=0.34). Patients admitted to the unit during the protocol care intervention period were less likely to be intubated (RR 0.16 95%CI 0.07 – 0.71; RRR 0.84 NNT 5.02; p=0.005) or fail extubation (RR 0.23 95%CI 0.05 – 0.98; RRR =0.77 NNT 6.95; p=0.04). The mean difference in the daily unit TISS-28 score between the two condition periods was 1.99 95%CI 0.65 – 3.35 (p=0.04). Patients managed by the protocol tended to remain in the hospital for a shorter time after unit discharge (p=0.05). There was no difference in the time spent on the ventilator (p=0.50), mortality (p=0.52) or in the six minute walk distance (p=0.65). In addition there was no difference in the proportion of patients who reached independence in any of the Barthel Index activities measured within 48 hours of discharge from the unit. Conclusions: The use of an evidence-based physiotherapy protocol for the comprehensive physiotherapeutic management of patients in a surgical ICU was feasible and safe. The preliminary results of this study suggest that a physiotherapy service, which is guided by an evidence-based protocol and offered by a dedicated unit therapist, has the potential to lower the cost of ICU care and facilitate the functional recovery of patients after unit discharge. This information can now be considered by administrators to optimize the physiotherapy service provided in ICU.
Implementation and evaluation of a validated evidence-based physiotherapy protocol in a surgical icu : a controlled before and after study
(Stellenbosch : Stellenbosch University, 2018-12) Karachi, Farhana; Hanekom, S. D.; Gosselink, R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health & Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY : Overall Aim: to implement and evaluate a tailored best-practice multifaceted implementation strategy (intervention) for the effective uptake of a validated evidence-based physiotherapy protocol for the management of patients in a surgical intensive care unit (ICU) in the Western Cape, South Africa (SA). Method: A phased, multipronged design. Phase 1 (survey): described i) the profile of the public sector physiotherapists and their department organisation and structure and ii) the profile and current practices of the public ICU physiotherapists and ICU organisation and structure in which they work. Phase 2 (systematic review): identified best-practice implementation strategies for the effective uptake of evidence-based clinical practice guidelines (CPGs) and protocols. Phase 3a) Nominal Group Technique (NGT): tailored the implementation strategies to the targeted physiotherapists; and b) controlled before and after (CBA) trial: implemented and evaluated the intervention for the uptake of the ICU physiotherapy protocol in a surgical ICU. Results: The physiotherapy survey received a 70% (n=46/66) response. 429 young, early-career physiotherapists with mainly Bachelor degrees, in production (‘junior’) level posts, in departments organised and structured on a departmental model with a hierarchal ranking of posts and physiotherapy to hospital bed ratio of 1:69 was identified. The ICU physiotherapy survey received a 34% (n=58/170) response. ICU physiotherapists had no ICU post-graduate training, 1-5years of ICU work experience, ICU services and practices that varied. Education, audit and feedback, reminders, support, multidisciplinary implementation team and plan, communication and case discussion including telemedicine strategies were identified. Multifaceted implementation strategies are four times more effective (OR: 4.07, 95%CI: 2.93-5.65; p<0.00001, I=89%) than single strategies in improving process of care measures in the ICU. The tailored intervention included an educational handbook, workshop series, grand rounds/bedside teaching sessions and reminders (pocket cards and posters). 