Dissertations / Theses on the topic 'Allied health and rehabilitation science'

Pre-existing dementia is associated with poorer functional outcome after stroke. It is unclear however whether this is due to lack of access to, or inequality in, stroke rehabilitation. This PhD used mixed methods to understand whether pre-existing dementia is a factor considered by clinicians when referring/admitting patients for rehabilitation, when providing rehabilitation interventions, and whether there is a difference in rehabilitation received by patients with and without pre-existing dementia. A background literature review informed the first study, which was a systematic review examining factors influencing clinical decision-making about access to stroke rehabilitation. The systematic review suggested that pre-stroke cognition influenced referrals/admission to rehabilitation, however, no studies examined this specifically. The qualitative study therefore used interviews (n=23) to explore clinicians experiences of decision-making about rehabilitation for patients with pre-existing dementia/cognitive impairments. The findings highlighted that clinicians own knowledge influenced their decision-making, with a common perception that people with pre-existing cognitive impairment lack potential to benefit from rehabilitation. The third study, a prospective cohort study, examined differences in rehabilitation received by patients with and without pre-existing cognitive impairments (n=139). People with pre-existing cognitive impairments received less rehabilitation than those without, particularly physiotherapy and referral to community therapies and more non-patient facing occupational therapy. This PhD identified that people with pre-existing dementia/cognitive impairment receive less rehabilitation when compared to those without. This may be, in part, due to clinicians decision-making about which patients should receive stroke rehabilitation. These findings have multiple clinical implications, particularly around the number of patients in stroke services with undiagnosed pre-existing cognitive impairment. Decisions can become more equitable by ensuring clinicians have access to relevant education, training and skills to work alongside patients with pre-existing dementia/cognitive impairments.

In 2011, a period began in which the United States demographic will change to include the largest, least prepared, and most diverse elderly population in our nation’s history. That was the year the “Baby Boomer” generation started retiring and members of this large cohort will continue to do so for approximately twenty years (Kemper, Komisar & Alecxih, 2005). Chronic health conditions and the obesity epidemic may make retirement years less healthy ones than for previous generations of older adults. Lifestyle changes in Baby Boomers as compared to previous cohorts of elders – increased divorce, fewer children, nontraditional family relationships – may result in less support for frail elders when they can no longer care for themselves, thereby increasing their vulnerability to long-term care placement (Cherlin, 2010; Ryan, Smith, Antonucci & Jackson, 2012

Excerpt: The Cardiopulmonary Science Program at East Tennessee State University is housed within the College of Clinical and Rehabilitative Health Sciences (CCRHS) along with other health care programs including: Dental Hygiene, Imaging Sciences (Radiography, CT, MRI), Nutrition, Speech Language Pathology, Physical Therapy, and Audiology.

Participants will discuss how they could use the lab concept in courses outside of the sciences to encourage and improve student engagement. The questions participants will be able to answer after attending the session will be: (1) How can I use a "lab" in my classes? and (2) How could use a lab improve student engagement?

Accurate detection and segmentation of intracranial aneurysms plays an important role in diagnosing and reducing the incidence of subarachnoid haemorrhage (SAH) which is associated with high rates of morbidity and mortality. This research proposes a computer aided detection (CAD) and segmentation (CAS) of intracranial aneurysm in computer tomography angiography (CTA). The efficiency of the CAD/CAS system is boosted by pre-processing the input image with non-linear diffusion to smooth the CTA data while preserving the edges. A 3D region growing-based approach is used to extract the cerebral arteries followed by entropy-based search space reduction to retain the volume of the circle of Willis (CoW) and the proximal cerebral arteries where nearly all intracranial aneurysms are located, whilst eliminating the extracranial and very distal intracranial circulation. Because cerebral aneurysms vary in size we regard the problem of cerebral aneurysm detection as an intrinsically multi-scale problem and employ a multi-scale approach to all detection analysis. Shape index analysis is employed to determine potential aneurysmal regions (PARs). Hessian analysis and gradient vector field analysis which reveal 3D local shape information are used to further characterise the initial PARs. False positive reduction is then performed based on the analysis of the shape characterisations of the PARs. A ranking score is defined based on the outcomes of the shape analysis to rank the likelihood of PARs. The system allows user to navigate through the ranked PARs and select a candidate aneurysm for further analysis (CAS). The boundary of the selected aneurysm and its parent artery is delineated by using a 3D conditional morphology-based region growing approach. The output is presented to the user to be assessed for the aneurysm orientation relative to the parent vessel. A semi-automatic process is applied to detach the aneurysm from its parent artery. To have a fine segmentation of aneurysm which can be used for characterization of the aneurysm, a 3D geodesic active contour implemented in a level set framework is applied. The volume of the separated aneurysm is quantified as a typical characterization ofthe aneurysm. The system has been validated on a clinical dataset of 62 CT A scans with average 274 slices per scan (involving 17,028 CT slices) containing 70 aneurysms. Sizes of aneurysms vary between 3-16mm. 42 CTA scans have been used as a training dataset for parameter selection and 20 CTA scans have been used as a test dataset. The sensitivity of the systems for the CAD component is 97% with the average false positive of 2.24 per dataset (0.008 per slice). CAS performance was evaluated by dual visual judgment of an expert neuroradiologist and neurosurgeon. The detection and segmentation performance indicate the approach has potential in clinical applications.

This study aims to understand the use of a computer during GP consultations and to enable the development of EPR systems which are easier to review, enter data into, use to take action, and is more sensitive to the clinical context. This thesis reports the development of a multi-channel video and data capture toolkit, the ALFA (Activity Log File Aggregation) because existing observation techniques have limitations. None of the existing tools are designed to assess human-computer interaction in the context of the clinical consultation, where the social interaction is the prime focus. The ALFA tool-kit has been used to observe and study 163 live primary care consultations supported by computer systems with four different designs. A detailed analysis of consultation interactions was then performed focusing on doctor-patient communication and the integration of the computer into the consultation workflow. The data collection elements of the ALFA supported recording of consultation activities by providing rating techniques attuned with the characteristics of those interactions. The Log File Aggregation (LFA) component of the ALFA toolkit aggregated those multitudes of data files into a single navigable output that can be studied both quantitatively and qualitatively. A set of Unified Modelling Language (UML) sequence diagrams were then created as they could be used by software engineers to develop better systems. This research proposes a framework with three elements to analyse the computerised clinical consultation; (1) the overview of the context within which the consultation was carried out, (2) time taken to perform key consultation tasks and (3) the process used. Traditional analysis with its emphasis on the technology often misses crucial features of the complex work environments in which the technology is implemented. Direct observation could inform software designers in developing systems that are more readily integrated into clinical workflow. Direct observation of the consultation, using the ALFA toolkit is acceptable to patients; captures the context of the consultation the precise timing and duration of key tasks; and produces an output a software engineer can understand. ALFA offers a range of possibilities for research in the consulting room. The computer should be considered as an active element of the consultation; room layout and consultation models should let the computer in, while software engineers take in the capacity to sustain patient centred social interactions as a core facet of their design agenda.

Pulmonary embolism (PE) is an obstruction within the pulmonary arterial tree and in the majority of cases arises from a thrombosis that has travelled to the lungs via the venous system. Pulmonary embolism (PE) is a fatal condition which affects all age groups and is the third most common cause of death in the US. Computed tomographic angiography (CTA) imaging has recently emerged as an accurate method in the diagnosis of pulmonary embolism. Each CTA scan contains hundreds of CT images, so the accuracy and efficiency of interpreting such a large image data set is complicated due to various PE look-alikes and human factors such as attention span and eye fatigue. Moreover, manual reading and interpreting a large number of slices is time consuming and it is difficult to find all the pulmonary embolisms (PE) in a data set. Consequently, it is highly desirable to have a computer aided detection (CAD) system to assist radiologists in detecting and characterizing emboli in an accurate, efficient and reproducible manner. A computer aided detection (CAD) system for detection of pulmonary embolism is proposed in CTA images. Our approach is performed in three stages: firstly the pulmonary artery tree is extracted in the region of the lung and heart in order to reduce the search area (PE occurs inside the pulmonary artery) and aims to reduce the false detection rate. The pulmonary artery is separated from the surrounding organs by analyzing the second derivative of the Hessian matrix and then a hybrid method based on region growing and a new customized level set is used to extract the pulmonary artery (PA). In the level set implementation algorithm, a new stopping criterion is applied, a consideration often neglected in many level set implementations. In the second stage, pulmonary embolism candidates are detected inside the segmented pulmonary artery, by an analysis of three dimensional features inside the segmented artery. PE detection in the pulmonary artery is implemented using five detectors. Each detector responds to different properties of PE. In the third stage, filtering is used to exclude false positive detections associated with the partial volume effect on the artery boundary, flow void, lymphoid tissue, noise and motion artifacts. Soft tissue between the bronchial wall and the pulmonary artery is a common cause of false positive detection in CAD systems. A new feature, based on location is used to reduce false positives caused by soft tissue. The method was tested on 55 data scans (20 training data scans and 35 additional data scans for evaluation containing a total of 195 emboli). The system provided a segmentation of the PA up to the 6th division, which includes the sub-segmental level. Resulting performance gave 94% detection sensitivity with an average 4.1 false positive detections per scan. We demonstrated that the proposed CAD system can improve the performance of a radiologist, detecting 19 (11 %) extra PE which were not annotated by the radiologist.

