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The aims of this thesis were to investigate the changes in muscle strength that occur in older adults during unplanned hospital admissions, and to investigate the feasibility and efficacy of in-hospital exercise interventions in improving muscle strength and functional outcomes. To investigate changes in muscle strength during hospitalisation, I conducted a systematic review and meta-analysis, and a repeated measures cohort study. The review concluded that adult patients who undergo an unplanned hospital admission may, regardless of age, experience a reduction of around 10% in knee-extension strength. To corroborate these findings in an older general medical population, I conducted a cohort study, which included 70 participants aged ≥75 recruited within 24 hours of acute hospital admission. Knee-extension strength declined during hospitalisation by 11% (p <0.001) but did not change by follow-up four to six weeks after hospitalisation (p = 0.458). General functional ability as measured by the Barthel Index deteriorated by 9 points (10%) between two weeks before admission and follow-up (p < 0.001). Functional mobility as measured by the de Morton Mobility Index improved by 6.5 points (15%) during hospitalisation (p < 0.001) but had not changed at follow-up (p = 0.508). A repeated measures mixed model showed that greater loss in knee-extension strength during hospitalisation was associated with increased sedentary time, frailty, baseline strength and lower baseline inflammatory levels. To investigate the feasibility and efficacy of in-hospital exercise interventions, I conducted a feasibility study and a meta-analysis. The feasibility study found that it is possible to conduct a randomised control trial of a twice-daily exercise programme for older adults during an acute hospital admission in an NHS hospital. The exercise intervention was well received, with most participants describing health benefits in terms of both physical improvement and increased confidence. The meta-analysis concluded that there is low certainty of evidence that exercise interventions, and more specifically progressive resistance training, when compared to usual care or sham interventions, results in improved independence with activities of daily living and functional mobility at discharge from hospital, without increasing the risk of adverse events. The thesis has several limitations including: that the primary research studies were all single-centre studies using convenience samples thereby limiting generalisability; that causality between sedentary activity and loss of knee-extension strength could not be confirmed in an observational design; and that recruitment to the feasibility study achieved only half of the initial target. Nevertheless, the objectives of the thesis were met, and provide a solid foundation to continue the development of interventions to prevent hospital-associated deconditioning. In line with the MRC guidance on the development of complex interventions, next steps will include refinement of the intervention, including identifying or developing an appropriate behavioural change theory, before further feasibility work and evaluation of the intervention.

This thesis critically explores and evaluates my own portfolio of music therapy work and reflects on my professional experience and dimensions of practice in different contexts. The critical review is framed by an evolving model of music therapy research, practice and pedagogy based on my own experience that explores questions relating to the identity of the C21st music therapist. The review contains three projects that illustrate the clinical, research and pedagogical elements of my work. It explores reflexively not only my own professional identity as an HCPC registered music therapist, but also the relevance of such a model to the profession as a whole. Project 1 contains work linked to the MA Music Therapy course at USW, Project 2 is centred on the development and evaluation of Interactive Therapeutic Music Making skill-sharing in Palestine, while Project 3 documents a low-intensity pilot music therapy project in a neonatal unit in South Wales. The projects are supported by a carefully curated selection of outputs that illustrate the scope and impact of the work. Within the model, two lenses are used to aid critical reflection. These are applied for the first time to music therapy practice. Using Healey's (2005) research/practice nexus as a retrospective critical lens, I specifically examine pedagogy as an overarching theme in each project while Boyer's Model of Scholarship (1990) provides a useful reflective lens to highlight the impact of my work in this field. Additionally, the idea and influence of pedagogical thinking being part of the work carried out by music therapists in certaincontexts has not being articulated in music therapy literature to date, while the development of a music therapy-specific pedagogy remains underrepresented in academic writing. The review highlights this aspect of music therapy practice and demonstrates the contribution to knowledge made by the application of this model and the selected lenses to music therapy practice in the twenty-first century in Wales, the United Kingdom and internationally. It challenges music therapists currently practising to review their identity in the light of this model, and to be proactive in celebrating the potential for this profession to contribute to contemporary healthcare.

This thesis is a philosophical criticism of physiotherapy ethics through the work of Theodor W. Adorno that adds to the growing literature on critical physiotherapy-a physiotherapy research field that draws on philosophy and critical social science. This is the first extended reading of Adorno in the context of physiotherapy and, more broadly, in healthcare. The thesis falls broadly within applied philosophy and ethics. My purpose is to reconfigure the understanding of theory and practice in physiotherapy ethics. I aim to answer the following: 1) How might the relationship between theory and practice be understood in physiotherapy? 2) How does Adorno's thinking help to clarify the relationship between theory and practice in physiotherapy? 3) How does the sort of understanding that emerges help to advance critical understanding of physiotherapy? The central ideas from Adorno's thinking that frame my argument are the following. First, Adorno's philosophy criticises objects 'immanently'-from within them rather than using external criteria. Second, Adorno criticises 'identity thinking'-the tendency to attach concepts to objects to categorise them-to emphasise the importance of the non-conceptual for rationality. Third, to open up rationality to the non-conceptual, Adorno uses the notion of 'constellations' to surround the object with concepts rather than simply attaching a definition to the object. Fourth, Adorno insists on the 'priority of the object': theory must begin with its object which mediates the response of philosophical practice. Finally, Adorno was an adamant critic of positivism. Chapter 1 frames the thesis by tracing Adorno's thinking about the relationship between theory and practice. Adorno argues that theory is a form of practice: theory must place its object as primary and aim at affecting change in a world that is antagonistic to its core. Theory must not prescribe the path to a better world but analyse why change for the better is not happening. Chapter 2 extends Chapter 1 to outline the idea of theory as practice for physiotherapy ethics and to defend theoretical analyses both against the notion of 'evidence-based ethics' and mistaken views of philosophical theory. Chapter 3 is a criticism of identity thinking in the claim that clarifying what the concept of 'person-centredness' is leads to the related practice becoming better. A direct path from clarified concept to practice is not guaranteed. Instead, I argue for placing 'person-centredness' in a constellation. Chapter 4 criticises immanently the four principles approach-a liberal theory of healthcare ethics that enjoys endorsement but has also been criticised widely. My criticism reveals that instead of placing the principle-abiding subject as primary, the priority of the object offers a basis for physiotherapy ethics. Chapter 5 focuses on Adorno's somatic philosophy and how physiotherapy ethics might be anchored in the body, its vulnerability and suffering.

The aim of the work described in this thesis is to design a wearable phototherapy device utilising LEDs. Phototherapy is the use of light to treat medical conditions, such as, eczema, psoriasis and newborn jaundice. Treatment usually takes place in a clinical environment, but a recent focus for phototherapy is the development of at-home devices. Currently available technologies consist of rigid LED arrays; identifying the treatment regime with these devices is diffcult due to the non-uniform light distribution. A poten-tial solution to this problem is to create a flexible and conformable device that allows for uniform light distribution over the treatment area by incorporating light scattering features. Broad area LEDs (UV and blue) and blue micro-sized LEDs are utilised as the light source coupled into the end of a thin polydimethylsiloxane membrane. High refractive index nanoparticles are embedded in a substrate and used to extract light from the surface of the membrane. By changing the size of these substrates, or by changing the nanoparticle concentration inside the substrates, uniform irradiance is demonstrated over an area of 15 x 15 mm2. Though not demonstrated in this thesis, there is potential for treatment over larger areas. Colloidal quantum dots can be embedded in elastomeric materials and used to down-convert the LED light into lower energy wavelengths. This is shown with red wavelength emitting quantum dots, producing a uniform red irradiance over the substrate area. A similar technique is shown to produce multi-wavelength blue and red uniform emission over the extraction area. The output of the device can be optimised by adding flexible reflective layers to one side of the membrane. This increases the light output from the extraction substrates, whilst maintaining the device flexibility. The light output can also be increased by adding secondary embedded waveguides into the membrane. These are coupled to the micro-LED light and can potentially produce structured emission over the treatment area. The device platform is also shown to be effective as a fluorescent evanescent waveguide sensor, utilising quantum dots as the fluorescent molecules and a smart phone camera to measure the fluorescence.

The emergence of therapeutic hypnotism or suggestive therapy at the end of the nineteenth century in Britain has been conceived as a primitive, irrelevant or even preposterous form of fringe medicine. However, this thesis argues that hypnotism while dismissed for its associations with spiritualism, popular Victorian entertainment and quackery, can be profitably understood as an important form of early psychotherapy and a potent technique for inducing the body's own healing through the placebo effect. It centres on the life of Charles Lloyd Tuckey, a successful London society doctor who was the first to advocate the 'New Hypnotism' in the United Kingdom despite strong resistance within the general public and the medical profession. Largely overlooked, Lloyd Tuckey's life, work and correspondence shed light on a significant occluded chapter of both medical history and popular culture, and the intersection and interaction of the two. Offering new critical and historical approaches, this thesis provides insights into the reasons for the improbable success of the New Hypnotists. It highlights the importance of the change of explanatory model from the medical doctrine of imagination to the emerging psychology movement's novel concept of 'suggestion'. It employs Gieryn's concept of boundary-work to look at the battle for legitimacy within medical culture. It considers this in relation to the societal response to hypnotism and suggestion in popular culture as demonstrated by the contemporary gentleman's periodicals and the ubiquity of hypnotism in late Victorian gothic fiction. Analysed in this literary and historical context, Tuckey's life story helps to rehabilitate an alternative non-Freudian British account of early eclectic mind cures, which has been previously neglected due to the dominant revisionist accounts of Freudian scholars. It also provides useful lessons for contemporary practice: understanding the historiography of orthodox medical histories and the importance and enigma of the placebo effect.

All known cultures experience music and the healing properties have been acknowledged for over 30,000 years. Research has indicated that music participation has the potential to support a range of well-being benefits, for example among older adults, people with dementia and people experiencing mental ill-health. Despite encouraging anecdotal reports, however, adults with learning disabilities have typically been under-represented in well-being research and there is very little literature examining music participation within this community. Those studies that do exist have tended to focus on separate components of well-being, which has presented an incomplete picture. This multiple methods research investigated how music participation can support the well-being of adults with learning disabilities, with a particular focus on adults with Down's syndrome. The research was conducted via three studies: (1) an ethnographic case study of four students attending regular music sessions via the Music Man Project UK, (2) a survey study exploring the prevalence of music usage within the UK Mencap network, and (3) a within-subjects intervention study to investigate the impact of a 10 week programme of music-making, delivered and supported by the Music Man Project UK, on well-being among adults with Down's syndrome. The results indicate that active music participation can indeed enhance positive well-being and reduce negative well-being for adults with Down's syndrome. Study 1 highlighted the wide ranging well-being benefits experienced by participants and their families, for whom music-making was a regular ongoing activity. Four overarching themes emerged: positive emotions; educational development; meaning; and, accomplishment. Study 2 provided an insight into how Mencap (the largest UK charity supporting people with learning disabilities) used music as part of its programme and identified barriers that potentially inhibited music-making. Study 3 demonstrated improved well-being scores following a 10 week intervention programme of music-making with participants who had not participated in regular music sessions previously. Implications from the research could inform accessible music intervention strategies to support and enhance well-being in this often marginalised group in society. In so doing, this research contributes to providing equal opportunities to music-making and its associated well-being benefits to people with learning disabilities, comparable to their non-learning disabled counterparts.