1509 patients were included in the 16month CBA trial analysis. Experimental Unit A had a higher TISS-28unit day score [2.3units, p=0.004] in the implementation phase compared to the baseline (pre-implementation phase) in Unit A and all phases in control Unit B. Time to first physiotherapy contact after ICU admission in the implementation phase was longer [adj. OR 1.2, 95%CI:1-1.4, p=0.02] in Unit A than the pre-implementation phase and pre-and implementation phase in Unit B. There was no change in time to first physiotherapy [adj. OR 0.9, 95%CI:0.7-1.1, p=0.19] and first nurse [adj. OR 1, 95%CI: 0.7-1.6, p=0.84] mobilisation into a chair after ICU admission and time to physiotherapy post-extubation [adj. OR 1, 95%CI: 0.9-1.2, p=0.83] in the implementation phase regardless of unit and phase. Patients in unit A were more likely to receive the physiotherapy process of care than patients in unit B at baseline. There was no difference in hospital mortality [adj. OR 1.1, 95%CI: 0.6 - 2, p = 0.78], ICU mortality [adj. OR 1.22, 95%CI: 0.59 - 2.52, p=0.59], intubation [adj. OR 1.1, 95%CI: 0.8 - 1.5, p=0.68] nor proportion of failed extubations [adj. OR 1.2, 95%CI: 0.8 – 2, p=0.39] in the implementation phase between Unit A and B. Conclusion: A tailored best-practice multifaceted implementation strategy and implementation fidelity alone did not facilitate effective uptake of and adherence to the protocol. ICU physiotherapy profile, organisation and structure and practice variation, high baseline process of care adoption rates, healthcare professional behaviour, attitude, knowledge and self-efficacy influenced protocol adherence. The use of a framework to guide ICU implementation initiatives and contextualize the implementation process in a resource limited setting is supported.
Preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy
(Stellenbosch : Stellenbosch Universit, 2013-12) Louw, Adriaan; Diener, Ina; Butler, David; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Background: On average one in three patients following lumbar surgery (LS) for radiculopathy experience persistent pain and disability following surgery. No perioperative treatments have shown any ability to decrease this persistent pain and disability. In another challenging low back pain (LBP) population, chronic LBP, pain education focusing on the neurobiology and neurophysiology of pain, has shown an ability to reduce reported pain and disability. The purpose of this research study was to develop and test a preoperative neuroscience education program for LS and determine its effect on pain and disability following LS. Research Design and Methods: After a series of studies, a newly designed preoperative neuroscience educational tool (PNET) was developed. Eligible patients scheduled for LS for radiculopathy participated in a multi-center study where they were randomized to either receive usual care (preoperative education), or a combination of usual care plus one session covering the content of the PNET, as delivered by a physiotherapist in a one-on-one verbal session. Prior to LS, and one, three and six months after LS, 67 patients completed a series of self-report outcome measures consisting of LBP and leg pain rating (Numeric Rating Scale), function (Oswestry Disability Index), fear avoidance (Fear Avoidance Beliefs Questionnaire), pain catastrophization (Pain Catastrophization Scale), pain knowledge (Pain Neurophysiology Questionnaire), various beliefs and experiences related to LS (Likert Scale), and post-operative utilization of healthcare (Utilization of Healthcare Questionnaire). Results: At six month follow up there were no statistical difference (p <0.05) between the experimental and control groups in regards to the primary outcome measures of function (p = 0.296), LBP (p = 0.077) and leg pain (p = 0.074). The experimental group scored significantly better on various questions regarding beliefs and experiences having undergone LS, compared to the control group indicating a more positive surgical experience. Analysis of healthcare utilization showed that patients who received the preoperative neuroscience educational program had dramatically less health care utilization (medical tests and treatments) in the six months following LS (p = 0.001), resulting in a 38% savings in healthcare cost. Conclusion: The addition of a preoperative neuroscience educational program to usual care for LS for radiculopathy resulted in a profound behavioral change leading to a more positive surgical experience, decreased healthcare utilization and resultant savings, despite persistent pain and disability.