Coronary artery disease is one of the most pernicious diseases around the world and early identification of vascular disease can help to reduce morbidity and mortality. Assessment of the degree of vascular obstruction, or stenosis, is critical for classifying the risks of the future vascular events. Automatic detection and quantification of stenosis are important in assessing coronary artery disease from medical imagery, especially for disease progression. Important factors affecting the reproducability and robustness of accuarate quantification arise from the partial volume effect and other noise sources. The main goal of this study is to present a fully automatic approach for detection and quantification of the stenosis in the coronary arteries. The proposed approach begins by building a 3D reconstruction of the coronary arterial system and then making accurate measurement of the vessel diameter from a robust estimate of the vessel cross-section. The proposed algorithm models the partial volume effect using a Markovian fuzzy clustering method in the process of accurate quantification of the degree of stenosis. To evaluate the accuracy and reproducibility of the measurement, the method was applied to a vascular phantom that was scanned using different protocols. The algorithm was applied to 20 CTA patient datasets containing a total of 85 stenoses, which were all successfully detected, with an average false positive rate of 0.7 per scan.

It is well known that the evolution of 4G-based mobile multimedia network systems will contribute significantly to future m-health applications that require high bandwidth and fast data rates. Central to the success of such emerging applications is the compatibility of broadband networks such as mobile WiMAX (IEEE 802.16e) and RSVP A, and especially their rate adaption issues combined with the acceptable real time medical quality of service requirements. The design of effective broadband mobile healthcare systems usmg emerging WiMAX and RSxP A networks is important from the medical perspective especially in applications such as remote medical ultrasound diagnostic systems. In this thesis, we introduce a new cross layer design approach for medical video streaming over mobile WiMAX and RSVP A networks. In particular, we propose an approach based on optimising medical Quality of Service (m-QoS) in mobile WiMAX network environments described in this work. Preliminary performance analysis of the proposed cross layer algorithm has been evaluated via simulation studies. These results show that the proposed cross layer optimizer achieves improved performance compatible with the necessary medical QoS requirements and constraints for the relevant clinical application. Furthermore, this work addresses the relevant challenges of cross layer design requirements for real time rate adaptation of ultrasound video streaming in Mobile WiMAX and RSVP A networks. The comparative performance analysis of such approach is validated in two experimental m-health testbed systems for both Mobile WiMAX and RSVP A networks. The experimental results show an improved performance of Mobile WiMAX compared to the RSVP A using the same cross layer optimisation approach. Additionally, we map the medical QoS to typical WiMAX QoS parameters in order to optimise the performance of these parameters in typical m-health scenarios. Preliminary performance analysis of the proposed multiparametric scenarios is evaluated to provide essential information for future medical QoS requirements and constraints.

In 2012, stroke affected over 420 000 people within Australia and the number of stroke survivors is anticipated to increase. Many stroke survivors live with a disability which affects their ability to carry out activities of daily living. In Australia stroke survivors are cared for by both publicly and privately funded hospitals. Available to both systems are the Stroke Foundation Clinical Guidelines for the Management of Stroke Survivors (SF 2010a). The Stroke Foundation carries out biannual national audits in Australia, one focusing on acute services and the other on rehabilitation services, to determine hospitals’ quality of care in accordance with the recommendations of the Stroke Foundation clinical guidelines. Participation of privately funded hospitals in both these national audits has been consistently low. Therefore, there is less understanding of how privately funded hospitals manage stroke survivors compared with publicly funded hospitals. Stroke survivors admitted to hospitals often journey through both acute and rehabilitation services. A stroke audit that follows the journey of stroke survivors by auditing both acute and rehabilitation services concurrently is required to gain a better understanding of how the clinical guidelines are applied across each service individually and across the combined services. When developing a stroke audit tool for either local or national use, clinicians tend to have limited input into the selection of audit criteria and tool development. As the overarching framework underpinning this research program, knowledge translation involves clinicians and researchers partnering to develop ready to use research. Therefore, in this research program allied health clinicians (physiotherapists, occupational therapists, social workers, speech pathologists, and dietitians) were invited to assist in the development of a stroke audit tool in a single privately funded hospital and to test its reliability. Establishing the reliability of the stroke audit tool adds to its robustness. The stroke audit tool was used to assess the adherence of allied health clinicians from a privately funded hospital to the selective Stroke Foundation clinical guidelines. The audit included stroke survivors with consecutive admissions to both acute and rehabilitation services. This research comprised two studies. Study 1 developed a stroke audit tool with allied health clinicians selecting the most relevant clinical guidelines from the Stroke Foundation Clinical Guidelines for Stroke Management (SF 2010a). Both inter and intra-rater reliability of the tool were tested with allied health clinicians who were able to agree on eight Stroke Foundation clinical guidelines with 70% agreement. An additional two Stroke Foundation clinical guidelines with 50% agreement and a further two Stroke Foundation clinical guidelines were added to ensure the stroke audit tool was relevant to all disciplines. Interrater reliability for the stroke audit tool was tested across ten clinical records by five (one from each discipline) allied health clinicians or raters. Inter-rater reliability was high with substantial consistency demonstrated across both services. Intra-rater reliability demonstrated substantial to moderate consistency. Study 2 comprised a 12-month retrospective clinical record audit of stroke survivors with consecutive admission to both acute and rehabilitation services. The stroke audit tool assessed the percentage adherence of allied health clinicians against the selected Stroke Foundation’s clinical guidelines included in the audit tool. Adherence was defined as stroke survivor care delivered in accordance with the Stroke Foundation clinical guidelines 2010. A minimal adherence level was set at 60% with an aspirational level set at 80%. Secondary analysis compared adherence across acute and rehabilitation services. Also, a subgroup analysis was undertaken investigating the influence of age, gender and length of stay to allied health clinician’s adherence of Stroke Foundation clinical guidelines. Allied health clinicians met the 60% adherence rate, for nine (out of 12) Stroke Foundation clinical guidelines, including three that were above 80% adherence rate (aspirational level). There was a significant difference across acute and rehabilitation services for eight of the 12 Stroke Foundation clinical guidelines. Age, gender and length of stay did not influence adherence rates of the allied health clinicians across acute and rehabilitation stroke services. Allied health clinicians from a privately funded hospital developed a reliable stroke audit tool. The stroke audit tool highlighted areas of adherence as well as service gaps across acute, rehabilitation and the combined service. Investigating adherence across both acute and rehabilitation services could lead to a co-ordinated approach to improving adherence towards Stroke Foundation clinical guidelines.

Firefighter coping strategies of Problem Focused Coping and Seeking Social Support were found to have positive significant relationships to Strategic Efficacy resulting in Outcome Coping Efficacy, after transitioning from one critical incident to a second. The coping strategies of Blamed Self, Wishful Thinking, and Avoidance appeared to have a negative significant relationship to Mobilization Efficacy in overall Outcome Coping Efficacy. Additionally, the Appraisals of Challenge and Positive Reappraisal to meet the Challenge appeared to have a positive significant relationship to Problem Focused Coping and Seeking Social Support. These findings of Outcome Coping Efficacy may be of help to firefighters for rehabilitative efforts after traumatic incidents.

Technology translation can be achieved through the blending of the sciences and arts in the form of digital imagery. Digital animation and video can be utilized to portray molecular events where the mechanism of action is known but the process occurs at a sub-microscopic level. There needs to be a strong collaboration between scientific advisors and digital artists when creating the animation such that the artistic interpretation of the molecular event conforms to the known and accepted confines of science. The finished animation may be used for information, education or persuasion as entrepreneurial biotechnical companies attempt to find markets, customers and investors interested in their inventions. Educational institutions with programs in the sciences, arts, digital media and medicine need to promote the interaction of students from these disciplines through cross-functional teams and courses. Solutions to problems developed by these teams tend to be broader and more comprehensive than more homogeneous teams.