This thesis comprises a mixed-methods study aimed at exploring whether an Alexander Technique intervention would enable participants aged 60 years and over to improve their balance and movement, thereby increasing balance confidence and reducing fear of falling. Frequency of delivery was explored for effect on the outcomes, experience and learning of the participants. Participants' feedback on Alexander Technique learning and the intervention encompassed: group learning; course content; and views on the usefulness of Alexander Technique in daily life. Two groups of participants were recruited from Extra Care sheltered housing schemes (once-a- week intervention, n=13; twice-a-week intervention, n=16). Quantitative assessments of balance confidence (practical assessment) and fear of falling (operationalised as falls-related self-efficacy, self-report) were carried out twice before the intervention (control period); immediately post-intervention; and at four-weeks post-intervention. Qualitative data was obtained by focus groups and individual interviews. The intervention comprised eight sessions of Alexander Technique instruction provided by qualified Alexander teachers, delivered using explanation, demonstration and observation only. Quantitative data (n=17) indicated an increase in balance confidence (significance inconclusive) and no change in fear of falling. Qualitative data provided evidence of increased activity levels commensurate with increased balance confidence. Fear of falling continued to be expressed, however, its effects appeared to be reduced, with implications for quality of life. This research demonstrated that older adults were willing to embrace and apply Alexander Technique, perceived as relevant to their daily lives and continuing independence. Application of learning within and outside the course sessions enabled participants to bring about improvements in balance and movement to meet their individual needs. Group learning was enjoyed and confirmed as successful for this age group. The study demonstrated that Alexander Technique is an appropriate intervention for older adults with fear of falling. Participants also recommended Alexander Technique learning for adults at a younger age.

Cell therapies are typically limited by the rapid dispersal of cells on delivery. Scaffolds offer an approach of enhancing therapeutic efficiency and efficacy as a delivery vehicle and implantable niche. This project aimed to combine the bio-intelligent properties of fibrin-based scaffolds with the potential of MSC cell therapies for activating healing in chronic wounds. A highly porous fibrin-based biomaterial scaffold was developed using an optimised emulsion templating technique. Templating enables reproducible manufacture of materials with a regular, highly porous structure with a high degree of pore interconnectivity and consistent pore size distribution. The method was optimised to generate a range of pore diameters suitable for skin tissue engineering, but it could be adjusted for other purposes. What differentiates this method is that the emulsion is amenable to incorporation of protein monomers without causing any denaturation, which allows the creation of a native-like structure during fibrin formation. The initial structure is then stabilised by glutaraldehyde cross-linking. The resulting scaffold is suited to cell ingress and supporting angiogenesis and allows fluid and nutrient exchange between the scaffold and the wound environment. The experimental work undertaken to design a suitable emulsion produced results which, to the authors' knowledge, have not been reported elsewhere. The two distinct patterns of behaviour identified suggest specific surfactant traits that make certain kinds of surfactants extremely useful in supporting high internal phase emulsions. The reason(s) for this are unclear, but the overall trend has potential utility in emulsion formulation. 'Oil carrying capacity' (OCC) is proposed as an index for ranking surfactants by the oil fraction (in an oil-in-water emulsion) for which stability is greatest. This project is divided into two main sections: emulsion formulation and using the optimised emulsion to template a scaffold that was then refined to produce a material with appropriate structural, mechanical, and biochemical properties for skin tissue engineering. Emulsion design encompassed degradation kinetics and achieving appropriate internal phase droplet size, packing and size distribution for cell and blood vessel ingress. Successful emulsions were then tested for protein compatibility and used to template various fibrin-based scaffolds. By iterative redesign, refined and reproducible scaffolds were produced that were characterised by various means to assess their suitability as skin tissue engineering scaffolds. This work describes a novel biocompatible fibrin scaffold with optimised microstructure for cell ingress and angiogenesis, excellent handling capabilities in both freeze-dried and rehydrated forms and biocompatibility as demonstrated by in vitro assays.

Microneedles (MN) arrays are micron-size needle arrays with length generally ranging between 50 μm and 2 mm. When applied to the skin surface, they pierce the stratum corneum creating micropores that can enhance the delivery of drugs into the viable skin layers. MN arrays offer great advantages for localised treatment of skin disorders which, in combination with skin hyperthermia can help inhibiting bacterial growth and induce apoptosis in cancer cells. In this thesis, new approaches to induce superficial and deep skin hyperthermia using gold nanorods (GnRs) were investigated. In addition, single needles, hollow and dissolving MN arrays for skin drug delivery were developed, aiming to enhance deposition of drugs in the dermis. GnRs were synthesized and loaded in hydrogels made from aqueous blends containing poly(methyl vinyl ether-co-maleic acid) and poly(ethylene glycol). These polymeric blends were used to fabricate films to heat up a thin skin model upon Near Infrared (NIR) laser irradiation. This technology circumvents skin deposition and injection of GnRs and, thereby, the uncertainty regarding their metabolism, safety and toxicity once they reach the systemic circulation. This approach was further improved in its use for skin hyperthermia, using GnRs coated on MN arrays where their efficacy heating up a thick skin model was confirmed. For intradermal drug delivery, hydrogel- forming single needles were fabricated, which were then coated with a model drug to investigate how deep these devices deliver the drug in a skin model. As the drug was coated and dried on the surface of needles, issues associated with hypodermic needles, such as stability of liquid formulations and generation of hazardous waste are avoided. When compared to a control formulation, single needles increased penetration depth of the drug significantly in the skin model, confirming the potential of coated polymeric needles for deep intradermal delivery. Finally, hollow polymeric MN arrays and dissolving MN arrays were fabricated to enhance the intradermal delivery of tofacitinib citrate, a drug for which clinical trials provide strong evidence for its effectiveness against inflammatory skin conditions. However, oral administration is not ideal due to reported side effects. Skin deposition studies showed that hollow MN arrays led to slightly higher deposition of drug in the dermis in comparison to a control cream. However, dissolving MN arrays showed superiority on this regard, providing proof of principle for intradermal delivery of tofacitinib citrate using MN arrays. Overall, the results shown in this thesis confirm the benefits of using MN arrays for skin hyperthermia and intradermal delivery and their potential future applications in the management of skin diseases.

This thesis explores the role of interactions between people and horses in Equine-Assisted Therapy and Learning interventions (EAT/L) for disadvantaged young people (YP). Part one is a conceptual review of the theories, methods, and techniques currently used in EAT/L research and practice for disadvantaged YP. Part two is an empirical research paper that explores the role of interactions between people and horses in interventions at a charity offering EAT/L for disadvantaged YP. It aimed to develop a theory of the role of horse-human interactions in EAT/L from the views and experiences of people facilitating and participating in it. It is a qualitative study using semi-structured interviews with 13 young people and 6 staff, and observations of EAT/L sessions that they participated in. Part three is a critical appraisal of the research process. It focuses on the ways in which the researcher’s worldview, experiences, preconceptions and intentions influenced the research process, and how the process of the research influenced the researcher’s personal development and clinical and research practice.

In global health it is commonly assumed that governments orchestrate a benevolent integration of "traditional medicine" into health systems and markets, through national policies and regulation, as in WHO's "Traditional Medicine Strategy". In China, rather than state orchestration, it is a healthcare market of products and services, operating within a nation-building framework, that shape "traditional medicine". Furthermore, it is the country's interests in developing materia medica for its domestic and export markets that are behind their long-lasting steering of the WHO's strategy. In this thesis, I draw on my multi-sited ethnographic fieldwork to document how this development is unfolding among people of the Qiang (Ch'iang) minority in China. I show the attempts of city and town dwelling Qiang practitioners, academics, government officials and members of the pharmaceutical industry to standardise medicinal herbs and compound medicines, as well as to systematise disputed medical theories and practices. I argue that they do this, in order to articulate "Qiang medicine" as a discipline and "Qiang medicines" as products. I then contrast these efforts with the afflictions and choices of care among Qiang villagers, for whom "Qiang medicine" emerges as a foreign concept. What becomes evident is that differences in the desire and legitimacy to articulate "Qiang medicine" relate to diverging personal aspirations, professional connections and living milieus. Thus, I argue that the WHO "Traditional Medicine Strategy" and China's "Chinese Medicine Law" predominantly favour the agendas of urban dwelling actors. These attempt to articulate "traditional" ethnic medicine and medicines by mirroring a scientised and state-sponsored contemporary Chinese medicine, for markets that are ultimately destined to cater for an ethnic Han majority. Ethnicity and medicine thus converge to serve a particular market dynamic. Such healthcare marketisation is embedded in a socio-political context that is specific to China, but relevant worldwide.

Background and aims. Respiratory failure, malnutrition, aspiration pneumonia and dehydration contribute to mortality in ALS. Loss of natural communication impacts quality of life. Previous studies demonstrate that music therapy exercises are effective for rehabilitation of patients with neurological conditions. The aims of the study were to investigate the feasibility of conducting home-based research, measuring the effects of a new music therapy protocol on bulbar and respiratory function in persons with ALS. It is the first biomedical music therapy research to do this and the first study of any kind to systematically look at supporting bulbar and respiratory functions in ALS. Methodology. Eight newly diagnosed patients were recruited. The music therapy protocol was delivered to all participants twice weekly for 6 weeks. The study duration was 16 weeks, with run-in, treatment and wash-out phases. Feasibility data (recruitment, retention, adherence, tolerability, self-motivation, personal impressions) were collected. Bulbar and respiratory changes were objectively measured. Results. High recruitment rate (100%), retention rate (87.5%) and mean adherence to treatment (95.4%) provide evidence for feasibility of the study protocol. The treatment was tolerated well. Mean adherence to the suggested independent exercise routine was 53%. The outcome measurements to evaluate the therapy-induced change in bulbar and respiratory functions were defined. Findings suggest that the protocol is safe to use in early and mid-stage ALS and that music therapy was beneficial for the participants' bulbar and respiratory functions. Mean trends suggesting that these functions were sustained or improved during the treatment period were observed for most outcome parameters: Maximal Inspiratory Pressure, Maximal Expiratory Pressure, Peak Expiratory Flow, Center for Neurologic Study - Bulbar Function Scale speech and swallowing subscales, Maximum Phonation Time, Maximum Repetition Rate - Alternating, Maximum Repetition Rate - Sequential, Jitter, Shimmer, NHR, Speaking rate, Speech-pause ratio, Pause frequency, Hypernasality level, Time-to Laryngeal Vestibule Closure, Maximum Pharyngeal Constriction Area, Peak Position of the Hyoid Bone, Total Pharyngeal Residue C24area. Conclusion. The suggested design and protocol are feasible for a larger study, with some modifications, including: aerodynamic measure of nasalance, abbreviated voice sampling and psychological screening.