Return to play in elite rugby players after severe knee injuries : addressing the knowledge gaps
(Stellenbosch : Stellenbosch University, 2022-04) Robyn, Aneurin Dean; Louw, Quinette; Baumeister, Jochen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health and Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY: Introduction: Rugby union has been a professional sport for many years. Along with the growing professionalism of the sport, there has been increasing scientific interest in the physical profiles of rugby players as such profiling may inform player selection, conditioning, monitoring, and injury prevention strategies. Medical professionals working in an elite sports environment have the challenging task of determining if an athlete is ready to return to the playing field after severe injury. Merely passing a battery of physical tests is arguably insufficient for an injured athlete to successfully recover to preinjury status. Aim: This dissertation aims to describe elite rugby union players' physical and psychological profiles at the return to play after sustaining severe knee injuries compared to their preinjury level. This dissertation contributes new knowledge and adds practical pieces to the growing return to play puzzle. Research setting: This study was performed in Cape Town, South Africa, with the identified participants of five elite rugby teams based in the Cape Winelands and Metropole areas. Testing was conducted in an indoor biomechanical laboratory and an indoor sports facility with an artificial grass surface. This kept the testing environment consistent by eliminating any weather condition interference. Methodology: Study 1: This descriptive cross-sectional study aimed to compare the anthropometry and physical profiles of elite junior rugby union players according to specific playing positions. Study 2: A prospective cohort study was performed to compare the injured participants' physical testing at return to play with baseline after sustaining a severe knee injury. Study 3: A prospective cohort study was done with injured participants completing two psychological questionnaires to assess their psychological readiness at return to play and evaluate if there was any improvement between return to training and return to play. Study 4: A prospective cohort study with a new analytical method of statistical parametric mapping analysis to assess the countermovement jump curve. Results: Study 1: This study provides up-to-date confirmation of the variation in specific playing position profiles and skills according to specific game demands at the junior elite level. Players’ profiles are matched to the specific demands of the game. Study 2: This study highlights that injured players’ running speed and decision-making time are slower after injury. The uninjured players' exposure to training and match stimulus improved their running speed and lower body explosive power during the season. Study 3: This study reported good psychological readiness and successful recovery to the preinjury status of elite rugby players after a severe knee injury. The improved scores from return to training to return to play give insight to treating professionals that athletes need longer recovery time as training exposure will decrease fear of reinjury and increase confidence in their knee function before returning to the competitive playing field. Study 4: This study's two key findings are that there was (i) no asymmetry detected and (ii) the improved peak force of affected limb at return to play after a severe knee injury which is contrary to current evidence. Conclusion: An athlete who returns to play is a complex problem and needs a complex solution. My dissertation has contributed to the elite sports population by providing return to play details on elite rugby union players’ physical and psychological profiles after a severe knee injury. This new information will give treating professionals the necessary insight and additional pieces to this complex return to play puzzle. Recommendation: An interdisciplinary approach with specific needs by developing a more holistic return to play recipe for better return to play decisions and lower reinjury rates. We monitor elite athletes for a more extended period (at least six months) after a successful return to the playing field; provide the sports medicine community information on any reinjuries, other musculoskeletal injuries, and return to (match) performance parameters. Artificial intelligence is one promising approach to inform decision-making processes by adding various player data in an algorithm to provide a return to play recommendation.