Background. The Swedish government states that participation and influence are among the most fundamental prerequisites of public health. Mobility services provide professional and high quality information, advice, and assessment to individuals with a medical condition or recovering from an accident or injury that may affect their ability to drive, access, or egress a motor vehicle. Although Swedish physicians must report drivers with medical conditions, rehabilitative training for driving licenses following injury or severe medical conditions does not exist within contemporary Swedish healthcare systems. Aim. This study aimed primarily to describe and compare two driving assessment models, i.e., the model used by Traffic Medicine Center (TRMC) Stockholm in 1998 and the model provided by Mobilitetscenter.se (MC.se) Gothenburg in 2007. The study also sought to determine the context of the changed provision of driving assessments and identify the significant components of this change. Method A literature review, synthesised with the author’s research and complemented by practice-based evidence, provided the knowledge base and starting point of this essay. Action research paired with intervention propelled the changes in the provision of mobility services in Sweden between 1998 and 2007. The author used John Ovretveit’s identification of significant change components to illuminate the complex change process that occurred.  Selection of an appropriate list of variables to compare the two assessment models derived from FORUM of Mobility Centres, the umbrella organization of British Mobility Centres that developed national guidelines for driving ability assessments in the UK; the QEF Mobility Centre was a member of that organization. The author used a questionnaire and a semi-structured interview to gather relevant data from the compared centers. Results TRMC aims primarily to provide services for society through its contributions to road safety. A Mobility Center focuses on providing assessment and rehabilitation services, optimizing impaired drivers’ mobility potential and minimizing collision risks. Cognitive assessment at TRMC accounted for a large part of this study’s time allotment. MC.se’s practical driving test in a suitably modified car provides the most significant difference between the two models.  In addition, MC.se has replaced physicians and psychologists with occupational therapists. Conclusion TRMC aims to ensure that current drivers comply with medical driving laws and regulations. MC.se provides assessments that maximize mobility potential and also ensure low collision rates. Thus, safety is balanced against the right to mobility. The study also explores coping strategies, training, adaptations, and choice of vehicle.

ISBN 978-91-85721-58-0

Retiring baby boomers and the lack of interest and awareness among college students to enroll in an accredited Clinical Laboratory Science (CLS) program have created a shortage of CLS professionals in the 21st century. The U.S. Bureau of Labor Statistics predicts 18,000 CLS vacancies by 2018. However, only about 5,000 students graduate from accredited CLS programs each year. The purpose of this study was to explore students' perceptions of allied health professions and factors that influenced students and CLS professionals to select CLS as a profession. Bandura's social cognitive career theory served as the theoretical framework for this phenomenological study. Convenient purposeful sampling was used to select the 7 CLS professionals, 5 high school students, and 5 college students in the Chicago area. Participants took part in either a 30- to 60-minute group session or a 45- to 90-minute semi structured interview. Qualitative analysis included open axial coding to identify emerging patterns and themes from the transcripts. Findings revealed that the perceptions of both high school and college students' knew little about the CLS profession, and factors influencing CLS as a career choice included interests in science, health care, and family. CLS professionals indicated their interests in science and a high demand for CLS services in the workforce led them to pursue careers in the field. Implications for social change include improving professional-development programs for student awareness of allied health professions and mitigating the shortage of clinical laboratory scientists.

At least two studies have been found conducted in the area of audiological in-services and their impact on the people to whom they were presented. In 1981, Dancer and Keiser studied the effects of empathy training on geriatric-care nurses and in 1985, Dampier, Dancer, and Keiser studied changing attitudes of college students toward older persons with hearing loss. Both of the studies investigated the effect of in-service training on empathy, rather than using the traditional academicallyoriented in-service program approach. Both studies found statistical results indicating a significant positive change in the subjects' feelings toward hearing impaired geriatrics. Additionally, Dancer et al. (1981) found a positive significant change in the subjects' perceptions of hearing impaired elderly persons. This study investigated the effect of an in-service training program on nursing home personnel. The in-service that was developed included both empathy training and factual information. It was hypothesized that both elements are important and the inclusion of both could result in a greater change in people's attitude. The empathy portion of this in-service included a taped interview with a hearing impaired older person, a tape dramatizing interactions between hearing impaired and normal hearing individuals, simulated high frequency hearing loss, an "unfair listening test" and suggestions for interacting with hearing impaired people. The factual information included anatomy and physiology of the ear, types of hearing loss, common characteristics of hearing loss among older people, and the impact of hearing loss on speech understanding.

The Second Joint Research Conference of the Universities of Gloucestershire and Chemnitz took place at the Chemnitz University of Technology from 09th to 11th of September 2009. There were presenters from seven different nations in the lecture theatre. The very close partnership of the two institutions is characterised by a very active student exchange programme, joint teaching modules and some collaborative research which has been extended after the conference as well as several extracurricular guest lectures. In 2007 our friends from Gloucester invited us to our first joint conference and set the standard. The topics of the 2009 Conference were Public health and Sports with three main areas of interest: 1. Physiology and Biomechanics, 2. Philosophy and Social Science, 3. Prevention, Rehabilitation and Health Promotion. Many interesting and inspiring presentations were given by colleagues, PhD students and research students. One example of inspiration was the Clem Burke Drumming Project (S. Draper and M. Smith), which we were kindly invited to join. This is an example par excellence on how to conduct international research by simply using existing resources and talking to each other. It caused huge interest among colleagues across the whole university that Chemnitz did not only follow the example of our colleagues in Gloucester, but also widened the research interest into the application of different types of drumming as a means of therapy. This was the beginning of the DRUM BEAT Project (P. Wright of the Chair of Sports Medicine). Furthermore, both universities - Chemnitz and Gloucester - are trying to establish outreaching programmes with local communities which have practical implications of research in the context of public health and/or health promotion. One of the presentations for instance referred to a concept called the Healthy Town Project Tewkesbury, a similar project is planned for Chemnitz called Healthy Community. These two outreaching programmes and other research synergies could be part of an attempt of both universities to establish stronger international research links and in this context also submitting joint proposals to funding agencies, i.e. the EU. Since this conference a joint EU research proposal was submitted by colleagues in Gloucester. Also, talks were held on the topic of establishing a joint international degree. Understandably a project of this scale will take more than a couple of conferences and work on both sides is necessary and last but not least is also depending on the political and funding situation. However, first small step was taken after the conference by conducting a joint teaching module in the Ore Mountains /Saxony. Students from both institutions and colleagues conducted a research project comparing physiological and cognitive parameters of cross-country skiing and running. Social and intercultural processes were just as important during this winter camp. Some of the data is presented in this book. I trust that the colleagues of both universities do agree that this is an outstanding and very productive partnership with a lot of potential for future development and I am looking forward to many more joint schemes, projects and conferences to come - perhaps even an international degree. Prof. Dr. Henry Schulz

Streamlining is an attempt to make an organizational process increase its efficiency. The 1992 Amendments to the Rehabilitation Act of 1973 defined changes within the service delivery system of the Public State/Federal Vocational Rehabilitation (PS/FVR) Program, that appeared to suggest that streamlining was a new requirement from Congress. However, Congress, Rehabilitation Services Administration (RSA) and/or Council of State Administrators for Vocational Rehabilitation (CSAVR) did not mandate streamlining for the Public State/Federal Vocational Rehabilitation (PS/FVR) Program. Training on streamlining was designated to the Regional Rehabilitation Continuing Education Programs (RRCEP). The RRCEP programs exist in the Rehabilitation Act of 1973 to provide continuing education to employees of the PS/FVR Program, This studies literature review revealed Streamlining has resulted in inconsistent implementation approaches across state agencies and/or federal regions. Currently there is no data and/or consistent approaches to streamlining in the PS/FVR Program. Because of inconsistency in implementing streamlining, the RRCEP's ability to develop appropriate in-service training curriculum that is sensitive to the new needs and issues is jeopardized. The lack of a consistent methodology for streamlining implementation creates problems in planning pre-service academic rehabilitation counseling programs. The study utilized a Chi-Square analysis design due to the small sample size. However, while the sample size was small, the data were global in nature because each number analyzed represents thousands of individual Vocational Rehabilitation (VR) cases. Streamlining was developed to impact the success markers in a positive direction, i.e, clients with severe disabilities would obtain successful employment with higher wages after their employment, an increased number of individuals with severe disabilities would be served, and the VR counselor would spend less money to accomplish the employment goals. Each of the results examining these variables in this study was statistically significant in the states that had implemented streamlining. The study gave support to the premise that streamlining has a positive impact on the vocational rehabilitation process in increased wages for PS/FVR clients, reduced time in service, and decreased case service dollars spent.