Prescribed exercise is a widely used and effective treatment for older people with musculoskeletal conditions. However, its effectiveness may be limited by adherence or non-adherence to exercise programmes. It is important to develop an understanding of how clinicians can help people change their behaviour and adhere better to their prescribed exercise programmes. The four work packages undertaken as part of this thesis aim to determine what approaches have been currently tested, in addition to exploring the exercise adherence experiences of patients and physiotherapists, in order to inform the development of a theoretically underpinned exercise adherence intervention. Work package one, a systematic review of exercise adherence interventions for older people tested in randomised controlled trials found eleven studies. These studies were categorised based on the interventions they tested using a pre-defined and published behaviour change technique taxonomy. Interventions that were categorised in the Feedback and Monitoring category demonstrated positive results, with three separate studies reporting significantly better adherence to exercise compared to controls. However, the generalizability of these results is limited by the risk of bias. Four of the included studies offered a theoretical justification for their intervention, the other seven did not. The review concluded with the need for improved use, reporting and development of theoretically underpinned interventions in the field of exercise adherence for older people. Work package two, a qualitative study explored how adherence and non-adherence affects physiotherapists and their practice. There are several approaches with the potential to help facilitate adherence to exercise that are underpinned by the interaction between clinicians and patients. It is therefore important to explore this problem from both sides. In the findings, physiotherapists outlined that this is a challenging area of practice, one where they need to be resilient. They spoke about the importance of knowing each individual patient and building a rapport with them. In addition to discussing a range of practical steps they try and take to facilitate improved exercise adherence. The findings highlight the need for robust interventions to help clinicians in this area. Work package three involved the development and testing of a theoretically underpinned exercise adherence intervention for older people with musculoskeletal conditions: The Adherence for Exercise Rehabilitation in Older People (AERO) intervention. This was developed using an Intervention Mapping approach and was underpinned by the COM-B model of behaviour change. It involved offering individually tailored exercise adherence strategies based on a behavioural assessment undertaken as part of a routine physiotherapy appointment. The feasibility, acceptability and thus potential of this new intervention was tested in a feasibility randomised controlled trial involving 48 participants. The intervention and associated trial procedures were found to be feasible. The fourth and final work package consisted of a second qualitative study to investigate the overall acceptability of the AERO trial and to explore exercise adherence from the patient's perspective. Patients discussed their experience of trying to adhere to an exercise programme and the acceptability of AERO and all its procedures. Some suggestions to consider in a future randomised controlled trial were also outlined along with the difficulties of adhering to exercise programmes. Patients outlined the importance of the approach taken by the physiotherapist, being recognised as an individual, and having a good working relationship with the physiotherapist. This research has shown the importance of exercise adherence for older people with musculoskeletal conditions, the lack of theoretically underpinned interventions in the literature, the challenge that exercise adherence is for both patients and clinicians, and the feasibility of delivering tailored exercise adherence strategies to individual patients based on a brief behavioural assessment. There are several considerations outlined across the work packages that could be of importance to physiotherapists in clinical practice, including monitoring and feedback and the therapeutic relationship. However there remains the need for robust interventions in this area to help clinicians to facilitate better adherence to prescribed exercise. The AERO intervention was tested for its feasibility and acceptability and should now be tested in a robust appropriately powered randomised controlled trial.

Anxiety is a common mental health problem that has been treated using imagery interventions, but there is little evidence investigating musical imagery (that is to say, imagining music). The present research explores the development of a novel anxiety reduction intervention - voluntary musical imagery (VMI). Chapter Two initiates this investigation by examining existing relationships between anxiety and musical imagery experiences, as well as associations with secondary variables including depression, thought control, and sleep. Individual differences relating to musical imagery experience in anxiety were found, namely that people with high trait anxiety do not have difficulty controlling deliberate auditory imagery, and report perceiving their frequent involuntary musical imagery (INMI) episodes as negative, yet also helpful. Chapter Four presents a systematic review of research concerning imagery-based interventions for anxiety. Forty-four percent of the studies reviewed provided evidence in support of imagery interventions reducing anxiety but showed no inclusion of musical imagery in the methods. Chapter Five investigates whether non-musicians (N = 34) can be trained in VMI using a four-day training programme, then conducts a preliminary comparison of the effects of VMI versus an active control on ratings of anxiety and mood. This study showed that training in VMI can improve one's VMI ability and that VMI was associated with lower anxiety levels and higher ratings of positive mood than the control. Chapter Six is a test of the effects of the VMI intervention on anxiety and mood in naturalistic settings over six days and showed that VMI is associated with shortterm decreases in anxiety and positive mood increases. This thesis provides the first demonstration of the beneficial application of VMI to reduce anxiety, discussing the mechanisms by which VMI might serve as an anxiolytic function, as well as offering suggestions for the optimal VMI use and suggested target populations.

Psychological therapy has not always been readily available for individuals with intellectual disabilities (ID) due to the belief that therapy was ineffective for this population group. This resulted in an avoidance of offering psychological therapy to clients with ID, often referred to as the 'unoffered chair' (Bender, 1993). Over time it has become evident that individuals with ID experience a wide range of emotions and often higher rates of mental health difficulties in comparison to non-disabled individuals. Psychological therapy is now increasingly offered to clients with ID and an abundance of psychological approaches are utilised in clinical practice. The first part of this thesis will systematically review existing systematic reviews on the effectiveness of psychological therapy for adults with ID and mental health difficulties. The intention was to bring the literature together and provide a useful document for clinical decision makers to easily compare and contrast the evidence. Twelve systematic reviews were identified which focused primarily on cognitive behavioural therapy, psychodynamic therapy, and third-wave therapies. This review tentatively suggested that psychological therapy can be effective for improving a variety of mental health difficulties in adults with ID, including reducing depression and anxiety. However, the review highlighted that the existing systematic reviews are of critically low quality. No conclusions could be made regarding which therapeutic approach works best for adults with ID, however, cognitive behavioural therapy reviews dominated the evidence base and were the only reviews to include comparison groups. The second part of this thesis explored the feasibility of an innovative Qmethodological design, with the hope that this would shed further light on what makes an effective therapist for adults with ID. Outside of the field of ID, a number of core qualities have been associated with increased therapist effectiveness. This has included the therapist's interpersonal skills, ability to be flexible and adaptive, and the ability to develop a therapeutic relationship with a broad range of clients. Twenty-seven clinical psychologists completed an online study and three distinct view points on what makes an effective therapist for this population were identified. However, delivering the Qsorting task online did not meet the feasibility criteria set out and resulted in a low participant sample size. Consequently, further statistical analysis was deemed inappropriate and recommendations are provided for future studies utilising this methodology. Together, the systematic review and research study provide further insights into psychological therapy for adults with ID and highlight the need for more research. The two studies indicate a lack of consensus regarding what works for clients with ID and also that there is not enough high-quality research regarding particular therapeutic modalities for clinicians to base their decisions on. If clinical psychologists vary considerably on what they believe is clinically effective in their work, then it is likely that their practice and possibly client outcomes, will subsequently vary also.

Introduction Multiple Sclerosis (MS) is an unpredictable progressive neurological condition that has a profound impact on the ability of people to engage and participation in occupations from onset which often occurs in early adulthood. At this stage of life Instrumental Activities of Daily Living (IADL), based in domestic and community contexts, constitute a complex and demanding group of occupations that contribute to occupational identity. Occupational therapy interventions have a complex role in enabling people with MS to engage and participate in purposeful and meaningful occupations such as IADL. Adopting a person-centred theoretical lens, the study reported in this thesis explored the experiences and perceptions of IADL and the occupational therapy interventions of five people with multiple sclerosis in the practice context of a community neurology team. Methods The research design consisted of a multiple case study incorporating mixed methods to collect predominantly qualitative data. A novel methodological approach adopted a world view influenced by pragmatism and critical realism. The Assessment of Motor and Process Skills (AMPS) providing case attributes that measured occupational performance in IADL. Semi-structured interviews were then conducted with the people with MS, their carers, occupational therapist, and other healthcare professionals. A questionnaire was also administered to the occupational therapists. The framework approach was applied to analyse the data systematically and robustly. Computer assisted qualitative data analysis software (NVivo) was used to manage data. Presentation of the framework analysis was supplemented by case summaries illuminating the narratives of the five people with MS. Findings Four core concepts were identified. The Person Living with MS represented the understanding of the impact of MS on occupational performance in IADL. The Occupations core concept demonstrated the variety of IADL participation and linkage to other groups of occupations. Occupational Therapy Interventions for People with MS revealed professional reasoning and featured fatigue management strategies, environmental interventions, and psychological interventions. The social context of Inter-relationships with other significant people and the MDT to support and enhance occupational performance was also identified. Development of a therapeutic partnership, that listens to and respects the diagnostic narrative of the person with MS, enables personalised interventions to support and empower participation in IADL and other occupations. The contemporary MS person-centred occupational therapy (MS-PcOT) practice model was constructed as a synthesis of the findings. Conclusion Occupational therapy interventions have a multi-faceted role in enabling people with MS to participate in occupations they want, need, and expect to do. The findings contribute new knowledge of professional reasoning in occupational therapy practice for people with MS. The findings also contribute to the understanding of experiences and perception of occupations in the domestic lives of people with MS. The MS-PcOT practice model is a person-centred and occupation based guide for occupational therapy practice. The model incorporates integrated and coordinated interdisciplinary practice to support people with MS in their daily occupations and maintain health and well-being.