Sedentariness and back health in Western Cape school learners : a feasibility study
(Stellenbosch : Stellenbosch University, 2023-03) Fisher, Dominic; Louw, Quinette A.; Cockcroft, John; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health and Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY: Introduction: Spinal musculoskeletal conditions and non-communicable cardiometabolic diseases are increasing global health concerns adding to the growing need for rehabilitation services. Sedentary behaviour has been associated with deleterious spinal and cardiometabolic health. School-based interventions aimed at stunting the progression of these conditions from childhood to adulthood by reducing sedentary behaviour have shown promise. Interventions that have shown efficacy in improving spinal health and cardiometabolic outcomes in developed, well-resourced settings cannot be effectively adopted in contexts challenged by socio-cultural, economic, and political factors. Preventative health strategies are favoured in contexts where health burdens are strained by prevalent infectious diseases. Aim: The aim of this project was to develop a contextualised, evidence-based intervention aimed at reducing sedentary behaviour and improve spinal health outcomes in South African school children and assess the feasibility of the intervention. Methodology: A systematic review of classroom-based interventions aimed at reducing sedentary behaviour and improving spinal health was conducted. The efficacy of interventions using objectively measured sedentary behaviour and spinal health outcomes included in the review were tabulated and a meta-analysis of homogenous review outcomes was conducted. Effective intervention strategies were extracted to inform the development of a proposed intervention. A qualitative study of educator’s perspectives of the factors that influence learners’ movement during class time was then conducted. Individual depth interviews with primary school principals and focus group discussions with primary school teachers in the Western Cape were recorded and transcribed. An inductive analysis was used to provide contextual insight of the environment into which the interventions would be implemented. A pragmatic stepped wedge cluster randomized controlled feasibility trial of an intervention aimed at reducing classroom sedentary behaviour and improving spinal health was conducted. The 13-week long intervention comprised a novel, multifunctional sit-stand desk and a playlist of health education and movement videos. Participants’ classroom furniture was replaced with the intervention furniture and teachers were provided with a playlist of health education and movement videos to be played routinely during school hours. Primary, feasibility outcomes were assessed through individual interviews with teachers and focus group discussions with a subsample of learners and researcher monitoring. Secondary, objective study outcomes related to sedentary behaviour and postural dynamism were measured using activPAL sensors and inertial measurement units respectively. Results: Nine sedentary behaviour and three spinal health intervention studies from high income countries were included in the review. A subset of the eight sedentary behaviour intervention studies that reported reduced classroom sitting time reported a significant pooled medium-term effect (P=.03). All the studies that reported a reduction in sitting time incorporated alternative classroom furniture that allowed learners to alternate between sitting and standing. A meta-analysis of the spinal health studies demonstrated significant improvements in spinal behaviour during a functional task. All the spinal health studies incorporated a health education component. Thirteen principal individual depth interviews and 6 teacher focus group discussions were conducted. Educators perceived that learner spent most of their class time sitting. We found that teacher-related factors pertaining to their ability to control the classroom and whether they had attended in-service learning on learners’ movement during class influenced learners’ movement. In addition, structural factors related to classroom size, the number of learners in the class and classroom furniture design also played a role. Educators’ attitude to learners’ movement in class was driven by school culture. Two classrooms were recruited into the feasibility study. Three of the five success indicators of the feasibility set a priori were met by both clusters. These included the delivery of the health education and movement videos, compliance with wearing activPAL sensors and IMUs and the integrity of the sedentary behaviour and postural dynamism data. The withdrawal of one cluster (classroom) from the study after completing the intervention period, but before follow-up measurements were taken meant that the feasibility criterion related to cluster (classroom) retention was not met. A positive trend of reduced sedentary behaviour was found after in the retained cluster. A one-year follow up measurement of sedentary behaviour showed a statistically significant reduction in sitting time (P=.001), increase in standing time (P=.002) compared to baseline measurements. There was also a statistically significant increase in postural dynamism at 13-week follow up as measured by total pause time. Conclusion: The study succeeded in developing a contextualised, evidence-based intervention that showed preliminary effectiveness in reducing classroom sedentary behaviour and improving spinal health. Based on the findings of this study, a pilot trial, incorporating recommendations strategies to improve cluster retention should be conducted in future.
Sitting posture : a predictive factor for upper quadrant musculoskeletal pain in computing high school students
(Stellenbosch : Stellenbosch University, 2012-12) Brink, Yolandi; Louw, Q. A.; Schreve, K.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Physiotherapy.