Baggrund: Sammenhæng i sundhedsvæsenets aktiviteter er et aktuelt fokusområde. Den danske strukturreform af 2007 tilsigtede, udover at videre udvikle et demokratisk styret offentligt sundhedsvæsen, at skabe sammenhæng, effektivitet og kvalitet i sundhedsvæsenet. Denne undersøgelse ser nærmere på begrebet sammenhæng. Formål: Belyse fænomenet sammenhæng i genoptræning i relation til rygsygdom og i relation til strukturreformen. Metode: Undersøgelsen rummer kvalitative gruppeinterviews af patienter og sundhedsprofessionelle og en modificeret fænomenologisk analysemodel. Teorigrundlaget er tre forskellige perspektiveringer; et sundhedsplanlæggende-, et subjekt- og et integrationsperspektiv. Resultater: Sammenhæng i genoptræning er når udgangspunktet for genoptræningen er en klar diagnose, når genoptræningen subjekt orienteres, når ræsonnementer vedrørende ressourcer tænkes ind i genoptræningen og når den faglige kapacitet udnyttes maximalt. Konklusion: En klar diagnose er helt central for sammenhængen både for patienter og terapeuter. Strukturreformen har forandret rammerne og ansvarsfordelingen for genoptræning, men har ikke i sig selv forbedret sammenhængen. Sammenhæng kan relateres til evalueringsmodellen indeholdende struktur, proces og resultat.
Background: Cohesiveness in health care activities is a current topic. The Danish structural reform of 2007 intended to create coherence, efficiency and quality in health care and to further the development of Denmark´s democratically run public health care system. Purpose: This study aimed to look more closely at the phenomenon of cohesive rehabilitation in relation to the structural reform, particularly regarding low back pain. Method: The investigation used group interviews with patients and health professionals, and a modified fenomenological model of analyses. Its theory is based on three different perspectives: a health planning perspective, a particular subject perspective and an integration perspective. Results: Cohesive rehabilitation exists when the basis for rehabilitation includes an evident diagnosis, subject orientated, considerations of resources, and completely exploited professional knowledge. Conclusion: An evident diagnose is a crucial aspect of cohesive rehabilitation for both patients and health professionals. Although reform changed the settings and responsibilities of rehabilitation it did not increase cohesiveness. Cohesiveness can be related to the model of evaluation including structure, process and outcome.

ISBN 978-91-86739-04-1

Formål: Formålet med undersøgelsen har været at få indsigt i og viden om, hvordan nytilskadekomne rygmarvsskadede patienter oplever og opfatter at deltage i tværfaglige patientkonferencer, hvor deres rehabiliteringsforløb tilrettelægges. Metode: Undersøgelsesmetoden er kvalitativ med en fænomenografisk forskningstilnærmelse. Dataindsamlingen er foretaget ved hjælp af kvalitative semistrukturerede interview. Der er gennemført 15 interview blandt otte indlagte patienter, tre kvinder og fem mænd i alderen fra 28 til 75 år Resultat: Analysen viste at patienterne fandt, at det var meningsfuldt at deltage i patientkonferencer om eget rehabiliteringsforløb og for de fleste en nødvendig og selvfølgelig del af rehabiliteringen. Der blev identificeret fire beskrivende hovedkategorier: Patientkonferencer oplevedes støttende i en rehabiliteringsproces; Forskellige følelser var i spil; Pårørendes deltagelse havde betydning; Mødekultur og deltageres betydning Konklusion: Denne undersøgelse viste, at nytilskadekomne rygmarvsskadede og sorgfyldte patienter oplevede, at de var i stand til og gerne ville deltage aktivt i beslutninger i forhold til eget rehabiliteringsforløb. Tværfaglige patientkonferencer blev opfattet som et forum, hvor patienter og pårørende kunne få overblik og kontrol i en situation, hvor patienternes livssituation var kaotisk i relation til komplekse og omfattende fysiske funktionstab. Undersøgelsen har afdækket områder, som har vist sig at have haft betydning for, om patienterne oplevede disse konferencer som meningsfulde og tilfredsstillende
Aim: This study aimed to increase understanding of how patients newly injured with spinal cord lesion experience rehabilitation planning conferences with their clinicians and therapists. Method: I used a qualitative methodology within a phenomenographic research approach. Data was collected during 15 qualitative and semi-structured interviews with eight hospitalized patients (three women and five men) ranging in age between 28 to 75 years. Results: The data suggests that patients view participation in rehabilitation conferences as essential. Indeed, some patients deemed participation a necessary and natural part of their rehabilitation. Four main categories were identified: patient conferences support rehabilitation; emotional vulnerability; family participation matters; and atmosphere and location of conferences are critically important. Conclusion: The results show that patients newly injured by spinal cord lesion can and want to participate in decisions about their own rehabilitation, even when they are grieving and in a state of shock. Interdisciplinary patient conferences that include relatives provide an ideal environment and help patients gain oversight and control in an often chaotic life situation resulting from complex and substantial physical disabilities. The data also revealed areas for improvement that will help ensure meaningful and satisfactory patient conferences

ISBN 978-91-86739-14-0

Background: The high levels of sickness absence and disability pensioning experienced during the 1990's and 2000's have become both socially as well as financially burdensome for society. Sickness absence implies a costly loss of production for society and large groups of individuals are risking to become marginalised on the labour market. Sickness absence is both a public health and an economic problem. Thus from both a human approach as well as from an economic perspective it is urgent to increase knowledge about what influences individual behaviour when it comes to sickness absence and return to work. Objectives: The overall aim of the thesis is to elucidate the decisive factors for explaining sickness absence. Three different aspects of sickness absence were considered, i.e. factors leading to sickness absence, factors preventing sickness absence and factors leading back to work ability and work when being sickness absent. This is done using a frame of reference involving broadly defined areas of work, health and social insurance related factors. Material and methods: Study I analyzes the outcome of unemployed sick-listed individuals. A total of 280 individuals from the county of Värmland were followed through register data between the years 2000 to 2001. Linear and logistic regression models were used to analyze the occurrence of short and long term economic incentives. Study II has a longitudinal design and explores determinants of return to work. Sick-listed individuals with a stress-related psychiatric diagnosis from the county of Värmland were analyzed over a period of three years (2000-2003) using logistic regression. The data comprised 911 individuals. Study III is a cross-sectional study using questionnaire data from the county of Värmland from year 2004. A total of 3123 persons either working or being self employed were analyzed on determinants of work presence through logistic regression. Study IV had a cross-sectional design and used questionnaire data from five counties in central Sweden. The data, from 2004, comprised 10536 individuals being employed, i.e. not self-employed, and with self reported physical and mental medical conditions. Logistic regression was mainly used in the analysis and the focus was on risk factors for long term sickness absence. Study V comprises cross-sectional data retrieved at three separate occasions between 1991 and 1994. It includes 8839 individuals from five counties in western Sweden with sickness absence spells over 60 days. The data was analysed through bi-variate probit regression with a focus on effects of vocational rehabilitation on return to work. Results: The results from study I were interpreted as that both short and long term economic incentives matter for the outcome of sickness absence through the interaction of different insurance systems. The principal findings from study II was that age, gender and factors implying less favourable health characteristics and thereby lower work capacity, reduce probabilities of returning to work after long term sickness absence. Considering study III determinants of work presence were found to vary between sexes and whether the determinants were counteracting long or short term sickness absence. Factors interpreted as job control counteracted short term absence. Sense of coherence was found to be an important determinant of work presence for women. In study IV long term sickness absence was found to be related to the level of ill-health. Moreover it was concluded that work environment factors as job strain, job satisfaction, physical work environment were important factors for explaining sickness absence in a population with impaired health. The results from study V indicated that vocational rehabilitation is a potentially effective instrument for improving the individual's work ability and chances of return to work. That no signs of prioritizing selection of rehabilitation participants to those likely to return to work with or without rehabilitation measures, i.e. "managerial creaming", were found was also considered as important results. Conclusions: This thesis shows that we need different models and approaches to improve knowledge about the various aspects of sickness absence as entry into absence, return to work or into disability retirement. It also has the implications that sickness absence behaviour can be influenced. Largely depending on what long term path is chosen for welfare policy at the political level it should be acknowledged that other means, improving working conditions and promoting rehabilitation rather than reducing benefit levels and narrowing the eligibility criteria for the insurance benefits are at hand.

