http://bura.brunel.ac.uk/handle/2438/8701 2026-04-14T06:39:21Z http://bura.brunel.ac.uk/handle/2438/30254 Title: Exploring strength exercise prescription and its dose in rheumatoid arthritis Authors: Boniface, Graham Abstract: Rheumatoid arthritis (RA) is a significant global burden. It causes pain and disability and has significant socio-economic implications. Non-pharmacological interventions are commonly prescribed to mitigate the impact of the disease. Strengthening exercise, supported by evidence from randomised controlled trials (RCTs), has gained wider acceptance. The National Institute for Health and Care Excellence (NICE) recommends strengthening exercise for managing the functional impairments associated with the disease. Whilst modest benefits have been demonstrated, uncertainties persist regarding the optimal dosage. This thesis endeavours to enhance our understanding of the prescription of strengthening exercise and its dose in RA through three original interrelated studies. Study one systematically reviewed contemporary RCTs where strengthening exercise was a main component of the intervention being evaluated. How dose of strengthening exercise was determined for the trial intervention was investigated. The majority of included RCTs did not: (1) Report piloting the intervention and its dose prior to conducting the RCT and (2) Cite any evidence underpinning the dose of strengthening exercise prescribed for participants taking part in the trial. Moreover, when evidence was cited, it varied in quality. Often the dose used or recommended in the underpinning evidence was inconsistently applied in the intervention being evaluated by the RCT. Frequently, the underpinning evidence was not directly applicable to individuals living with RA. The findings of this review cast doubt on whether dose of strengthening exercise is optimised for individuals with RA in RCTS. Study two investigated the dose in hand strengthening exercise prescribed and completed during the Strengthening And Stretching For Rheumatoid Arthritis of the Hand (SARAH) multicentre RCT. The study utilised the area under the curve (AUC) method to quantify the overall dosage of hand strengthening exercise prescribed across the five face-to-face exercise sessions. General estimating equation (GEE) multiple regression analysis was then employed to determine: (1) The relationship between prescribed overall dose and key outcomes (overall hand function and grip strength) and (2) What factors were associated with the overall dose prescribed. Results indicated that participants who were prescribed a higher overall dose of hand strengthening exercise exhibited better overall hand function and grip strength. Factors that influenced overall dose prescribed included the professional background of the therapist (i.e. occupational therapist or physiotherapist) and baseline participant characteristics including metacarpophalangeal joint deformity, number of swollen wrist/hand joints, grip strength, participant mood, and confidence to exercise without fear of making symptoms worse. Study three employed judgement analysis (JA) to evaluate how occupational therapists and physiotherapists (therapists) judge what intensity (a key dose parameter) of hand strengthening exercise to prescribe an individual with pain and dysfunction of the hand associated with RA. A modified Delphi process involving therapists experienced in managing hand impairments associated with RA was used to prioritise the key clinical cues included in the case scenarios. Therapists based in the United Kingdom (UK) were then invited to assess a set of sixty-nine case scenarios (54 + 15 repeats) via an online platform. Their judgements on prescribed intensity of hand strengthening exercise were explored using multiple regression analysis. Results indicated all therapists reduced the intensity of the exercise as the severity of the clinical cue increased. The cues that influenced therapists the most included: (1) Patient’s pain performing the exercise, (2) Disease activity and (3) Average pain over the preceding week, (4) Hand range of movement, (5) Ulnar drift and (6) Patient grip strength. Sub-analysis employing the Cochran-Weiss-Shanteau (CWS) index of expertise identified therapists who were more consistent in their prescribing judgements relied on fewer clinical cues (1-3), implying a form of pattern recognition may be associated with their prescribing judgements. In summary, dose is a crucial aspect of therapeutic exercise prescription. These studies provide new insights into prescribing and dosing of strengthening exercises for RA in both clinical trials and practice. Based on these findings, this thesis proposes several future research directions. First, the issues identified in study one may not be limited to strengthening exercises and RA. Investigating whether similar issues exist in RCTs evaluating other therapeutic exercise-based interventions used to manage other musculoskeletal disorders is urgently needed to understand whether dose is sufficiently optimised in rehabilitation research more broadly. Second, to actualise the full potential of therapeutic exercise-based interventions, alternative methods for optimising dose warrant investigation. Dose escalation methodology may offer healthcare researchers a viable alternative to employing past research, which for strengthening exercise in RA, is often low quality and not applicable to the clinical population of interest. Third, further exploration around how healthcare professionals optimise dose of exercise-based interventions at the point of contact is essential for optimising exercise prescription in clinical practice. Description: This thesis was submitted for the award of Doctor of Philosophy and was awarded by Brunel University London 2024-01-01T00:00:00Z http://bura.brunel.ac.uk/handle/2438/27078 Title: The elusive sense - vestibular dysfunction and falls risk in older adults Authors: Hannah, Barbour Abstract: Background: Falls are a significant and growing public health concern in the UK. Maintaining balance, involves the complex interaction of multiple systems. The vestibular system is a key sensory system in maintaining balance, that deteriorates with ageing. However, the impact of ageing on the vestibular system’s ability to maintain postural control and its impact on falls risk remains unknown. This multiple methods approach thesis, aimed to address the following questions in an older adult population: 1. Does dizziness increase the risk of falling? (Dizziness is a key symptom of vestibular dysfunction) 2. Does asking regarding dizziness effective at screening for vestibular dysfunction? 