Volunteering is associated with a range of health and employability benefits. However, there is limited evidence of the collective experience of volunteering for people recovering from mental illness. This thesis presents a participatory action research project in collaboration with a group of ten working age adults comprising four men and six women of white British ethnicity, predominantly Scottish and all living in the same Scottish city. All had lived experience of mental illness; many had significant experience of volunteering and all were actively engaged at the time of the research in unpaid volunteering in the community through personal choice as part of their recovery journey. The aim of the project was to hear about the benefits and challenges of volunteering including the positives and negatives of sociopolitical and welfare systems that support people with lived experience of mental illness to volunteer, with a view to producing something through action that would be of benefit to the group and/or the wider community. Participants took part in a preliminary interview and attended a series of five participatory action research groups. Thematic data analysis of the interviews was carried out by the researcher. Data generation and analysis of the PAR groups was combined and followed Freire's (1970, p. 80; p. 104) process of "problem posing" and "conscientization" or critical consciousness raising where participants by asking critical questions about their situation recognised the potential for transformation. Data analysis of the PAR groups was collaborative, iterative, cumulative and coconstructed with themes revisited and revised by participants. Findings revealed factors that supported and hindered a positive volunteering experience including challenges from the socio-political impact of welfare reform. Participants produced a briefing paper to inform newly devolved powers supporting the Social Security (Scotland) Bill to support change at policy level and resolve the problem of mandatory volunteering in Scotland. This project has generated a new understanding of the experience of volunteering for people with lived experience of mental illness proposing an original theory of five conditions for successful volunteering that are necessary to support recovery namely: readiness and support to volunteer; synergy between volunteer and experience to ensure volunteering is meaningful; flexibility to stay well; opportunity to meet needs for identity and connectedness; and opportunity for influence and activism. Findings have also highlighted the negative effects of neoliberal welfare policies on the experience of volunteering for out-of-work disabled welfare recipients; demonstrated how PAR contributes to positive socio-political change with findings supporting Scottish Government policy development; and exposed how at a practice level the hegemony of paid work dominating occupational therapy vocational services limits an understanding of volunteering to one viewed solely through a work lens, with limited critique.

Acupuncture is the medical practice of inserting fine needles at specific places in the body, named acupoints. These points are located on pathways (called meridians) that run through the body, normally depicted as lines on the body's surface. According to the medical paradigm of the Han era (206BCE-220CE) these are areas where the Qi or vital essence of the body can be accessed and manipulated to engender harmony and balance, thereby promoting health. Meridians and acupoints are widely considered to be esoteric in nature, and how they were originally discovered is an enduring mystery. Today, the exact nature of meridians and acupoints, along with the mechanism through which acupuncture acts, are the subject of substantial debate and research. The first descriptions of meridians are found in the ancient Chinese Mawangdui medical manuscripts, which were found in the Mawangdui tomb, closed in 168BCE and reopened in 1973CE. This initial exposition is developed in the later Huangdi Neijing, a substantial collation of medical texts spanning the whole Han dynasty. In the four papers that comprise this thesis, I resolve this ancient mystery by uncovering how these meridians and acupoints were arrived at. I hypothesise that Han era physicians conducted systematic anatomical examination of the body over an extended period of time (>300 years) and that the meridians and acupoints are detailed descriptions of their observations. This early anatomical research is roughly contemporaneous with the early Greek anatomists Herophilus and Erasistratus whose works were destroyed in the fire at the library of Alexandria. The ancient Chinese texts, by contrast, survived. The Mawangdui manuscripts are thus the earliest surviving anatomical atlas in the world based on humans. The papers that comprise my thesis are presented in the order in which they were written: The first is about the use of the Chinese character for silk as part of the name for the meridian network. I show that fascia has a silk-like visual and textural quality, and suggest that the meridian pathways may be related to fascial pathways. The second is a study of parts of the later Huangdi Neijing describing a single meridian, 'chong'. This paper shows, again through dissection, that the character for 'chong' describes the vasculature of the body, primarily veins. The same character is used in the names for acupoints which lie over key vascular landmarks. The third paper is an extended exploration of the relationships between the various anatomical structures found at acupoints, and the characters used in their naming. I show extensive correlations between naming conventions and anatomical structures. The fourth is an exposition of the Mawangdui medical texts. We explain how the texts refer to particular parts of the body and the structures that pass through them. Many of these structures are only visible on dissection and some, like the perforating veins in the leg, require careful and methodical dissection to visualise. This strengthens the argument that this was dissection carried out for the purpose of anatomical examination. All four papers thus demonstrate that these works constitute an anatomical atlas that was arrived at through direct observation of the human body through dissection. They show what is being described, and how that knowledge was embedded into Han medical culture. This has implications for Chinese medical history, which can now fill a gap that has existed for millennia. That meridians and acupoints form an anatomical atlas rather than a network of physiologically 'special' areas also requires that modern researchers re-evaluate what they are investigating. My work thus establishes a new foundation for medical studies of acupuncture and the history of medicine in the Han dynasty.

This research examined the effectiveness of a learning management system (LMS) embedded instructional multimedia on musculoskeletal manual therapy psychomotor learning in physical therapy students. The traditional educational strategy for providing instruction for these psychomotor skills is live demonstration followed by student practice, which requires significant face-to-face class time. By contrast, the framework of this study used Elaboration Theory, which sequences key learning concepts hierarchically from simple to complex. In this study, half of the live demonstration manual therapy skills were replaced by LMS-embedded multimedia instruction. The skill demonstration was the simple component of the sequence increasing available classroom time for complex lessons. After obtaining ethical approval from the University of St. Augustine for Health Sciences (USAHS) and the University of Liverpool, the study was conducted using a census sample. Two groups of students in the USAHS Doctor of Physical Therapy program were asked to participate in a fifteen-week study. Cohort one had 54 students, and cohort two had 59 students that agreed to participate. A mixed-methods sequential explanatory design was utilized. Two practical examinations given during the course measured student performance on psychomotor skills acquisition and compared the live demonstration and the LMS-embedded multimedia instruction. Two cohorts allowed for a balanced cross-over design for the practical examination comparison. At the end of the course, a questionnaire was administered, which was followed by a focus group discussion to assess the perceived student experience. The mean scores on the practical examination were compared using a one-way repeated measures ANOVA. The results for the upper extremity manual therapy skills comparison demonstrate that the live demonstration instruction examination scores were slightly higher than the LMS-embedded multimedia instruction. While the differences were statistically significant, the partial eta squared value is small. The results of the lower extremity manual therapy skills comparison demonstrate that the live demonstration examination scores were slightly lower than the LMS-embedded multimedia instruction. However, the difference between these means is not statistically significant. These findings reveal similar outcomes for both instructional strategies on psychomotor examination tests. The questionnaire showed that most of the students found the LMS-embedded multimedia instruction useful for review of skills and that it facilitated learning. The focus group discussions highlighted that the videos standardized expectations and made a review and practical examination preparation easier. The group further noted the importance of maintaining the allocated classroom time for practice and instructor feedback for these skills. The findings of this study provide support for the use of educational technology in the application of Elaboration Theory to facilitate a student-centered classroom and provide time to train doctoral students in higher-order thinking such as the utilization of these psychomotor skills through case scenarios and problem-based learning.

External beam radiation therapy using accelerated protons has undergone significant development since the first patients were treated with accelerated protons in 1954. Widespread adoption of proton therapy is now taking place and is fully justified based on early clinical and technical research and development. Two of the main advantages of proton radiotherapy are improved healthy tissue sparing and increased dose conformation. The latter has been improved dramatically through the clinical realization of Pencil Beam Scanning (PBS). Other significant advancements in the past 30 years have also helped to establish proton radiotherapy as a major clinical modality in the cancer-fighting arsenal. Proton radiotherapy technologies are constantly evolving, and several major breakthroughs have been accomplished which could allow for a major revolution in proton therapy if clinically implemented. In this thesis, I will present research and innovative developments that I personally initiated or participated in that brought proton radiotherapy to its current state as well as my ongoing involvement in leading research and technological developments which will aid in the mass adoption of proton radiotherapy. These include beam dosimetry, patient positioning technologies, and creative methods that verify the Monte Carlo dose calculations which are now used in proton treatment planning. I will also discuss major technological advances concerning beam delivery that should be implemented clinically and new paradigms towards patient positioning. Many of these developments and technologies can benefit the cancer patient population worldwide and are now ready for mass clinical implementation. These developments will improve proton radiotherapy efficiencies and further reduce the cost of proton therapy facilities. This thesis therefore reflects my historical and ongoing efforts to meet market costs and time demands so that the clinical benefit of proton radiotherapy can be realized by a more significant fraction of cancer patients worldwide.

Peptide Receptor Radionuclide Therapy is one of the most efficient therapies against Neuro endocrine tumours. In clinical practice, absorbed dose calculations are computed based on the Medical Internal Radiation Dose (MIRD) schema which is not planned or optimised for patient-specific characteristics. This PhD project has aimed to assess the impact that advanced personalised 3D dosimetry can have within a Molecular Radiotherapy (MRT) treatment with an image-based dosimetry component. For this purpose, the impact of image registration algorithms has been studied, comparing rigid and non-rigid schemes. Results showed that nonrigid algorithms performed better than rigid equivalents in aligning images to the same frame of reference. The non-rigid algorithm was then used to investigate a workflow which involved dose maps instead of SPECT images, because such analysis has not previously been reported in the literature. Raydose, a Monte Carlo-based software package, was used to perform 3D personalised dosimetry; the results were compared against the calculations carried out with OLINDA/EXM, a MIRD-based software system. Differences were statistically significant only for kidneys and lesions (p-value < 0.005). Finally, a new segmentation method for tumour delineation is described and its performance compared with a manual segmentation performed by expert 2 physicians. JACCARD analysis showed that the two methods do not have a good overlap (mean JACCARD coefficient = 0.29). From visual assessment, the proposed approach obtained better results than the manual segmentation according to the target tissue characteristics. Furthermore, quantitative analysis showed that the manual segmentation significantly overestimates the volume by 3.7 ± 13.3 cc (p-value < 0.05), while it significantly underestimates the dose by -2.67 ± 6.8 Gy (p-value < 0.05) compared to the proposed method. This study has demonstrated the importance of assessing accurate personalised 3D absorbed dose distribution to lesions and organs at risk. It also has the potential to be extended to other MRT treatments and other tumour sites.

