Doctoral Degrees (Physiotherapy)

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    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.
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    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.
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    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.
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    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.
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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.