ENGLISH ABSTRACT: Introduction: The increased prevalence of adolescent upper quadrant musculoskeletal pain (UQMP) is becoming a great concern to health professionals. The risk factors associated with adolescent UQMP are complex and multifactorial, including, among others sitting as a physical risk factor. However, no evidence exists to support sitting postural angles as a potential predictive factor for adolescent UQMP in computing high school students. Thus, the current project aimed to describe the three-dimensional (3D) sitting postural angles of computing South African high school students in a real-life setting, using a well-tested and documented posture measurement instrument. Methodology: This research project is comprised of seven related studies. Part I of the dissertation presents a systematic review describing the reliability and validity testing of posture measurement instruments. This is followed by three primary correlation and repeated measures observational studies aimed at ascertaining the reliability and validity of a newly developed 3D Posture Analysis Tool (3D-PAT) in the measurement of nine sitting postural angles of computing high school students. Part II of the dissertation presents a systematic review, that evaluates the latest published research evidence of whether sitting is related to UQMP, and, if so, to identify the elements of sitting that significantly contribute to UQMP. This review is followed by a description of a cohort study, with a prospective period of one year. The 3D-PAT was implemented in a clinical research setting in order to measure the 3D sitting posture of a cohort of asymptomatic computing high school students and in order to assess the outcome, seated-related UQMP, prospectively. The prospective study design enabled the research project to contribute to an understanding of any causative relationship between the exposure (sitting postural angles) and the outcome (seated-related UQMP) in a subgroup of adolescents (computer users). Results: After the first phase of psychometric testing of the 3D-PAT using high school students, the findings indicated that the instrument required modifications prior to further psychometric testing. The second phase of testing revealed that the 3D-PAT compared very well with the reference standard for measurement of the X-, Y- and Z-coordinates of the reflective markers on a mannequin. The findings from the phase three study, again using high school students, indicated that the 3D-PAT compared very well with the reference standard and justified its use for the measurement of six sitting postural angles of the upper quadrant in computing high school students. For the cohort study, a 60% response rate for participation was achieved at baseline, with 98% of the students participating at six-month and 80% at one-year follow up. Of the students, 33.5% complained of seated-related UQMP during the follow-up period. Exposure to increased head flexion (>80°) (ρ=0.0001) and the combination of increased head flexion and decreased cranio-cervical angles (ρ=0.007) were significant predictors of seated-related UQMP for those computing high school students complaining of pain greater than the 90th percentile for such. Conclusion: The project described in the current dissertation is the first research project to assess sitting postural angles in asymptomatic high school students, while they worked on desktop computers in a school computer classroom and to assess UQMP prospectively. The research project reports a causal relationship between increased head flexion and seated-related UQMP as increased head flexion was found to be a predictor of seated-related UQMP developing within six to 12 months for computing high school students with a pain score equal or greater than the 90th percentile for pain. The research project emphasises that further research is warranted to investigate the causal pathway between sitting posture and adolescents’ UQMP.
A tailored training programme for South African physiotherapists on the use of evidence-based clinical practice guidelines when treating patients with acute and sub-acute low back pain
(Stellenbosch : Stellenbosch University, 2020-12) Stander, Jessica; Brink, Yolandi; Grimmer, Karen Anne; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health and Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY: Introduction: Over the last 30 years there has been increasing international recognition of the importance of, and challenges involved in, applying best-available evidence to ensure consistent delivery of best-practice care to patients. This is called knowledge translation (KT). One KT vehicle is good quality clinical practice guidelines (CPGs), which summarise best-available evidence into concise recommendations for practice. This study was undertaken to fill a gap in knowledge about how best to educate South African physiotherapists (PTs) working in primary healthcare settings, about how to apply CPGs to inform diagnostic and management decisions. South African primary healthcare settings are generally resource-constrained, which can limit access to, and availability of, effective, and cost- and time-efficient care. This study focused on low back pain (LBP), the fourth-most common burden of disease in South Africa, and the most common primary healthcare condition treated by PTs. Methods: A multi-stage, mixed methods study was designed to develop and test a tailored training programme (TTP) that addressed factors influencing CPG uptake by South African primary healthcare PTs. The Implementation of Change model informed the study framework. Three set-up phases underpinned the draft TTP’s content and delivery method (two literature scoping reviews, and individual interviews exploring PTs’ perceptions of, and experiences with, CPG use). An expert validation study confirmed TTP content and delivery methods. The feasibility, acceptability and likely impact of the TTP was then piloted. Participants’ self-perception of CPG use and understanding of CPGs was captured pre-post TTP using