Background: Religion touches our everyday lives. Some have a deeply held faith while others engage infrequently in rites of passage such as marriage or funerals, but religion is a common worldwide phenomenon. Globally, millions of people engage in religious practice or religious ‘doing’ daily, but occupational science has not explored this common occupation widely, and occupational therapists continue to struggle to consider religious practice within the occupational needs of their clients. Within increasingly multi-cultural and multi-faith communities, it is imperative that the occupation of religious practice is better understood and considered within practice. Method: An auto/biographical overarching research orientation is used to encompass a reflexive awareness of my own experiences as a Christian. And I take an occupational science perspective to explore religious ‘doing’. This is achieved by the use of a facet orientation to construct three studies which explore different aspects of religious practice. A systematic scoping review of literature examined the current understanding of religious practice. A photovoice study examined the lived experience of religious practice from a variety of faith perspectives and auto/biography was used to explore barriers to participation in religious practice. Findings: Religious practice continues to be perceived as a difficult area by occupational therapists however, familiar occupational features such as routine, interpretation of rules, symbols, connectedness, and contemplation, exist across faith traditions. Participation in religious practice involves a complex relationship between community and place, religious coping strategies and religious identity. Conclusion: This thesis offers an original occupational science contribution concerning religious practice as a valued occupation. It offers a UK based, multi-faith perspective, in an area dominated by North American, Judeo/Christian literature. Most importantly, it shines a light on common everyday religious ‘doing’ which is as much a valued occupation as any other everyday activity. This thesis positions religious practice as an everyday occupation that occupational therapists can, and should, address using existing skills.

In proton beam therapy knowledge of the detailed beam properties is essential to ensure effective dose delivery to the patient. Clinical settings currently implement interceptive ionisation chambers which require daily calibration and suffer from slow response times. With new and emerging treatment techniques using ultra high dose rates, there is a demand for the development of novel beam monitors, which are fast, non-invasive and calibration-free. This work presents a new non-invasive method for online dose monitoring. It is based on the multi-strip silicon sensor LHCb VELO (VErtex LOcator), developed originally for the LHCb experiment at CERN. The semi-circular detector geometry offers the possibility to correlate the beam intensity through halo measurements without interfering the beam core. Several adaptations needed to be carried out to transfer this technology from the CERN environment to a stand-alone setup. This included the development of a venting and cooling system for safe operation in air. A positioning system was also developed for secure and precise handling of the modules. The VELO detector modules were implemented at the 40 MeV proton beamline at the University of Birmingham, UK and synchronised with an ionisation chamber and the RF cyclotron frequency. This required a modification to the timing control of the readout boards. Proton beams with beam currents, from 0.2 nA to 6 nA, and different beam sizes, from a diameter of 7 mm to 20 mm, were precisely measured online using only the beam halo information. Experimental results demonstrate the linearity, accuracy, reproducibility and sensitivity of the VELO detector modules for a suitable use as a beam monitor. The standard deviation of the registered hits are very low and equal or below 1%. Furthermore, the results were used to derive a characteristic beam Halo to Dose relationship via comparison with beam tracking GEANT4 simulations and EBT3 GAFchromic film measurements. These results have demonstrated the applicability of the VELO detector modules as a beam monitor for medical accelerators, however the outdated electronics hardware and pre-processing software make more improvements difficult and would highly benefit from a redesign.

Radiotherapy is a common treatment modality for NSCLC which despite continuing advances in the field still presents very high rates of recurrence, with secondary tumours typically more difficult to treat, due in part to the radioresistance of these tumour's cells. This ultimately leads to poor treatment outcomes. One contributing factor may be the induction of senescence, a form of permanent cell cycle arrest, following radiotherapy treatment. While senescence is initially considered beneficial to the outcome of radiotherapy, an accumulation of senescent cells is known to disrupt tissue homeostasis and even favour the growth and survival of cancer cells. Therefore, the use of senolytics in combination with radiotherapy could greatly benefit NSCLC patients. Thus far use of such drugs has not been possible as there are no targetable markers of senescence specific enough to prevent damage to other cell types. The relative radiosensitivity of a panel of four NSCLC cell lines was assessed following different doses of ionising radiation (IR) and then investigated for the presence of senescence under the same conditions. This showed a correlation between radioresistance and the cells' ability to induce senescence following radiation. The senescence associated secretory phenotype (SASP) of the panel was analysed using shotgun proteomics to search for the presence of novel markers of senescence. Several interesting candidates were found which could present better targets for novel senolytics. The effects of these SASP on other cells were also tested, which showed increases in wound healing activity and invasion, indicating that the secretome of senescent cells had pro-proliferative activity on neighbouring cells. Our results demonstrate that clinically relevant doses of IR induce senescence in NSCLC cells and that their SASP can affect surrounding cells. We propose that the presence of senescent cells post IR treatment may be leading to high rates of radiotherapy failure and recurrence.

The current Thesis concentrates on the construction and efficiency assessment of Terpsichore, a software interface designed to assist individuals with autism spectrum disorders (ASD) in developing their competence, and ideally independence, in composing original tonal and soundscape-based music. It does not only serve educational purposes, but also exhibits a therapeutic nature consistent with the accomplishment of non-musical goals, implying a reciprocal relationship between music education and music therapy. It is also distinguishable in its evidence-based character, as its construction is based on a broad spectrum of personality traits. The software consists of two educational modes (Tonal and Soundscape and Indefinite Pitch), in which constituent levels are arranged to reflect a process comprising three thematic sections: sound component identification and reproduction, minor amendments to existing musical material, and composition of musical patterns from point zero. To best determine the efficiency of the interface components in a wide variety of situations, a bilateral approach was adopted, which consists of a bibliographical case study approach and a practical research component. In the case study involving nine individuals from the relevant autism and music therapy literature, various Terpsichore areas were carefully suited to the personality, condition and particularities of each learner, while observations were extracted through critical bibliographical analysis of interface components and their role in music interventions for ASD. Practical research involved a series of tutor-administered sessions in four different special education institutions in the Attica region of Greece, where twenty-eight participants were instructed to employ both modes of the software. Responses and trends were measured via a comprehensive questionnaire addressing multiple areas of music education and therapy and how these evolved throughout the software instruction process. The Thesis demonstrates that Terpsichore addresses a broad variety of cognitive and treatment aspects, assists in a meaningful and rewarding creative musical occupation without unnecessary structural complexity, and generally contributes in a positive manner to mental condition treatment as a result of the music education components incorporated in the interface. The software also possesses a potential to treat various lapses in communication, behaviour and concentration, while rendering the music and sound composition process more comfortable, especially in the pitch-defined music domain, thanks to the increased understanding of tonal relationships. Findings from this study are useful in encouraging caregivers, music therapists, psychologists and relevant practitioners to incorporate and further develop Terpsichore in everyday music and general learning schedules for individuals with ASD.

Background: The Royal College of Occupational Therapists (2019a) state that “ ... occupation must be the core of every occupational therapy pre-registration curriculum, into which all other subjects are integrated. The centrality of occupation in human life and in the occupational therapy curriculum must be made explicit for learners to experience the transformative potential of occupation” (p. 3). However, the concept of occupation is acknowledged as complex and multifaceted (Pierce, 2001), which makes it challenging for educators to develop students’ understanding of the concept (Hocking, 2009). Aims: To investigate the pedagogic use of a newly developed occupation focused teaching tool. To critically explore the influence of the teaching tool on development of occupational therapy students’ knowledge and understanding of the concept of occupation. Method: This study is informed by a grounded theory approach. The research consists of two distinct phases of investigation; Phase I and Phase II. Phase I consisted of twelve semi-structured teaching observations, used to investigate the pedagogical impact of the teaching tool on student learning. Phase II consisted of four peer-learning observations, in which students worked together, to investigate their use of the teaching tool; exploring a case scenario; the influence of the teaching tool on the development of understanding of the concept of occupation. Participants: Eighty-two participants were involved in this research; fifty-seven student-participants in Phase I, twenty-four student-participants in Phase II, and one participant-researcher in each phase. In Phase I, six student-participant groups involved first year pre-registration occupational therapy students, who had no prior learning regarding the concept of occupation. An additional six student-participant groups involved final year pre-registration occupational therapy students who had prior knowledge of the teaching tool. All Phase I student-participants were recruited from one U.K. University (Higher Education Institute - H.E.I. 1). Four student-participant groups were recruited in Phase II. Two participant groups involved second year occupational therapy students studying at Bachelor level at H.E.I. 1. These student-participants had received teaching regarding the concept of occupation through use of the teaching tool in the first year of their education. The remaining two participant groups recruited occupational therapy students from a second U.K. based H.E.I. (H.E.I. 2). These student-participants were enrolled on a Master pre-registration occupational therapy programme. They had received initial education regarding the concept of occupation, though not through the use the teaching tool. Findings: Phase I: Findings demonstrate student-participants gained knowledge of the concept of occupation, as understood by the profession of occupational therapy, through an academic’s use of the teaching tool. Provision of a dynamic, physical model of the concept afforded visual identification of the multitude of internal components of occupation, thus aiding student-participants’ knowledge development. Phase II: Findings demonstrate student-participants developed understanding of occupation through their own use of the teaching tool in exploration of a client-based scenario. Hence, the teaching tool has capacity to be used by students in tutor-supported collaborative- learning events. Furthermore, occupational therapy student-participants, with no prior knowledge of the teaching tool, recognised the tool as representative of the professional understandings of occupation as a concept. Conclusions: The occupation focused teaching tool enhances the development of knowledge, and understanding, of the professional conceptualisation of occupation. The teaching tool enables the concept of occupation to be treated as a threshold concept. Use of the teaching tool through employment of an active learning approach, supports the use of pedagogic methods of analogies and storytelling, thus, enhancing student learning.

This thesis details the production and characterisation of a range of photosensitiser (PS)- incorporated polymeric microparticles, optimising the photodynamic antibacterial activity exerted. Specifically, their ability to reduce the bacterial bioburden of solutions, with low visible light illumination, was studied. An oscillatory ball milling process was employed to mechanically break down a range of synthesised acrylate-based monoliths to produce microparticles of varying sizes, providing large available surface areas for complementary PS incorporation. Cationic PSs, toluidine blue O (TBO) and tetrakis(4-N-methylpyridyl)porphyrin (TMPyP), were electrostatically incorporated to the anionic polymeric microparticles produced. Conversely, anionic PSs (rose bengal (RB), tetrakis(4-carboxyphenyl)porphyrin (TCPP) and meso-tetra(4- sulfonatophenyl) porphine (TPPS)) were incorporated to cationic polymeric microparticles. The anionic microparticles loaded with a 22 μg/mL TBO solution yielded the most potent, minimal leaching PS-incorporated microparticles, achieving 99.9999% reductions of both Gram-negative and Gram-positive microorganisms within 60 minutes of low intensity red-light irradiation. Overall, the broad-spectrum activity of photodynamic antimicrobial chemotherapy measures, and the unlikely development of microbial resistance reported, the potential for these PS- incorporated microparticles is encouraging.

