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- PublicationRehabilitation in the Fragile Health Systems of Low-Resource and Conflict-Affected Settings(University College Dublin. School of Public Health, Physiotherapy and Sports Science, 2023)The World Health Organization’s Rehabilitation 2030 initiative and call for action to integrate rehabilitation within health systems has led to increased collaborations, research projects and awareness since its launch in 2017. However, a large number of people with disabilities do not benefit from these developments as they live in countries of protracted conflict with health systems too fragile to prioritise rehabilitation. Research on rehabilitation in such contexts is still extremely rare and has not yet been conducted on a cross-national scale. Therefore, the aim of this PhD is to understand rehabilitation in the fragile health systems of low-resource and conflict-affected contexts to identify priorities for the development of rehabilitation services there and for future research. A mixed methods approach was employed. Two retrospective observational studies analysed the demographic and clinical characteristics of 287,274 rehabilitation users in 14 countries and the demographic and amputation characteristics of 28,446 rehabilitation users with amputation in five countries, using descriptive statistics. Data originate from an ICRC-developed database of routinely collected data on persons accessing ICRC-supported rehabilitation structures. Two qualitative focus group studies identified the perspectives of 35 ICRC-employed or -partner physiotherapists from 18 countries about barriers and facilitators of rehabilitation service development and about measuring rehabilitation outcomes in such contexts, using reflexive thematic analysis in an inductive and deductive approach to data analysis, respectively. To discuss study findings, the Rehabilitation in Conflict (RiC) framework was developed. It consists of the four components Context, Systems, Population and Services. Key findings were the diversity and complexity of context, which affects rehabilitation needs and how they are addressed. Indicators of weak health systems were found in all studies, as well as fragmented education, economic, and other systems. Rehabilitation users were characterised by low female representation, young age and disabilities caused by conflict and system challenges. Rehabilitation services were marked by a lack of recognition and health systems integration and a strong but insufficient workforce of mainly physiotherapists who lack appropriate outcome measures to reliably demonstrate impact. It is recommended that rehabilitation strengthening in such contexts starts on services level to drive change on systems level. This requires simple, reliable data collections, training, and service provision that pilots feasible, contextualised rehabilitation outcome measurement and models of care. Future research should explore disability prevalence, rehabilitation needs and outcomes including the perspectives of users, access barriers for women and possibly other neglected populations, using participatory approaches. Finally, implementation research is advised to investigate the development of rehabilitation in the most fragile contexts worldwide.
- PublicationHeart Rate Variability Monitoring in Athletes(University College Dublin. School of Public Health, Physiotherapy and Sports Science, 2022)Introduction: Heart Rate Variability (HRV) is a popular assessment of the autonomic nervous system (ANS). It is a non-invasive measure commonly used in clinical settings to evaluate cardiovascular health and ANS function. In athletes/athletic populations it provides insight into recovery status and readiness for training. Although this assessment has been validated in clinical populations, the reliability of using HRV measurements in practical settings has not been comprehensively studied nor is there any universal guidelines dictating best practice for use with athletes. This thesis outlines some of the concerns pertaining to the reliability of this assessment and the steps in developing new guidelines to ensure best practice can be met, both for research and practical uses. The aim of this thesis is to investigate the reliability and practicality of using HRV to monitor athletes, (1) in a systematic review of studies examining the reliability of HRV in athletes and (2) through a test-retest reliability study of HRV. Methods: Elite or regularly active athletes of all sports, (including endurance, team sport and power-based sports) were eligible for inclusion in both the systematic review and research study. In the systematic review, the reliability of different HRV measurement protocols were examined. The systematic review included 11 papers and a total of 215 participants. In the test-retest reliability study participants were tested for HRV on 4 occasions determined from a 30 minute 3-lead ECG measurement. The research study included 16 athletes (5 male, 11 female). Results: The systematic review found that the 1996 guidelines created by the Electrophysiology Task Force of the European Society of Cardiology and the North American Society of Pacing for HRV measurements in athletes are underutilised and the reporting of methodologies was not consistent amongst studies. Reliability results were also not consistent among the studies investigated (CV ranging from 1.80 – 61.0% for lnRMSSD). The original research study conducted showed that the use of an average of two 30minute HRV measures within a one-week period is a reliable method to assess HRV (ICC = 0.798, CV = 5.88 +/- 4.34%). It also showed that shorter HRV measurements are as reliable as the 30minute reference measure when using this protocol. Conclusions: The current recommended guidelines for HRV measurements in the general population are both insufficient and under used in the testing of athletic populations. Care should be taken in future studies to ensure methodologies are appropriately reported. HRV can be a reliable tool for monitoring autonomic function in athletic populations if suitable protocols are followed.