Legislative reforms aimed at slowing growth of US healthcare costs are focused on achieving greater value, defined specifically as health outcomes achieved per dollar spent. To increase value while payments are diminishing and tied to individual outcomes, healthcare must improve at predicting risks and outcomes. One way to improve predictions is through better modeling methods. Current models are predominantly based on logistic regression (LR). This project applied Reconstructability Analysis (RA) to data on hip and knee replacement surgery, and considered whether RA could create useful models of outcomes, and whether these models could produce predictions complimentary to or even stronger than LR models. RA is a data mining method that searches for relations in data, especially non-linear and higher ordinality relations, by decomposing the frequency distribution of the data into projections, several of which taken together define a model, which is then assessed for statistical significance. The predictive power of the model is expressed as the percent reduction of uncertainty (Shannon entropy) of the dependent variable (the DV) gained by knowing the values of the predictive independent variables (the IVs). Results showed that LR and RA gave the same results for equivalent models, and showed that exploratory RA provided better models than LR. Sixteen RA predictive models were then generated across the four DVs: complications, skilled nursing discharge, readmissions, and total cost. While the first three DVs are nominal, RA generated continuous predictions for cost by calculating expected values. Models included novel comorbidity variables and non-hypothesized interaction terms, and often resulted in substantial reductions in uncertainty. Predictive variables consisted of both delivery system variables and binary patient comorbidity variables. Complications were predicted by the total number of patient comorbidities. Skilled nursing discharges were predicted both by patient-related factors and delivery system variables (location, surgeon volume), suggesting practice patterns influence utilization of skilled nursing facilities. Readmissions were not well predicted, suggesting the data used in this project lacks the right variables or that readmissions are simply unpredictable. Delivery system variables (surgeon, location, and surgeon volume) were found to be the predominant predictors of total cost. Risk ratios were generated as an additional measure of effect size. These risk ratios were used to classify the IV states of the models as indicating higher or lower risk of adverse outcomes. Some IV states showed nearly 25% of patients at increased risk, while other IV states showed over 75% of patients at decreased risk. In real time, such risk predictions could support clinical decision making and custom-tailored utilization of services. Future research might address the limitations of this project's data and employ additional RA techniques and training-test splits. Implementation of predictive models is also discussed, with considerations for data supply lines, maintenance of models, organizational buy-in, and the acceptance of model output by clinical teams for use in real-time clinical practice. If outcomes and risk are adequately predicted, areas for potential improvement become clearer, and focused changes can be made to drive improvements in patient care. Better predictions, such as those resulting from the RA methodology, can thus support improvement in value--better outcomes at a lower cost. As reimbursement increasingly evolves into value-based programs, understanding the outcomes achieved, and customizing patient care to reduce unnecessary costs while improving outcomes, will be an active area for clinicians, healthcare administrators, researchers, and data scientists for many years to come.

Background: Aphasia is an acquired communication disorder that affects approximately 30% of first ever stroke survivors and persists one-year post-stroke in up to 61% of survivors. Aphasia impacts on all communication modalities with significant negative consequences for social participation, interpersonal relationships, autonomy, capacity to work and quality of life. It is recognised that the environment can influence neural remapping during early stroke recovery. However, patients with aphasia (PWA) following stroke have been observed to spend less than 30% of their day communicating and 44% of their day alone during their first weeks of in-patient rehabilitation. Inadequate opportunities for communication places PWA at risk of developing maladaptive behaviours such as learnt non-use of language. This can negatively impact on aphasia language recovery through lack of language use with adverse consequences for healthrelated quality of life. An enriched environment (EE) refers to conditions which promote physical, cognitive and social activity and has been shown in animal models of stroke to enhance neuroplasticity, promote better learning and memory, and contribute to significant improvements in motor function. The human equivalent model in an acute and a rehabilitation unit results in patients following stroke spending more time engaged in activity and less time sleeping and alone, however is yet to demonstrate positive effects on clinical outcomes. Aphasia is a complex language impairment and PWA may need support within an EE. This pilot study explores the development, implementation and investigation of an adapted model of an EE, a Communication Enhanced Environment (CEE) model, as a strategy to provide PWA and patients without aphasia (PWOA) greater opportunities to engage in language activities during in-patient rehabilitation early after stroke. Method: This before-and-after mixed methods pilot study involves one mixed acute and slow stream rehabilitation ward and one rehabilitation ward in a metropolitan private hospital in Perth, Western Australia. A hospital-based CEE model was developed, implemented and investigated. As a basis for implementation of an individual and systems-level behavioural change intervention, the study design aligned with implementation science principles. The study included: i. the before phase which involved observation of patients following stroke (the control group; n=7; PWA=3, PWOA=4). Behavioural mapping was completed during the first minute of each five-minute interval over 12 hours (between 7am and 7pm) to determine patient engagement in language activities. Semi-structured interviews which incorporated a qualitative description approach were conducted with patients (n=7) to determine factors that were perceived to facilitate or create a barrier for communication. A qualitative description approach was also used throughout focus groups that were conducted with hospital staff and volunteers (n=51) to explore their perceptions of: their knowledge of, skills with, and attitude towards aphasia and communication; opportunities for potentially enhancing communication and language activities for patients; and additional aspects that could be included in the CEE model. ii. the implementation phase where the CEE model was developed and embedded in usual care. iii. the after phase which involved repeated data collection with a different cohort of patients (the intervention group; n=7; PWA=4, PWOA=3). The availability of the CEE model was monitored by hospital site investigators (a senior physiotherapist and a speech pathologist). Comparisons of patient engagement in language activity levels were conducted. Patient interviews (n=7) and staff and volunteer focus groups (n=22) were conducted. This was to determine differences following the implementation of the CEE model in: patient experiences of communication; hospital staff knowledge of, skills with, and attitudes towards aphasia and communication; and staff experiences of the implementation and use of the CEE model. Results: A total of 29 of the 41 (71%) CEE model initiatives were reported to be available to the intervention group. A total of 24 of the 29 (83%) CEE model initiatives were reported to be available for PWA. A total of 5 of the 12 (42%) CEE model initiatives were reported to be available for PWOA. The intervention group engaged in higher, but not significant (CI 95%), levels of language activities (600 of 816 observation time points, 73%) than the control group (551 of 835 observation time points, 66%). Patients described variable experiences accessing different elements of the CEE model, which were influenced by individual patient factors, staff factors, hospital features as well as staff time pressures. Patients who were able to access elements of the CEE model described positive opportunities for their engagement in language activities. Staff perceived the CEE model increased their knowledge of aphasia and developed their skills and confidence in using communication supportive strategies. After the implementation of the CEE model, staff reported embedding communication within usual care tasks and rehabilitation activities, and perceived communication as a shared responsibility within the multidisciplinary team. There were several unforeseen factors that occurred which may have influenced the implementation and use of the CEE model including: a reduction in stroke admissions at the hospital site; a reduction in nurse-to-patient ratio; a ward reconfiguration; and reduced access to communal dining opportunities. Staff identified a range of factors which influenced the implementation and use of the CEE model. These included: the hospital context; and individual staff, volunteer and patient characteristics; the ease of use for both staff and patients and the implementation approach. Conclusions: Consideration of implementation science approaches in this pilot study informed the development of a CEE model. This individual and service-level multidisciplinary team intervention was successfully implemented in clinical practice in a mixed acute and slow stream rehabilitation ward and a rehabilitation ward in a private hospital. This study demonstrated that the implementation of a CEE model within this hospital setting was feasible, with patients, staff and volunteers reacting positively to the CEE model overall. The unforeseen contextual challenges that occurred during the study period were beyond the control of the research team and demonstrated the everchanging and challenging nature of the hospital environment. The reduced availability of the CEE model for PWOA requires further attention to determine if the elements of the CEE model could be better applied to meet the needs of this population. Differences between levels of patient language activity before-and-after the implementation of the CEE model did not reach statistical significance. However, some individual increases taken together with the positive feedback suggest that a CEE model has value in enhancing the ward environment for staff and volunteers, the hospital system, and patients following stroke. This study highlights the complex and dynamic nature of the hospital environment which should be considered in future studies investigating individual and hospital service-level interventions such as EE or CEE models. Staff perceptions of factors contributing to the implementation and use of the CEE model provide valuable insights which may inform the implementation approach of future innovative interventions and subsequent development of the CEE model. Results from this study highlight the need to further explore the question of feasibility of a CEE model and patient access to the intervention across multiple ward contexts before we can explore the question of effectiveness. Future iterations of a CEE model should co-designed with patients and their family members.