Recently, there has been a growth in using post-treatment dosimetry after the first treatment cycle to plan the prescription for subsequent administrations to achieve an acceptable safe dose to kidneys and therapeutic dose to tumour. This level of personalisation recognises inter-patient variability in the uptake and clearance of 177Lu-DOTATATE by the kidneys and tumours. Increasingly, studies are showing additional variation in pharmacokinetics between cycles in an individual patient which may be particularly relevant in NETs cases in paediatric cases like NBL. The central goals for this work were to characterise variability in the spatial and temporal patterns of renal and tumour biokinetics and dose during a four cycle course of 177Lu-DOTATATE and investigate relationships between these variabilities and patient response. To accomplish this, an open-source software platform was written to facilitate calculation of per cycle pharmacokinetics of organs at risk and lesions using published clinical protocols. Subsequently, we applied these protocols on a single pretherapy Ga68-DOTATATE PET/CT and intra-therapy longitudinal SPECT/CT image sets acquired in six children with NBL after each cycle to understand the temporal change in physical dose and effective half life over a course of treatment in two anatomical and one functional region. The kinetics of radiobiological dose in the tumour was explored using parameters derived from in-vitro experiments. The effective half life of 177Lu-DOTATATE in the tumour showed the greatest variation between cycles. Overall, the temporal and spatial variability in renal and tumour pharmacokinetics and dose showed no clear relationship with response in this small cohort. This thesis is a significant step towards further understanding intra-cycle variability during a course of treatment which may impact dosimetry based treatment planning aimed at delivering a set dose per cycle.

Background: The treatment of cancer with radiation uses advanced techniques such as intensity modulated and stereotactic radiotherapy. These modalities can provide sub millimetre accuracy, delivering high radiation dose to the tumour and reduced dose to the surrounding normal anatomy. Building a mental model of the size, shape and position of the tumour in relation to the surrounding anatomy and proposed radiation beam direction requires radiotherapy radiographers to have well developed three- spatial visualisation skills. The introduction of the Virtual Environment for Radiotherapy Training (Vertual Ltd, Hull, United Kingdom), an immersive 3-D visualisation platform in 2007, offered the potential for developing new ways of supporting the development of these visualisation skills in pre-registration radiotherapy learners in a simulated environment. Aims: This programme of research aimed to measure the baseline three dimensional spatial visualisation skills of new radiotherapy learners, to compare their performance with new learners in diagnostic imaging, to determine if 3-D visualisation skills could develop over time and to identify those learners most likely to benefit from learning in the virtual environment for radiotherapy training. Methods: This programme of research employed a QUANT + qual mixed model approach with purposive convenience sampling of year one diagnostic imaging and radiotherapy students to develop an online, three-dimensional spatial visualisation test using objects from two traditional paper based spatial visualisation tests for mental rotation and cross sectional visual perception (the pilot phase). The experimental phase employed an online test platform in a controlled, single subject design, longitudinal study using a second cohort of students to determine their 3-D spatial visualisation skill at the start of their pre-registration radiography programme and to track any change over three additional time points during an 18-month period between the start of year one and the end of year two. For the radiotherapy cohort, the relationship between baseline spatial visualisation skill and patient positioning performance was investigated using a simulated treatment delivery task conducted within the Virtual Environment for Radiotherapy Training. Results: The pilot phase comparison of performance scores for the paper based and online versions of the three-dimensional spatial visualisation test did not produce statistically significant differences, suggesting that a move to an online test platform would not disadvantage any participant. Results from the experimental phase (study four) identified that the baseline 3-D spatial visualisation skill of 54 pre-registration learners in radiotherapy (n = 15) and diagnostic imaging (n = 39) could be measured and performance classified as being low, intermediate or high at the start of their radiography education. Across both pathways, 13 participants (24%) were identified as having low skill, 36 (67%) were intermediate and 5 (9%). Performance gains were observed in the growth trajectory for mean spatial visualisation test score over the 18 month time period for both pathways. Analysis of performance in the mental rotation and cross section subcomponents indicated that one third of all participants might benefit from additional support in mental rotation or perception of cross sections. For the radiotherapy positioning task, correlations between task performance metrics for task completion time, number of equipment adjustments and set up accuracy and baseline demonstrated a weak positive relationship meaning that the results were inconclusive. Conclusions and contributions to knowledge: The measurement of 3-D spatial visualisation subcomponent performance as a surrogate for accurate patient positioning and beam alignment has provided an enhanced understanding of baseline visualisation skill. Analysis of these subcomponents, with an emphasis on patterns of incorrect answers, in addition to overall performance score provides a method for identifying those individuals with less well-developed skills. These are the learners who may have difficulty with mental model and relationship building and would benefit from the additional support of focused tutorials with personalised spatial visualisation syllabus activities. This enhanced understanding will provide opportunities for the development of the spatial visualisation syllabus beyond the often opportunistic, and ad-hoc structure of clinical practice and a one-size fits all approach to campus based simulation and visualisation activities.

The six-year study explored whether biographical and spiritual disruption may have both negative and positive aspects – a disturbance or challenge may lead to positive as well as negative consequences. A chronic illness model was derived from the literature: good health, illness disruption, expression and evaluation, role recovery and resolution. The model was tested through a theoretical coding process against narrative interviews. Field data was used to analyse types of disruption response – peak, trough, progressive and regressive. Twelve narrative interviews were coded using narrative, theoretical and disruption-response coding. This led to a revision of the illness model, now seen as a sequence of disruption and response cycles. Faith subjects also recounted faith stories about struggle and survival. Faith practice and observance was interrupted by illness. Patients’ initial response was disorientation, but responses stabilised over time to a consistent pattern – the learning response. Key areas of study were learning effective illness responses, resolving disruption cycles, pursuing role recovery, expanding faith, and disclosing and processing suffering. Three general conclusions about chronic illness were formed – that chronic illness involves learning, that it requires different kinds of chronic illness work (narrative work, emotion work, grief work, identity work and faith work), and that it creates a specific kind of narrative quest, whose purpose is to define the subject’s role and resolve the chronic illness story. People with long term conditions often work hard, they deal with repeated disruption, they learn new roles, they construct survival stories, and learn ways of resolving each disruption stage. The study suggests a view of long-term conditions different from the accepted picture of progressive decline. It suggests that individuals become more resourceful, more skilled and better able to deal with suffering and loss as their illness progresses. With faith subjects, faith grows and adapts to face the challenges found in living with illness and apply faith to each new situation.

This commentary presents a critical analysis of prior published work by the PhD candidate within the field of occupational therapy. Occupational therapy is a discipline which promotes participation in daily life activities (occupations) across the lifespan, from children with developmental delay to older adults managing the functional impact of chronic disease. The integration of technology and increased cultural diversity among patient populations are two major trends impacting teaching and practice, representing the themes of this commentary. The studies regarding technology highlight effectiveness of specific technologies, perceptions of specialty clinicians regarding technology-based clinical resources, as well as the physical impact of mobile technology use. The studies regarding cultural diversity focus specifically on international service learning (ISL) as pedagogy for the development of cultural competence for future occupational therapists. The collective findings of the studies make a novel contribution to the literature, evaluating the efficacy of a specific app-based technology, analyzing the musculoskeletal impact of mobile technology use, exploring clinician’ perceptions of technology integration in clinical settings, as well as providing support for ISL as a pedagogy for culturally-competent practice.

This study looks into the perspectives of occupational therapists and families of children with disabilities in Jordan engaged in Early Intervention (EI) programmes. The aim of this study is to explore how EI programmes apply the family-centred approach, and specifically to investigate: • The perspectives of families regarding their role within the intervention, and what steps were taken by OT to establish and encourage this role. • The perspectives of OT on how they facilitate family-therapist collaboration within EI programmes. • Generate a theory to describe parent-therapist collaboration within early intervention in Jordan. Data were collected from multiple-sources including field notes, session observations, and interviews with experienced early intervention Jordanian occupational therapists and their clients’ families, to determine the extent to which family centred model is being promoted by accessing records, observing parent- therapist meetings, and studying intervention records. Grounded theory is used to explore the different factors influencing the process of constructing family-therapist collaboration. Findings: Several themes emerged from the data describing the parent-therapist collaboration within the early intervention programme in Jordan, including: power imbalance in the parent-therapist collaboration, early intervention within the Jordanian culture, categorising parents, and language use in sessions. These themes generated the Power Scale framework, which describes the therapeutic collaboration between therapists and parents within EI programmes. The Power Scale framework has three main elements: Knowledge, Expectations, and Engagement. Each element is described from the perspective of parents and then the therapist at the start of the collaboration, with an explanation of the relationship between these elements which changes as the collaboration progresses. The Parent-therapist collaboration in early intervention is also impacted by a variety of external factors including the cultural view and political context within which this collaboration operates. Only through understanding the elements of the parents-therapist collaboration and the external factors impacting it can we achieve a positive therapeutic relationship within the early intervention programme. Conclusion: The parent-therapist collaboration within the early intervention is a complex process that starts at the beginning of the intervention and develops over time. This process is influenced by internal factors including parents’ and therapists’ knowledge, expectations, and is reflected in their engagement. It is also impacted by external factors such as the cultural understanding of the role of health professionals, the awareness of the OT role, and the policies governing early intervention programmes in Jordan. Although family centred model within early intervention ideally promotes a partner role for the parents with the therapist assuming a support role, the reality of early intervention programmes in Jordan reveal a compromise achieved by therapists and parents which allow for different versions of this role ranging from recipient to trainees, and depending on the internal and external factors that influence parent-therapist collaboration.