- PublicationAn investigation into the physiological and genetic determinants of sarcopenia and the enhancing of current strategies for skeletal muscle screening(University College Dublin. School of Public Health, Physiotherapy and Sports Science, 2022)The age-related deterioration of muscle strength and mass, known as ‘sarcopenia’, is a major public health burden, due to its high and increasing prevalence and association with several adverse health outcomes. Although decades of research have been dedicated to understanding its aetiology and developing preventative strategies, sarcopenia effects >40% of those aged =80 years. Thus, there is a clear need to further elucidate the mechanistic pathways underlying sarcopenia, and to enhance current screening and treatment measures. To date, barriers associated with attaining accurate muscle measurements have impeded a proficient implementation of preservative and diagnostic strategies in clinical practice. Correspondingly, the potential benefits of a blood-based sarcopenia assessment, incorporating markers indicative of its aetiological underpinnings, have gained credence. In this regard, although the clinical manifestation of sarcopenia is multifaceted, recent data suggest neural processes to be of principal importance, and so exploring markers of neural integrity is particularly relevant. In addition to barriers associated with muscle quantification, the paucity of suitable, high-quality normative data for certain populations presents further impediments to the clinical interpretation of muscle health across the lifespan. Consequently, the potential for an accurate and timely identification of those at risk of, or with poor muscle health is greatly reduced. In this regard, although sarcopenia is diagnosed as the simultaneous presence of low muscle strength and mass, muscle strength is recognised as the cardinal diagnostic criterion, and so establishing muscle strength norms is particularly urgent. Accordingly, this thesis sought to: a) generate physiological and genetic data to illuminate the aetiological mechanisms underpinning sarcopenia development; b) identify promising blood-based markers that may enhance current screening strategies; and c) establish high-quality normative data and diagnostic thresholds for muscle strength. This thesis incorporated data from 9431 individuals aged 18-92 years (mean age: 44.8 ± 13.4 years; 57% females). Detailed phenotypic data (anthropometrics, body composition, muscle strength, cardiorespiratory fitness, blood sampling, health and lifestyle information) were collected for each participant, while plasma and genetic analyses were performed in subpopulations (n=300, aged 50-83 years; and n=6715, aged 18-83 years, respectively). Results confirmed the relevance of plasma C-terminal agrin fragment, a marker of neuromuscular junction (NMJ) stability, to sarcopenia, and illuminated novel associations between plasma neurofilament light chain, a marker of axonal integrity, and sarcopenia. Additional novel associations are highlighted between genes involved in regulating NMJ health (AGRN and PRSS12) and several phenotypes relevant to sarcopenia. Collectively, the physiological and genetic data provide strong evidence of the neural contribution to sarcopenia development, and suggest NMJ and axonal integrity to be of central importance. Finally, the normative data and diagnostic thresholds established in this thesis may help inform the clinical interpretation of muscle health across the entire adult age-span. Importantly, the diagnostic thresholds were proficient in identifying those with poor performance across a myriad of clinically relevant health domains, and suggest the cut-points currently in widespread use, may be too stringent.