Formål: Å undersøke foreldreerfaringer med tjenester fra Habiliteringstjenesten for barn i Nord-Trøndelag, Norge. Metode: Det ble gjort en deskriptiv tverrsnittsundersøkelse blant foreldre, hvis barn fikk tjenester fra avdelingen i en periode på et år. MPOC-20 NO, et spørreskjema spesielt utviklet for målgruppen og oversatt til norsk, ble brukt. Det inneholder fem faktorer: dyktiggjøring og parterskap, generell informasjon, spesifikk informasjon, helhetlige og koordinerte tjenester og respektfull og støttende omsorg. Det er 3-5 spørsmål innen hver faktor. Resultater: Svarprosenten ble 54,4% og foreldre til barn med større funksjonsvansker var overrepresentert blant svarene. Resultatene bør derfor tolkes med forsiktighet. Resultatene viste at gjennomsnittskår på generell informasjon var lavere enn på de andre faktorene. Gjennomsnittsskår i Nord-Trøndelag var lavere enn resultater fra Canada, men lik resultater fra Uppsala, Sverige. Foreldre til barn under 6 år hadde bedre erfaringer enn foreldre med eldre barn. Foreldre til barn med mindre funksjonsvansker ga bedre tilbakemeldinger. Foreldre under 36 år og mødre hadde bedre erfaringer enn eldre foreldre og fedre. Foreldre som bodde mindre enn 11 dager/mnd sammen med barnet hadde lavere tilfredshet. Å ha en individuell plan og/eller koordinator utgjorde en positiv forskjell på informasjonsområdet, men ikke på de andre faktorene. Konklusjon: Svarene viste at visse områder og kvaliteter ved avdelingens tjenester burde videreutvikles og noen grupper av foreldre burde få et tjenestetilbud bedre tilpasset deres behov. Det bør vurderes andre metoder for rekruttering til spørreundersøkelse og innhenting av svar fra målgruppen for å sikre høyere svarprosent.
Aim: To explore experiences with professional services among parents of disabled children in contact with Childrens Habilitation Department in Nord-Trøndelag, Norway. Method: A descriptive cross-sectional survey among parents, who’s children received services from the Childrens Habilitation Department during one year, was done. MPOC-20 NO, a questionnaire developed for this target group and translated into norwegian, was used. It consists of five factors: enabling/partnership, general information, spesific information, co-ordinated/comprehensive care and respectful/supportive care. Each factor consists of 3 – 5 questions. Results: The respons rate was 54,5%, parents of children with severe disabilities were overrepresented. Thus the results should be interpreted with care. The mean score on general information was lower than on other factors. The mean scores in Nord-Trøndelag was generally lower than in Canada, but about the same as results from Uppsala, Sweden. Parents of children under 6 years had better experiences than parents with older children. Parents with children with minor disabilities were more satisfied than others. Parents under 36 years and mothers had better experiences than older parents and fathers. Parents living together with their child less than 11 days/month were less satisfied than others. Having a key worker and/or an individual service plan made a positive difference on information factors, but not on the other factors. Conclusion: The answers showed that certain areas and qualities of the departments service should be better developed and some groups of parents should get a service delivery more fitted to their needs. Other methods should be considered to recruite parents and collect anwers to ensure a higher response rate.

ISBN 978-91-85721-37-5

ABSTRACT Background: Previous criminal justice policies have been non-effective leading to overpopulated prisons and unsuccessful reintegration. There is a lack of effective supportive and/or rehabilitative services resulting in high rates of recidivism and mental health implications. Objective: This study investigated the perceived impact that incarceration and reintegration with little to no supportive and/or rehabilitative services has on the mental health status of an individual. The emphasis was on participant perception and not on professional reports because of underreporting and lack of attention to mental health in the criminal justice system. Methods: Focus groups in the Inland Empire and Coachella Valley were held to gather preliminary data used to develop the survey for this study. The survey was distributed to 88 male and female ex-offenders over the age of 18 who were no longer on probation or parole. Secondary data from United Way 211 and California State Reentry Initiative was collected to report current trends of supportive and/or rehabilitative services. Results: Incarceration was found to negatively impact perceived mental health status, but reintegration was not. Supportive and/or rehabilitative services continue to be rarely offered and accessed, but when accessed, perceived mental health status is better. Supportive and/or rehabilitative services are more readily available. People who are using these services are improving their quality of life, becoming productive members of society, and preventing recidivism. Conclusions: A paradigm shift is currently under way to reduce recidivism by improving supportive and/or rehabilitative services during incarceration and reintegration. Many offenders are receiving services as an alternative to incarceration, recidivism rates are being reduced, and ex-offenders are becoming productive members of society. The field of social work is an integral part of reentry services and should continue advocating for policies and services that support reintegration efforts at the micro and macro level.

This thesis shows how the Process Analysis Method (PAM) can be applied to assess technologies used to mitigate arsenic from drinking water in rural India, using a set of sustainability indicators. Stakeholder perspectives, gathered from a fieldwork survey of 933 households in West Bengal in 2012, played a significant role in this assessment. This research found that the ‘Most Important’ issues as specified by the technology users are cost, trust, distance from their home to the clean water source (an indicator of convenience), and understanding the health effects of arsenic. It was also found that none of the ten technologies evaluated are economically viable, as many do not charge user-fees, which creates reliance upon donations to meet recurring costs. Utilisation of a technology is strongly related to sociocultural capital, but in many cases, features that contribute to sociocultural value, like regular testing of the treated water, are not included in the financial budget. It is suggested that increased awareness might change attitudes to arsenic-rich waste and its disposal protocols. This waste is often currently discarded in an uncontrolled manner in the local environment, giving rise to the possibility of point-source recontamination. All technologies proved to have difficulties in dealing with waste, except the Tipot and Dug wells which produce no waste. Of the methods considered, the BESU technology scored highest, but still only with 47-62% of the maximum scores achievable within each domain. This explains the widespread failure of mitigation projects across the region. The indicators and metrics show where improvements can be made. A model scheme based on these findings is outlined which could be applied with the objective of increasing utilisation and improving sustainability. It can be concluded that a product stewardship approach should be taken in regard to design, implementation and operation of the technologies, including the creation of a regulated toxic waste collection and disposal industry.

Through research, inquiry, and an evaluation of Recovery By Design, a ‘design therapy’ program that serves people with mental illness, substance use disorders, and developmental disabilities, it is my assertion that the practice of design has therapeutic potential and can aid in the process of recovery. To the novice, the practices of conception, shaping form, and praxis have empowering benefit especially when guided by Conditional and Transformation Design methods together with an emphasis on materiality and vernacular form.