The Siddis, a tribe of African descent in Gujarat, have been part of India for more than six centuries. This study was conducted in three different villages (Jambur, Sasan Gir and Sirvan) located on the periphery of the Gir Sanctuary and National Park in Gujarat, India. The research shows how medical pluralism in India (especially, Ayurveda and biomedicine) has shaped Siddi ethnomedicine. The thesis also compares ethnographic and ethnobotanical data from India to the published literature on traditional medicinal practices (use of plants, ritual healing acts, role of music and dance) of African diaspora peoples in the Americas. The research reveals that the healing system of Siddis brings together their ethnobotanical medicine (dava), which is similar to that of the neighboring Maldhari tribe and spiritual medicine (dua), which resonates with their African heritage. A total of 149 plant species, their uses, and methods of preparation have been documented in the Siddi herbal pharmacopoeia. The thesis also discusses the role of diet and the concept of 'Fo-Med' (Food as medicine), reasons behind a gradual shift toward preferences for Ayurvedic and pharmaceutical medicines, humoral theory of 'hot and cold' and the core of the healing system of this African diaspora population, i.e. woman and child healthcare. Siddi healing is a medical representation of cultural syncretism and is also at the interface of medicine and religion. The study discusses the important role of Siddi ancestral saints and the diasporic history of Siddis to contextualise the spiritual aspects of Siddi healing. The reinvention of many Siddis as spiritual guides, and the emergence of some Siddi mausoleums as important healing centers for the people from all religions and socioeconomic strata have helped Siddis to create space and identity for themselves in India through their healing art. The role ofmusic, including dancing and drumming (referred as dhamaal) in the healing system of Siddis is also discussed. With a main focus on Nagarchipir's dargah 'mausoleum' at Jambur village, where drumming is performed daily, I describe the role of dua in ritual healing of ailments, which Siddis consider as the "domain of the transcendental". The two main areas of focus of Siddi healing, i.e., reproductive/maternal and child healthcare reflect both the strength and concern of the Siddi healthcare system (dava + dua) and they also exemplify the dynamic presence of medical pluralism and its subsequent role in Siddi healthcare. The analysis includes a comparison of the theories of causation of female reproductive healthcare problems, and related therapeutic remedies between the African diaspora people in Americas and the Siddis. The main findings show that like women in Africa or from African diaspora, Siddi women in Gujarat also emphasise a lot on vaginal health and its tightness. However, Siddi women rely more on ingestion technique i.e. use of golis "vaginal balls" which are mainly made of plants than on vaginal steams and herbal baths that are more common in African women or African diaspora women in other parts.

Problem: Academic study of religious healing has recognised its symbolic aspects, but has tended to frame practice as ritual, knowledge as belief. In contrast, studies of scientific psychiatry recognise that discipline as grounded in intellectual tradition and naturalistic empiricism. This asymmetry can be addressed if: (a) psychiatry is recognised as a form of “religious healing”; (b) religious healing can be shown to have an intellectual tradition which, although not naturalistic, is grounded in experience. Such an analysis may help to reveal why globalisation has meant the worldwide spread not only of modern scientific medicine, but of religious healing. An especially useful form of religious healing to contrast with scientific medicine is Sufi healing, as practised by the Naqshbandi-Haqqani order, which has become remarkable for its spread in the “West” and its adaptation to vernacular cultures. Research questions: (1) How is knowledge generated and transmitted in the NaqshbandiHaqqani order? (2) How is healing understood and done in the Order? (3) How does the Order find a role in the modern world, and in the West in particular? Methods: Anthropological analysis of psychiatry as religious healing; review of previous studies of Sufi healing and the Naqshbandi-Haqqani order; ethnographic participant observation in the Naqshbandi-Haqqani order, with a special focus on healing. Ethnography was done at many sites, over a period of 11 years. Findings: (1) Knowledge is generated by means of the individual’s contact with Shaykh Nazim, who, in turn, is said to be in contact with the Prophet. Knowledge is therefore personalised, situational, and ever-changing. Purification of the nafs (psyche, soul) is held to increase the capacity for knowledge. (2) Discourse in the Naqshbandi-Haqqani order centres around healing of the soul, which is held to be a salvific and intellectual exercise. Activities and intellectual disciplines are subsumed into soul-healing. Healing techniques are eclectic and universally applied, ultimately under the perceived direction of Shaykh Nazim. (3) The Order attracts followers through charisma and personal contacts; adapts to local vernaculars; creates alternative social networks; makes everyday activities part of soul-healing; provides low-cost personalised healing; and reflects postmodern concerns and ecumenism. Implications: Healing that reflects pre-modern, religious models of the intellect, and a medical science that is not merely naturalistic, has encompassed scientific narratives and gained adherents in the postmodern world.

Chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD) are significant and growing causes of morbidity and mortality worldwide. Poor disease control causes a substantial burden on patients, their families and society. Inhaler therapy is the most popular asthma and COPD treatment, but patients are compromised from inappropriate medication use. How to measure adherence to medication is a huge global problem. This thesis presents an original audio-based monitoring system for the pressurised metered-dose inhaler (pMDI), which has been developed to track and analyse the patient's dose delivery and inhaler technique. Prior to this study, there existed no automated system, based on acoustic monitoring, to track and assess pMDI inhaler technique. In terms of the hardware, this system combines accelerometer and acoustic sensors to enable a comprehensive assessment of the pMDI technique. For recognition of the breath phases, this research initially employed a hidden Markov model (HMM) with a Gaussian mixture model (GMM) to identify the phases of the breath sound. Ultimately a model was developed that concatenating two deep learning models (1-D ResNet18 and CLDNNs), which improved the recognition accuracy of acoustic signals degraded by noise. Respecting motion events, this thesis introduces a method based on a root mean square (RMS) framing window in combination with a rotation matrix to achieve robust shake detection and vertical holding detection, respectively. This thesis further describes a series of experiments. Experiment 1 to 3 was designed to characterise the strengths and weaknesses of the system, in which testing also provided useful information for further system development. The final experiment was a real-patient study that involved the recruitment of six patients diagnosed asthma or COPD. The system tracked their pMDI use for three weeks and established the deviations of pMDI usage and technique that existed between the patients' self-reports and independent electronic reports. Characterisation of these differences, and the ability of the system to not only to monitor adherence but also to identify usage failure points suggest that the monitoring system will, in the future, be a highly desirable component of digital healthcare provision.

Cancer is a leading cause of death, being responsible for over 9.6 million deaths worldwide in 2018. Photodynamic therapy (PDT) is an alternative cancer treatment with FDA approval. It is based on the use of photosensitisers (PS) such as protoporphyrin IX (PpIX), which are activated through light and produce singlet oxygen when irradiated, leading to tumour ablation. Highly controlled light dosimetry and rapid drug uptake maximizes the PDT effect while protecting surrounding tissue from damage. However, it is limited by inefficient drug accumulation in target tissue, light scattering, variable oxygen gradients, and high toxicity. Carbon dots (CDs) are carbon-based fluorescent nanoparticles that have gained attention due to their interesting photophysical properties, low toxicity, tuneable surface functionality and adaptable synthesis making them ideal candidates for drug delivery, bioimaging, and theragnostics applications. CDs have been previously used for PDT as PS carriers and have shown great success in improving treatment efficiency. However, to date, no comparison between conjugates with different drug loading strategies has been made to determine the best-performing methodology. This research aimed to produce PpIX-loaded conjugates capable of an enhanced PDT effect. Conjugates should be water-dispersible and produce singlet oxygen, demonstrating enhanced photoluminescence, fast intracellular uptake, low dark toxicity, and high light toxicity. In this work, carbon dot (CD) and protoporphyrin IX (PpIX) conjugates were fabricated using microwave-assisted pyrolysis. CDs were shown to be highly useful and effective carriers for PpIX, demonstrating an enhanced PDT effect through advantageous intracellular localization and decreased cytotoxicity. The use of cancer spheroids and morphometric parameter acquisition demonstrated how multiple treatment parameters can be simultaneously screened to determine optimum ranges for further experiments.

Stereotactic radiotherapy (SRT), which delivers ablative radiation doses, is increasingly becoming a standard of care in many clinical scenarios. Radiobiological studies help to understand clinical radiotherapy, including SRT, better. In-vitro radiobiological studies designed to explore complexities of SRT, and the large potential experimental space of radiation-drug combinations would require a high-throughput in-vitro system, which should be relevant to clinical radiotherapy. My programme of work led to the development of a high-throughput in-vitro radiobiology platform using an advanced clinical radiotherapy technique, intensity modulated radiotherapy (IMRT) using widely available clinical facilities to recapitulate clinical radiotherapy as close as possible. My work also examined some of clinically relevant radiation physics and clinical parameters that are related to SRT. My work, in contrast with other work showed that there might not significant biological implications of different radiation-doses rates and intra-fraction treatment breaks used in SRT. This could be due to ablative radiation doses used in SRT. Using in-vitro tumour models, I demonstrated a novel radiosensitisation strategy of using Notch inhibition that has a potential for clinical translation in melanoma where, because of its relative radioresistance phenotype could prove to be a successful strategy to widen the clinical application of radiotherapy. My work also showed that Notch inhibition could potentially reduce the risk of development of metastasis and demonstrated potential mechanistic basis for this combined approach. I also demonstrated a novel, first-in-class radiosensitisation approach with a folate depletion strategy based on sound biological rationale with various in-vitro tumour models differing in their radiosensitivities that would require in-vivo validation. My work would hopefully encourage other institutions to develop their own radiobiology programmes using clinical radiotherapy facilities to interrogate potential biological uncertainties of SRT and also expedite pre-clinical evaluation of radiation-drug combinations.

This exploratory study asks what factors a music therapist needs to consider when working with a child whose cultural background differs from their own. Our cultural background and worldview influence many aspects of our lives and those of the people we work with, and yet there is little music therapy research that examines the impact of cultural difference on music therapy practice, or research in which the voices of participants are heard. This is especially important given that the music therapy profession worldwide shows an underrepresentation of minority ethnic groups, as music therapists are often drawn from privileged, majority groups. This means music therapists are less likely to have lived minority experience, and be less able to practise with cultural empathy. Qualitative methods were employed to examine three main sources of data: a review of music therapy literature, eight case studies of children who participated in music therapy in two special schools and eight parent interviews analysed using Interpretative Phenomenological Analysis. All the children included in the study came from families where English was not the first language spoken at home. They were referred for music therapy following the usual criteria in their school. Their parents attended some or all of their child's music therapy sessions and subsequently answered questions via semi-structured interviews relating to their home life, use of music and language, and their experiences of the music therapy sessions. The themes that arose from the three sources of data: the interviews, the case studies and the literature review, were triangulated to address the research questions. The main themes coming out of this study include the importance of music therapists acknowledging their own cultural influences, the various forms of discrimination encountered by minority ethnic groups from professionals and institutions, the value of collaborative approaches with parents in music therapy and in research, and the importance of acknowledging cultural identity and cultural factors but at the same time avoiding making cultural assumptions. Developments in intercultural practice such as cultural empathy, cultural competence and cultural safety were explored, as well as implications from the study for future research and training.