- PublicationEpidemiological analyses to support national control of SARS-CoV-2 in Ireland(University College Dublin. School of Public Health, Physiotherapy and Sports Science, 2022)Pathogen emergence has been increasing in recent decades. In December 2019, an outbreak of atypical pneumonia emerged in Wuhan, central China. The cause of the disease, was subsequently identified as a novel coronavirus (SARS-CoV-2) and the disease named COVID-19. Over a short period of time SARS-CoV-2 rapidly spread throughout mainland China and surrounding countries in the western pacific before cases appeared in Europe in February of 2020. The first case in Ireland was documented in Ireland on the 29th of February 2020. In response, a series of epidemiological analyses were conducted to support decision making in the national control of the disease. The objective of this thesis was to provide regions-specific estimates of region-specific epidemiological parameters of interest, to aid in the accurate modelling of the disease in the country. The ultimate goal was to improve models so that more accurate information could be provided to decision makers. Chapter one proposed the use of the number of close contacts of infected cases over time as a metric for monitoring behaviour of infected contacts. The study found that the distribution of contacts per case was overdispersed, with a small proportion of cases reporting very large numbers of contacts. The study also provided an evidence basis for mathematical age-cohort compartmental models, by providing data on the social contacts of the Irish population under different levels of restriction. Chapter two estimated the serial interval of SARS-CoV-2 in Ireland using contact tracing data. The median serial interval was 4.0 days which was lower than estimates previously used for the statistical approximation of the serial interval in Ireland. Furthermore, the study also suggested that up to two thirds of transmission events were likely to have occurred prior to the onset of symptoms in the primary case. Finally, chapter three evaluated the potential use of Rapid Antigen Diagnostic Tests in screening individuals attending mass gatherings. The baseline risk of infection in the tested population is of key importance when interpreting the results of any imperfect diagnostic tests. This study provided a mechanism for estimating the baseline risk, as well as the uncertainty around that risk, using incidence data. The studies presented in this thesis demonstrate that secondary analyses of contact tracing data can yield meaningful and useful pieces of information that may be used to more accurately reflect transmission in the population of interest. However, it is also worth pointing out that certain opportunities were underutilized in the collection and analysis of contact tracing data. Given the apparent acceleration of pathogen emergence, evidenced in particular by the temporal proximity of repeated coronavirus outbreaks in the past 20 years, it is vital that Ireland take steps to develop infrastructure to deal with the current pandemic as well as the threat of future endemic diseases. Similar to work in other countries, this thesis demonstrates the strength of a OneHealth approach to the management of emerging infectious diseases.
- PublicationAn investigation of professional practice and practitioner development in applied sports performance analysis(University College Dublin. School of Public Health, Physiotherapy and Sports Science, 2022)Applied Performance Analysts (PAs) are increasingly seen as professional practitioners in the sports performance industry, providing stakeholders with support in the collection, analysis, interpretation, and translation of performance data. The role is relatively new and evolving at a pace which is not supported by the ‘normal’ trappings of professional practice such as demonstrable theoretical and practical expertise, guides for practice, organisation and regulation. This thesis leverages the learning accrued from the literature in applied PA, interactions with elite applied practitioners and academics in the field, and from the design of a practitioner development pathway to conceptualise the role of an applied PA and consider how best to support the development of the profession. The aim of the thesis was to understand professional practice in applied PA and explore how best to support practitioners in their professional development. A dual approach was applied to the investigative process. The first was a traditional research approach as a framework analysis of nearly twenty years of applied PA literature was employed to identify the components of professional practice and expertise which underpinned these. This framework was validated through a series of focus group interviews with elite applied PAs and experienced academics and additionally captured their perspectives on applied practice and the profession. The second approach was of participatory action research which saw the design, implementation and evaluation of an accreditation and practitioner development programme delivered in partnership with the Gaelic Athletic Association (GAA). This research conceptualises and defines the applied PA role, identifying the components of practice and the expertise required at a level of minutia which can act as a guide, an audit tool and a platform for further research. It is the first comprehensive discussion of applied PA as a profession, focusing on the challenges it faces in the absence of robust professional infrastructure, and the opportunity to reimagine and rebrand the role. It also reports how action research can support the development of an applied PA community of practice and accreditation process, through a practitioner development pathway.