3. Does the presence of a wider range of vestibular symptoms increase falls risk? 4. How does this population define dizziness? 5. What are the barriers and enabling factors for accessing healthcare? 6. Is there an association between physical functioning and vestibular dysfunction? Methods: Primary data was collected via surveys, physical functioning tests and qualitative interviews. Longitudinal secondary data analysis was also undertaken. Results: Dizziness and wider vestibular symptoms are associated with an increased falls risk (Chapters 4 and 5). Chapter 6 reported that the reliance on the presence of dizziness to diagnosis a vestibular dysfunction lacks specificity. Clinicians need to be skilled in communication to ensure a shared understanding when a patient presents with dizziness. Significant barriers exist for this population in accessing healthcare at a personal and service level (Chapter 7). Increased severity of vestibular symptoms was associated with worsening performance on physical functioning tests indicating a possible reason for their increased falls risk (Chapter 8). Conclusion: In conclusion, dizziness and the vestibular system are elusive in their difficulty to be defined and their lack of clear, concrete symptoms, however, a clear link has been demonstrated between them and an increased falls risk. Description: This thesis was submitted for the award of Doctor of Philosophy and was awarded by Brunel University London 2023-01-01T00:00:00Z http://bura.brunel.ac.uk/handle/2438/20944 Title: Using the International Classification of Functioning, Disability and Health (ICF) to promote biopsychosocial clinical reasoning and person-centred practice (PCP) in two multi-disciplinary teams Authors: Jefferson, Richard David Abstract: Title: Using the International Classification of Functioning, Disability and Health (ICF) to promote biopsychosocial clinical reasoning and person-centred practice (PCP) in two multi-disciplinary teams. Background: The ICF has been advocated as a way to enhance the biopsychosocial analysis of functioning and as a vehicle for implementing PCP. PCP has been recommended as a model to address contemporary healthcare needs. This action research study has identified factors required to facilitate biopsychosocial clinical reasoning and promote PCP through the implementation of the ICF. Setting and aims: Two multi-disciplinary teams, with different contexts, cultures and characteristics, participated in this study. One was community-based, included all members within the study group and sought to promote biopsychosocial multi- disciplinary clinical reasoning. The other was unit- based, utilised a sub-group of research participants and required a clinical reasoning model that embraced all disciplines and enhanced PCP. Methods: Data were generated through the use of iterative action research cycles which employed a variety of qualitative and quantitative methods. Findings were analysed through immersion and thematic analysis and descriptive statistics. Key findings were drawn from across all the data sources. Findings: Through the process of developing and implementing ICF-based clinical reasoning tools six themes emerged. The need for: a shared team culture aligned to that of the organisation; a resilient and innovative team culture and; the adaptation of the ICF to the context of practice reflecting the patients’, teams’ and organisational needs and capabilities. When present, these led to: enhanced communication and reasoning between team members and with patients; a greater awareness of the biopsychosocial needs of individuals and; enriched PCP. Conclusions: This thesis makes an original contribution about the prerequisites, contextual conditions, modifications and developments required to implement the ICF to promote biopsychosocial clinical reasoning and PCP. Description: This thesis was submitted for the award of Doctor of Philosophy and was awarded by Brunel University London 2020-01-01T00:00:00Z http://bura.brunel.ac.uk/handle/2438/19031 Title: The feasibility and acceptability of virtual reality gaming technologies for upper-limb stroke rehabilitation: A mixed-methods study Authors: Warland, Alyson Isobel Abstract: Background: Evaluation of virtual-reality gaming technologies for upper-limb stroke rehabilitation has focused on those with mild to moderate impairment. This mixed-methods study details the development and evaluation of the feasibility, acceptability and preliminary efficacy of the custom-developed, Personalised Stroke Therapy (PST) system, in strokesurvivors with mild to moderately-severe levels of impairment. Methods: The PST system was iteratively designed with input from stakeholders. Twelve stroke-survivors (nine females, mean age 58 years, median stroke chronicity 42 months, stroke severity 14-25 for shoulder and elbow on the Motricity Index) aimed to complete nine, 40-minute sessions on the PST system over three-weeks. Feasibility and acceptability were assessed though semi-structured interview, recording of adverse effects, adherence, enjoyment and perceived exertion. Assessments of impairment, activity and participation, were completed at baseline, immediately post-intervention and 4-weeks post-intervention. Data were analysed using Thematic Analysis of interview transcripts and field-notes, and Wilcoxon Signed Ranks. Side-by-side displays were used to integrate quantitative and qualitative findings. Findings: Integrated findings of safety and ability to use the PST system suggested system feasibility. Themes of the need for personalisation of activities and the necessity of a handsfree system helped explain findings of feasibility. Integrated findings of enjoyment, the acceptability of using the system in different settings and the importance of feedback provided evidence of acceptability. Themes of physical and psychological benefits were supported by improvements in measures of impairment, activity and participation between baseline and immediately post-intervention (p<0.05 for all measures). Conclusion: Personalisation of activities and use of a hands-free system resulted in feasibility and acceptability of the PST system in a group of community dwelling strokesurvivors including those with moderately-severe disability. Therapists should consider using such technologies as an adjunct to traditional rehabilitation, particularly in those with greater stroke severity for whom a lack of suitable alternatives are available. Description: This thesis was submitted for the award of Doctor of Philosophy and was awarded by Brunel University London 2018-01-01T00:00:00Z