Music Therapy (MT) literature reviews report a reduction of Behavioural and Psychological Symptoms associated with Dementia (BPSD) after MT for Persons Living with Dementia (PWD). However, a consensus on how to implement MT in dementia care is still lacking and further research is needed. This study aims to identify MT Techniques (MTTs) and significant moments, contributing to a reduction in BPSD during MT group sessions. Six groups of 3 PWD aged between 65-100 and manifesting behavioural symptoms participated in 12 weekly active Group MT (GMT) sessions. A mixed method research approach was applied. Agitation Behaviour Mapping Instrument (ABMI), Observed Emotion Rating Scale (OERS), and Music in Dementia Assessment Scale (MiDAS), quantitative direct observation tools, detected Moment(s) of BPSD Reduction (MBR) during the session. A qualitative assessment based on Interpretative Phenomenological Analysis attempted to describe how MBR occurred by identifying relevant MTTs, sonority and sound interaction at MBR (MBR descriptors). A prevalence analysis and an artificial neural network system (Auto-Contractive Map) identified qualitative data associations. A pool of four qualitative MBR descriptors (pool-components) for each of the following syndromes was identified: Aggression - Features of Clinical Environment, Calming, Pacing, and Rhythmic Grounding; Depression - Rhythmic Grounding, Introducing Change, Music Therapist’s Flexibility, and Features of Clinical Environment; Apathy - Rhythmic Grounding, Group As a Resource, Group Creation, Features of Clinical Environment; Hyperactivity - Giving, Client Validation, Giving Value to Client’s Music and Sound, Rhythmic Grounding, Making Spaces. The qualitative analysis of the nature of the pools highlighted a two-phase mechanism for MBRs. Results showed that Rhythmic Grounding, Features of Clinical Environment, Pacing, and Making Spaces were functions for preparing the conditions for MBRs in music therapy (first phase), all the other pool components were essential functions for achieving MBR in GMT (second phase). The Rhythmic Grounding technique was a constant component through all the phases and conditions for achieving MBRs. The clinical conditions expressed by the pools contribute new knowledge of the internal mechanism of MT at MBR.

Background - Physiotherapy education aims to prepare graduates for the world of work, and this includes being autonomous reflective practitioners, and lifelong learners. Many universities use a student continuing professional development (CPD) portfolio to achieve this, however there is no research investigating whether developing and completing an undergraduate portfolio has any impact on the graduate’s motivation to engage with continuing professional development. This study aimed to explore both undergraduate and graduate views on whether their level of motivation for CPD and lifelong learning (LLL) had been influenced by using a student CPD portfolio. Methods – This was a mixed methods study, in an idealistic research paradigm, with an inductive methodology. The study used two online questionnaires and semi-structured telephone interviews with final year physiotherapy students and qualified physiotherapists in the UK to collect data, with statistical, content and thematic analysis applied as appropriate. Findings – There is evidence to suggest that requirement and assessment of the portfolio, portfolio structure, and perceived level of support and guidance for the portfolio building process all influence student motivation towards lifelong learning and using a CPD portfolio post-graduation. From a graduate physiotherapy perspective, those who completed a student portfolio were more motivated to use a portfolio and to undertake CPD, although other variables may have influenced these results. There is also evidence that motivation fluctuates depending on point on career path, with those in middle grade bandings least motivated to undertake CPD and use a portfolio. A model of motivation was developed from analysis of the findings from the study, showing the internal and external motivating factors that influence physiotherapists’ engagement with CPD portfolios, CPD and LLL. Implications – Physiotherapy educators should be aware of the internal and external factors influencing motivation towards use of a portfolio and utilise these to engage students in the portfolio building process to improve motivation for LLL. Physiotherapists and physiotherapy managers should consider the influence of internal and external motivating factors when discussing on-going development. Original Contribution to Knowledge – The research concludes that completing a student portfolio has a positive influence on motivation towards CPD portfolios, CPD and LLL, and that if students perceive the structure of the portfolio to be helpful, and receive useful support and feedback for portfolio development, the positive influence of completing the portfolio on motivation towards CPD portfolios, CPD and LLL is enhanced. The findings also suggest that portfolios that are a requirement of the course and/or are assessed reduce the positive influence of completing a portfolio on motivation for future use of a portfolio and learning. The research indicates that physiotherapists perceive greater benefit from learning that is internally motivated, and there are many internal and external motivating factors that can influence the decision to learn, both positively and negatively. Ultimately, this study has shown that physiotherapists and student physiotherapists will only engage in learning when the perceived benefits outweigh the perceived costs.

The overall aim of the thesis was to design and test modified neonatal parenteral nutrition (PN) formulations with additional arginine content in very preterm neonates (VPNs) dependent on PN. Review of the literature resulted in a dose concentration graph that suggested a percentage content of about 14% and absolute arginine intake of about 600mg/kg/day to achieve target plasma arginine levels ≥80 micromoles/L. Previous studies have reported that VPNs dependent on PN have low plasma arginine levels and an oversupply of essential amino acids (EAAs). The difficulties with assessing amino acid (AA) status were explored using published AA profiles. Modified PN formulations using two different base AA solutions, Vaminolact® and Primene®, containing 14% arginine were designed and manufactured in an aseptic, clean room setting. These formulations were tested in a stability testing study using common physical tests such as visual appearance, pH, optical rotation, UV absorbance and sub-visible particle count. This thesis included AA assay of PN formulations as a part of PN stability testing. It was included to monitor the AA content in the PN formulations tested. The results showed that the modified PN formulations with 14% arginine were stable for 90 days (without trace elements solution - PeditraceTM) and 7 days (with PeditraceTM). The AA assay results proved that the modified PN formulations contained 14% arginine as per the designed calculations and it also provided evidence that AA assay is a new, practical and reliable method to quality control arginine supplementation of PN formulations. The stability testing study also demonstrated that single sampling for each test point is crucial for PN stability testing to reduce the risk of contamination and oxidation to an extremely complex solution such as PN formulations. A clinical study (PAINT-NH4) compared the plasma AA profiles of VPNs on standard PN formulation (containing 6% arginine) versus intervention PN formulation (containing 14% arginine). The findings suggested that on Day 3, plasma arginine levels were significantly different between the treatment groups. Whereas on Day 10, plasma arginine levels were not significantly different. The high dependence on PN during first few days of life (Day 3) resulted in a significant impact from the intervention while the decreased PN dependency of the intervention group infants by Day 10 of life reduced the impact of the intervention and hence affected the plasma arginine levels. The comparison of the entire plasma profiles between the treatment groups in PAINT-NH4 illustrated that an increased arginine content while maintaining overall AA content (with reduction of all other AAs except arginine) resulted in rebalancing of the profiles to more closely resemble the reference range of healthy breastfed preterm infants. Plasma arginine levels increased whereas the oversupply of EAAs reduced. This indicated that rebalancing of AA content in PN formulations are reflected in the plasma AA profiles of VPNs. Although plasma arginine levels increased, the mean plasma arginine levels did not achieve the target levels above 80micromoles/L. Therefore, future work has been proposed to test a 18% arginine content solution with current AA intakes.

Microbeam Radiation Therapy (MRT) is an emergent treatment modality that uses spatially fractionated synchrotron X-ray beams. MRT has been identified as a promising treatment concept that might be applied to patients with malignant central nervous system (CNS) tumors for whom, at the current stage of development, no satisfactory therapy is available yet. The use of a fractionated beam allows a better skin sparing and a better tolerance of healthy tissue to high dose rates. MRT consists of a stereotactic irradiation with highly collimated, quasi-parallel array of narrow beams 50 μm wide spaced with 400 μm made of synchrotron generated X-rays at an energy ranging from 0 to 600 keV. The European Synchrotron Radiation Facility (ESRF) as an X-ray source allows a very small beam divergence and an extremely high dose rate. The dose deposited on the path of the primary photons (peak dose) of several hundred grays (Gy) is well tolerated by normal tissues and provides at the same time a higher therapeutic index for various tumor models in rodents. The high dose rate forces us to develop an accurate and reproducible dosimetry protocol to ensure the matching between the prescribed and the delivered dose. MRT is by definition a non-conventional irradiation method, therefore the number of dosimetric errors becomes larger than in conventional treatments due to two reasons (i) the reference conditions recommended by the Association of Physicists in Medicine (AAPM) or the International Atomic Energy Agency (IAEA) cannot be established, (ii) the measurement of absorbed dose to water in composite fields is not standardized. This PhD is focused on bridging the gap between MC simulated values of output factors (OF) and peak-to-valley dose ratios (PVDR) and experimental measurements. Several aspects of the irradiation setup such as insertion devices on the path of the X-ray beam are accounted for as well as the internal structure of the dosimeters. Each contribution to OF and PVDR is quantified to correct for the measurements.

Proton beam therapy is an alternative to traditional X-ray radiotherapy utilised especially for paediatric malignancies and radio-resistant tumours; it allows a precise tumour irradiation, but is currently limited by knowledge of the patient density and thus the particle range. Typically X-ray computed tomography (CT) is used for treatment planning but CT scans require conversion from Hounsfield units to estimate the proton stopping power (PSP), which has limited accuracy. Proton CT measures PSP directly and can improve imaging and treatment accuracy. The Christie Hospital will use a 250 MeV cyclotron for proton therapy, but 330 MeV protons are needed to image the largest adult. In this thesis the feasibility of a pulsed linac upgrade to provide 100 MeV acceleration in a cyclinac set up is studied. Space constraints require a compact, high gradient (HG) solution that is reliable and affordable. An overview of accelerator physics and beam dynamics are presented alongside the phenomenology of breakdown in high gradient RF structures. Both a small and large aperture solution are investigated. The small aperture option aims to keep the beam size to a minimum using focussing magnets between cavities and accelerate with a very high gradient. The large aperture solution aims to occupy more of the available space with accelerating structures and less with focussing magnets. This way the optics are simpler and the beam size is larger throughout the linac. The small aperture optimisation investigated S-, C- and X-band cavities. Firstly with simple pill-box structures then looking at the effect of nose cones on RF efficiency and breakdown limits. Multi-cell structures are then investigated employing side-coupling for standing wave (SW) cavities and various different magnetic coupling slots for backward travelling wave structures (bTW). Limited by 100~MW/m a 15~cm bTW solution was proposed with a calculated gradient of 65~MV/m. Unfortunately to be used with a cyclotron, which typically have large emittance, infeasibly strong magnets would be required. The large aperture optimisation only considers S- and C-band structures as they exhibit higher shunt impedance with larger apertures than X-band cavities. Side-coupled SW structures and magnetically coupled bTW structures are re-optimised for a larger aperture. An S-band side-coupled SW structure is subsequently identified as being the optimum for this energy range. A full 11-cell structure design with input coupler and end cells is presented calculated to reach 54~MV/m. A beam dynamics study is also presented considering both the small and large aperture schemes. For the large aperture scheme a particle tracking study is also presented. Mechanical engineering considerations are presented with a novel disk design manufacturing each individual cell from two machined copper disks. Thermal analysis of the temperature distribution inside the cavity is presented alongside heat transfer calculations for the cavity cooling system. Finally the conditioning and high power test of a similar S-band medical structure is presented with comparison made to the prototype structure designed in this study.