surveys. Recorded discussions during the TTP, and after its completion were analysed descriptively for evidence of personal barriers and growth. Outcomes included knowledge, attitudes and behaviours. Results: The TTP content and delivery method was based on PTs’ learning needs and styles, and typical primary healthcare cases. The TTP consisted of a one-day interactive face-to-face KT session based on case studies, preceded by six podcasts (one-hour total), based on participants’ knowledge needs, attitudes and time constraints. The TTP was evaluated by 11 rural primary healthcare PTs. Pre-TTP evaluations demonstrated scepticism towards CPG-use in clinical practice, with most participants seemingly unaware of the nature, intent and construction of CPGs, or how to access or implement them. However, most participants identified areas of clinical practice where they required guidance, and all indicated an interest in learning more about providing evidence-based care. Immediate post TTP, evaluations showed improvements in knowledge, attitudes and skills in CPGs, and feedback was that the TTP was of unanticipated value in assisting PTs to use CPGs to better manage patients with LBP. Post TTP follow-up demonstrated significant behaviour change with PTs using CPGs more regularly, for patients with LBP, and other challenging conditions. Conclusion: The careful evidence based staged TTP development ensured that it addressed South African primary healthcare PTs’ needs and concerns. Its content and delivery methods were feasible and acceptable, and the TTP appeared to be effective in improving knowledge, attitudes and behaviours in the short and longer-term for rural PTs in one province of South Africa. The TTP is valid and ready for wider application to larger PT groups in primary healthcare settings.
Towards strengthening of rehabilitation at primary care : exploring the needs and perspectives regarding rehabilitation services in two South African and Zimbabwean settings
(Stellenbosch : Stellenbosch University, 2024-03) Charumbira, Maria Yvonne; Louw, Quinette; Berner, Karina; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Health and Rehabilitation Sciences. Physiotherapy.
ENGLISH SUMMARY: Introduction: There is an escalating demand for rehabilitation as a health strategy globally. The growing burden of health-related disability, particularly pronounced in low-and-middle-income countries (such as South Africa and Zimbabwe) will strain the already-compromised health systems. This juxtaposition of growing functioning problems and reportedly poor rehabilitation, notably at primary care, signifies an important gap towards strengthening of rehabilitation services. Detailed contextual information regarding the patients’ rehabilitation needs is required to inform the development of targeted strategies. Aim: The overall aim of the study was to explore the type and impact of functioning problems in adults, the associated rehabilitation service needs, and strategies to strengthen primary care rehabilitation in low-resource contexts. Research setting: The research was conducted across10 systematically selected primary health care facilities in two districts of the Eastern Cape, South Africa (Amathole and Buffalo City), and two districts in Manicaland, Zimbabwe (Mutare Urban and Makoni). Methodology: The research encompassed three interrelated studies: Study 1: A scoping review synthesized the status of peer-reviewed literature on functioning problems linked to health conditions contributing significantly to adult disability in South Africa and Zimbabwe. The problems were mapped to the International Classification of Functioning, Disability and Health framework. A web-based application, Rehab4all, was developed to facilitate this review. Study 2: A qualitative, descriptive study obtained diverse perspectives from 43 purposefully selected adult patients regarding the perceived impact of their functioning problems on their life roles and suggestions on how rehabilitation services can be improved. Study 3: A qualitative, descriptive study gained insights from 37 primary care providers on current rehabilitation service delivery and innovative ways of enhancing primary care rehabilitation. Results: A 130 distinct functioning problems were identified from 282 studies. There was a huge lack of evidence on health-related functioning problems among Zimbabwean adult populations. In South Africa, the top 20 functioning problems, with prevalence ranging from 15 – 70.6%, were predominantly related to mobility, pain, and mental health. The South African and Zimbabwean primary health care facilities were ill-equipped to address the wide array of prevalent functioning problems, as rehabilitation services are inadequate, inappropriate, or absent. A complex network of intertwined factors resulted in sub-optimal provision, access to, and utilization of rehabilitation. These factors included patients’ and providers’ lack of interest, awareness, knowledge, and skills regarding rehabilitation, compounded by lack of resources and high levels of undesirable social determinants of health. To improve the current situation, patients and providers recommended multifactorial strategies including education, skills training, community engagement and financial investment to ensure adequate supplies, infrastructure, and human resource capacity. Conclusion: Patients attending primary health care in South Africa and Zimbabwe have a high but under-recognised need for rehabilitation. The primary health care system falls short in its ability to identify, manage, and support the rehabilitation needs of people with functioning problems. Individuals’ participation in society is further hampered by the lack of development and integration of other government sectors. Achieving transformation in primary care rehabilitation within these countries will require an all- sector and society approach. This involves collaboration and coordination across various sectors and engaging the broader community in rehabilitation service development.