More than 2.6 million troops have deployed in support of the wars in Iraq and Afghanistan. Still, surveys reveal that more than half feel “disconnected” from their civilian counterparts, and this feeling persists despite ongoing efforts, in the academy and elsewhere, to help returning veterans overcome physical and mental wounds, seek an education, and find meaningful ways to contribute to society after taking off the uniform. This dissertation argues that Iraq and Afghanistan War veterans struggle with reassimilation because they lack healthy, complete models of veteran identity to draw upon in their postwar lives, a problem they’re working through collectively in literature and artwork. The war veteran—returning home transformed by the harsh realities of military training and service, having seen humanity at its extremes, and interacting with a society apathetic toward his or her experiences—should engage in the act of storytelling. This act of sharing experiences and crafting-self subverts stereotypes. Storytelling, whether in a book read by millions, or in a single conversation with a close family member, should instruct civilians on the topic of human resiliency; it should instruct veterans on the topic of homecoming. But typically, veterans do not tell stories. Civilians create barriers to storytelling in the form of hollow platitudes—“thank you for your service” or “I can never understand what you’ve been through”—disconnected from the meaning of wartime service itself. The dissonance between veteran and civilian only becomes more complicated when one considers the implicit demands and expectations attached to patriotism. These often well-intentioned gestures and government programs fail to convey a message of appreciation because they refuse to convey a message of acceptance; the exceptional treatment of veterans by larger society implies also that they are insufficient, broken, or incomplete. So, many veterans chose conformity and silence, adopting one of two identities available to them: the forever pitied “Wounded Warrior” or the superficially praised “Hero.” These identities are not complete. They’re not even identities as much as they are collections of rumors, misrepresentations, and expectations of conformity. Once an individual veteran begins unconsciously performing the “Wounded Warrior” or “Hero” character, the number of potential outcomes available in that individual’s life is severely diminished. Society reinforces a feeling among veterans that they are “different.” This shared experience has resulted in commiseration, camaraderie, and also the proliferation of veterans’ creative communities. As storytellers, the members of these communities are restoring meaning to veteran-civilian discourse by privileging the nuanced experiences of the individual over stereotypes and emotionless rhetoric. They are instructing on the topics of war and homecoming, producing fictional and nonfictional representations of the veteran capable of competing with stereotypes, capable of reassimilation. The Introduction establishes the existence of veteran culture, deconstructs notions of there being a single or binary set of veteran identities, and critiques the social and cultural rhetoric used to maintain symbolic boundaries between veterans and civilians. It begins by establishing an approach rooted in interdisciplinary literary theory, taking veteran identity as its topic of consideration and the American unconscious as the text it seeks to examine, asking readers to suspend belief in patriotic rhetoric long enough to critically examine veteran identity as an apparatus used to sell war to each generation of new recruits. Patriotism, beyond the well-meaning gestures and entitlements afforded to veterans, also results in feelings of “difference,” in the veteran feeling apart from larger society. The inescapability of veteran “difference” is a trait which sets it apart from other cultures, and it is one bolstered by inaccurate and, at times, offensive portrayals of veterans in mass media and Hollywood films such as The Manchurian Candidate (1962), First Blood (1982), or Taxi Driver (1976). To understand this inescapability the chapter engages with theories of race, discussing the Korean War veteran in Home (2012) and other works by Toni Morrison to directly and indirectly explore descriptions of “difference” by African Americans and “others” not in positions of power. From there, the chapter traces veteran identity back to the Italian renaissance, arguing that modern notions of veteran identity are founded upon fears of returning veterans causing chaos and disorder. At the same time, writers such as Sebastian Junger, who are intimately familiar with veteran culture, repeatedly emphasize the camaraderie and “tribal” bonds found among members of the military, and instead of creating symbolic categories in which veterans might exist exceptionally as “Heroes,” or pitied as “Wounded Warriors,” the chapter argues that the altruistic nature which leads recruits to war, their capabilities as leaders and educators, and the need of larger society for examples of human resiliency are more appropriate starting points for establishing veteran identity. The Introduction is followed by an independent “Example” section, a brief examination of a student veteran named “Bingo,” one who demonstrates an ability to challenge, even employ veteran stereotypes to maintain his right to self-definition. Bingo’s story, as told in a “spotlight” article meant to attract student veterans to a college campus, portrays the veteran as a “Wounded Warrior” who overcomes mental illness and the scars of war through education, emerging as an exceptional example—a “Hero”—that other student veterans can model by enrolling at the school. Bingo’s story sets the stage for close examinations of the “Hero” and the “Wounded Warrior” in the first and second chapters. Chapter One deconstructs notions of heroism, primarily the belief that all veterans are “Heroes.” The chapter examines military training and indoctrination, Medal of Honor award citations, and film examples such as All Quiet on the Western Front (1930), Heroes for Sale (1933), Sergeant York (1941), and Top Gun (1986) to distinguish between actual feats of heroism and “Heroes” as they are presented in patriotic rhetoric. The chapter provides the Medal of Honor citations attached to awards presented to Donald Cook, Dakota Meyer, and Kyle Carpenter, examining the postwar lives of Meyer and Carpenter, identifying attempts by media and government officials to appropriate heroism—to steal the right to self-definition possessed by these men. Among these Medal of Honor recipients one finds two types of heroism: Sacrificing Heroes give something of themselves to protect others; Attacking Heroes make a difference during battle offensively. Enduring Heroes, the third type of heroism discussed in the chapter, are a new construct. Colloquially, and for all intents and purposes, an Enduring Hero is simply a veteran who enjoys praise and few questions. Importantly, veterans enjoy the “Hero Treatment” in exchange for silence and conforming to larger narratives which obfuscate past wars and pave the way for new ones. This chapter engages with theorists of gender—such as Jack Judith Halberstam, whose Female Masculinities (1998) anticipates the agency increasingly available to women through military service; like Leo Braudy, whose From Chivalry to Terrorism (2003) traces the historical relationship between war and gender before commenting on the evolution of military masculinity—to discuss the relationship between heroism and agency, begging a question: What do veterans have to lose from the perpetuation of stereotypes? This question frames a detailed examination of William A. Wellman’s film, Heroes for Sale (1933), in the chapter’s final section. This story of stolen valor and the Great Depression depicts the homecoming of a WWI veteran separated from his heroism. The example, when combined with a deeper understanding of the intersection between veteran identity and gender, illustrates not only the impact of stolen valor in the life of a legitimate hero, but it also comments on the destructive nature of appropriation, revealing the ways in which a veteran stereotypes rob service men and women of the right to draw upon memories of military service which complete with those stereotypes. The military “Hero” occupies a moral high ground, but most conceptions of military “Heroes” are socially constructed advertisements for war. Real heroes are much rarer. And, as the Medal of Honor recipients discussed in the chapter reveal, they, too, struggle with lifelong disabilities as well as constant attempts by society to appropriate their narratives. Chapter Two traces the evolution of the modern “Wounded Warrior” from depictions of cowardice in Stephen Crane’s The Red Badge of Courage (1895), to the denigration of World War I veterans afflicted with Shell Shock, to Kevin Powers’s Iraq War novel, The Yellow Birds (2012). As with “Heroes,” “Wounded Warriors” perform a stereotype in place of an authentic, individualized identity, and the chapter uses Walt Kowalski, the protagonist of Clint Eastwood’s film, Gran Torino (2008), as its major example. The chapter discusses “therapeutic culture,” Judith Butler’s work on identity-formation, and Eva Illouz’s examination of a culture obsessed with trauma to comment on veteran performances of victimhood. Butler’s attempts to conceive of new identities absent the influence of systems of definition rooted in the state, in particular, reveal power in the opposite of silence, begging another question: What do civilians have to gain from the perpetuation of veteran stereotypes? Largely, the chapter finds, the “Wounded Warrior” persists in the minds of civilians who fear the veteran’s capacity for violence. A broken, damaged veteran is less of a threat. The story of the “Wounded Warrior” is not one of sacrifice. The “Wounded Warrior” exists after sacrifice, beyond any measure of “honor” achieved in uniform. “Wounded Warriors” are not expected to find a cure because the wound itself is an apparatus of the state that is commodified and injected into the currency of emotional capitalism. This chapter argues that military service and a damaged psyche need not always occur together. Following the second chapter, a close examination of “The Bear That Stands,” a short story by Suzanne S. Rancourt which confronts the author’s sexual assault while serving in the Marines, offers an alternative to both the “Hero” and the “Wounded Warrior” stereotypes. Rancourt, a veteran “Storyteller,” gives testimony of that crime, intervening in social conceptions of veteran identity to include a female perspective. As with the example of Bingo, the author demonstrates an innate ability to recognize and challenge the stereotypes discussed in the first and second chapters. This “Example” sets the stage for a more detailed examination of “Veteran Storytellers” and their communities in the final chapter. Chapter Three looks for examples of veteran “difference,” patriotism, the “Wounded Warrior,” and the “Hero” in nonfiction, fiction, and artwork emerging from the creative arts community, Military Experience and the Arts, an organization which provides workshops, writing consultation, and publishing venues to veterans and their families. The chapter examines veteran “difference” in a short story by Bradley Johnson, “My Life as a Soldier in the ‘War on Terror.’” In “Cold Day in Bridgewater,” a work of short fiction by Jerad W. Alexander, a veteran must confront the inescapability of that difference as well as expectations of conformity from his bigoted, civilian bartender. The final section analyzes artwork by Tif Holmes and Giuseppe Pellicano, which deal with the problems of military sexual assault and the effects of war on the family, respectively. Together, Johnson, Alexander, Holmes, and Pellicano demonstrate skills in recognizing stereotypes, crafting postwar identities, and producing alternative representations of veteran identity which other veterans can then draw upon in their own homecomings. Presently, no unified theory of veteran identity exists. This dissertation begins that discussion, treating individual performances of veteran identity, existing historical, sociological, and psychological scholarship about veterans, and cultural representations of the wars they fight as equal parts of a single text. Further, it invites future considerations of veteran identity which build upon, challenge, or refute its claims. Conversations about veteran identity are the opposite of silence; they force awareness of war’s uncomfortable truths and homecoming’s eventual triumphs. Complicating veteran identity subverts conformity; it provides a steady stream of traits, qualities, and motivations that veterans use to craft postwar selves. The serious considerations of war and homecoming presented in this text will be useful for Iraq and Afghanistan War veterans attempting to piece together postwar identities; they will be useful to scholars hoping to facilitate homecoming for future generations of war veterans. Finally, the Afterword to the dissertation proposes a program for reassimilation capable of harnessing the veteran’s symbolic and moral authority in such a way that self-definition and homecoming might become two parts of a single act.

Musculoskeletal pain is highly prevalent and a significant contributor to global disability and disease, with most countries reporting neck and low back pain as a leading cause of disability. The use of the complementary therapy, dry cupping and its modified technique, myofascial decompression are becoming an increasingly popular modality utilised by manual and physical therapists in western clinical practice, aimed at reducing musculoskeletal pain and improving mobility. The aim of this thesis was to investigate the efficacy of dry cupping techniques in the treatment of musculoskeletal pain and improving range of motion. Firstly, this research critically evaluated the evidence from randomised controlled trials through a systematic review and meta-analysis to determine the efficacy and safety of western dry cupping methods. A systematic literature search was performed from March until April 2018, for randomised controlled trials (RCT) pertaining to musculoskeletal pain or reduced range of motion, treated with dry cupping. Outcomes were pain, functional status, range of motion and adverse events. Risk of bias and quality of evidence was assessed using the modified Downs & Black checklist and GRADE. A total of 21 RCTs with 1049 participants were included. Overall, the quality of evidence was fair, with a mean Downs & Black score of 18/28. Low-quality evidence revealed that dry cupping had a significant effect on pain reduction for chronic neck pain (MD, -21.67; 95% CI, -36.55, to -6.80) and low back pain (MD, -19.38; 95%CI, -28.09, to -10.66). Moderate-quality evidence suggested that dry cupping improved functional status for chronic neck pain (MD, -4.65; 95%CI, -6.44, to -2.85). For range of motion, low quality evidence revealed a significant difference when compared to no treatment (SMD, -0.75; 95%CI, -0.75, to 0.32). Dry cupping was found to be effective for reducing pain in patients with chronic neck pain and non-specific low back pain. However, definitive conclusions regarding the effectiveness and safety of dry cupping for musculoskeletal pain and range of motion were unable to be reached due to the low to moderate quality of evidence. Secondly, this research aimed to test the feasibility of a randomised controlled crossover trial comparing dry cupping techniques to provide recommendations for future research. The study compared myofascial decompression (dry cupping with active movement) with static dry cupping (dry cupping with no movement) and an active movement protocol (control) and assessed pressure pain threshold and range of motion. This study’s findings suggest that dry cupping techniques improve both pain threshold and range of motion; however, it is unknown whether myofascial decompression is superior to active movement only and could be investigated in future studies. This thesis provides a critical review of the available evidence for the use of dry cupping therapy for musculoskeletal conditions. For definitive conclusions on the efficacy of dry cupping, further systematic reviews and meta-analyses are required as larger dry cupping randomised controlled trials are published. Furthermore, this thesis provides a basis for future research to be undertaken, specifically investigating the efficacy of myofascial decompression for the treatment of musculoskeletal pain and improving range of motion.

The Second Joint Research Conference of the Universities of Gloucestershire and Chemnitz took place at the Chemnitz University of Technology from 09th to 11th of September 2009. There were presenters from seven different nations in the lecture theatre. The very close partnership of the two institutions is characterised by a very active student exchange programme, joint teaching modules and some collaborative research which has been extended after the conference as well as several extracurricular guest lectures. In 2007 our friends from Gloucester invited us to our first joint conference and set the standard. The topics of the 2009 Conference were Public health and Sports with three main areas of interest: 1. Physiology and Biomechanics, 2. Philosophy and Social Science, 3. Prevention, Rehabilitation and Health Promotion. Many interesting and inspiring presentations were given by colleagues, PhD students and research students. One example of inspiration was the Clem Burke Drumming Project (S. Draper and M. Smith), which we were kindly invited to join. This is an example par excellence on how to conduct international research by simply using existing resources and talking to each other. It caused huge interest among colleagues across the whole university that Chemnitz did not only follow the example of our colleagues in Gloucester, but also widened the research interest into the application of different types of drumming as a means of therapy. This was the beginning of the DRUM BEAT Project (P. Wright of the Chair of Sports Medicine). Furthermore, both universities - Chemnitz and Gloucester - are trying to establish outreaching programmes with local communities which have practical implications of research in the context of public health and/or health promotion. One of the presentations for instance referred to a concept called the Healthy Town Project Tewkesbury, a similar project is planned for Chemnitz called Healthy Community. These two outreaching programmes and other research synergies could be part of an attempt of both universities to establish stronger international research links and in this context also submitting joint proposals to funding agencies, i.e. the EU. Since this conference a joint EU research proposal was submitted by colleagues in Gloucester. Also, talks were held on the topic of establishing a joint international degree. Understandably a project of this scale will take more than a couple of conferences and work on both sides is necessary and last but not least is also depending on the political and funding situation. However, first small step was taken after the conference by conducting a joint teaching module in the Ore Mountains /Saxony. Students from both institutions and colleagues conducted a research project comparing physiological and cognitive parameters of cross-country skiing and running. Social and intercultural processes were just as important during this winter camp. Some of the data is presented in this book. I trust that the colleagues of both universities do agree that this is an outstanding and very productive partnership with a lot of potential for future development and I am looking forward to many more joint schemes, projects and conferences to come - perhaps even an international degree. Prof. Dr. Henry Schulz

Cognitive Rehabilitation is an umbrella term which encompasses a number of restorative and compensatory techniques commonly and widely applied to assist with the sequelae following traumatic brain injury (TBI). Such techniques have been well established within the literature. More recently, an increasing body of research has emerged suggesting that electroencephalography (EEG) biofeedback is an effective intervention for sequelae following TBI. The purpose of the study was to investigate the effectiveness of cognitive rehabilitation and EEG biofeedback as treatments for moderate to severe TBI. It aimed to determine the effectiveness of each intervention in treating cognitive, emotional, and behavioural sequelae following TBI. Methods: A multiple single case study cross-over (ABBA) design was used with six adult participants, no less than one year post TBI. Three of the participants received the two treatments in the opposite order to the remaining participants, each serving as their own controls. Over ten weeks, each participant received 20 hours of Treatment A. Then, following a ten week break they received 20 hours of Treatment B, with a final ten week follow-up. A number of cognitive, emotional, and behavioural measures were administered pre-post treatments. Quantitative electroencephalographs (qEEG) were also administered pre-post treatments to evaluate any change in the electrophysiological dynamics of the brain. Results: EEG biofeedback appeared to be more effective than cognitive rehabilitation in improving information processing impairments, namely, complex attentional control, response inhibition, and speed of language and comprehension. Cognitive rehabilitation appeared to be more effective than EEG biofeedback in improving visual memory. Both treatments were effective in reducing depression, anxiety, anger, and neurobehavioural symptomatology. Although both treatments were effective in reducing depression, greater reductions were evident following EEG biofeedback. A number of self-reported functional changes were also noted by each participant. EEG biofeedback was more effective than cognitive rehabilitation in the normalisation of dysregulated EEG (as measured by qEEG). Conclusions: Overall, EEG biofeedback appeared to be more effective in improving information processing skills, while cognitive rehabilitation was more effective in improving visual memory. Both treatments were effective in the treatment of emotional and behavioural sequelae following TBI. EEG biofeedback was more effective in normalising the participants'. However, the clinical meaningfulness of the qEEG finding is questioned. Speculations are made about the possible functional brain changes which may occur following rehabilitation.

Tennis is a popular racquet sport played at various ability levels. It can be played from early childhood through to an elderly age. The aim of this study was to determine the injuries obtained by Victorian Institute of Sport, Australian Institute of Sport and Grade 1 or State Grade pennant players in the 15-25 year age group, over a 6-month period from February-July 2005. This study also sought to determine the medical care participants sought for their injuries and the impact of the injury in terms of time lost from play. The study investigated injury patterns in players attempting to enter a world-class standard of tennis. From this study it was concluded that upper extremity injuries were the most common region injured. The wrist is the most common specific location of a tennis injury. Overuse injuries, especially sprains and strains are the most common type of perceived injury in this population. Players who are injured spend less time cross training than non-injured players. Remedial/Massage Therapists is the most common health professional sought by the young sub-elite player. It is hoped that data obtained from this study may be useful in constructing strength/conditioning programs to help potentially reduce the number of injuries and effect of injuries in the sub-elite junior tennis player. This minor thesis was written by a post-graduate student as part of the requirements of the Master of Health Science (Osteopathy) program.