Virtual reality exposure therapy as treatment for pain catastrophizing in Fibromyalgia patients : proof-of-concept
(Stellenbosch : Stellenbosch University, 2013-03) Morris, Linzette Deidre; Louw, Quinette; Grimmer, Karen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Physiotherapy.
ENGLISH ABSTRACT: Research objective To test a novel concept that exposing patients with fibromyalgia syndrome (FMS) to visuals of exercise activities elicits neurophysiological changes in functional brain areas associated with pain catastrophization; thereby providing preliminary support for the further development/testing of a virtual reality exposure therapy (VRET) exercise program aimed at reducing pain catastrophization toward exercise therapy in patients with FMS. Methods The main study of this research consisted of a three-phase exploratory fMRI study. Phase 1 involved the development/validation of the fMRI visual task. Phase 2 involved the exploration of the differences in neural correlates associated with pain catastrophizing between participants with FMS and healthy controls when exposed to various visuals of exercise and passive/relaxing activities. Phase 3 involved the testing of the preliminary efficacy of a novel VRET exercise program on pain catastrophization in participants with FMS. The fMRI task consisted of two stimuli: active (exercise activity visuals)/passive (relaxing activity visuals). Structural images as well as blood-oxygenation-level-dependent (BOLD) contrasts were acquired for the conditions and compared within-subjects/groups and between-groups. The condition of interest was the active>passive condition (where brain activations for the passive condition were subtracted from the active condition). The brain volumes collected during ‗on‘ conditions were compared with the brain volumes collected during ‗off‘ conditions using Students‘ t test. Statistic images were thresholded using clusters determined by Z>2.3 and a (corrected) cluster significance threshold of p=0.05. Results The right (R) middle and inferior frontal gyrus and R posterior cerebellum were significantly activated for the participants with FMS, and not the healthy control group, during the active>passive condition (phase 2). At baseline, during the active>passive condition (phase 3), the intervention/VRET group showed significant activation (p<0.05) in the R insular cortex, R anterior and posterior cerebellum, R parahippocampal gyrus, R middle frontal gyrus, R corpus callosum, R thalamus, R supramarginal gyrus and R middle and superior temporal gyrus; the control group showed significant activation in the R anterior and posterior cerebellum, R middle and superior temporal gyrus, R middle frontal gyrus, R insular cortex, R supramarginal gyrus and R precentral gyrus. Post-intervention, during the active>passive condition, R posterior cerebellum activation was still significant (p<0.05) for the intervention group; R anterior cerebellum, left (L) middle and inferior frontal gyrus, and R superior parietal lobe activation was found to be significant (p<0.000) for the control group, although these areas were not found to be significantly activated at baseline for the control group. Conclusion We could not provide confirmatory evidence for the efficacy of a novel VRET program for pain catastrophization in patients with FMS. However, the findings of this study does suggest that pain catastrophization in patients with FMS could be confirmed with fMRI. Research is therefore warranted to further develop a proper VRET exercise program and to test the effect of this program on pain catastrophization in patients with FMS.

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