Cerebrovascular disease (CVD) is strongly linked to hypertension and generally occurs later in life than coronary artery disease (CAD). Three quarters of the patients with symptomatic CVD are above 65 years of age. The risk factors are the same for CVD and CAD, but the relative importance of the vascular risk factors differs greatly. Genetic causes of stroke are relatively rare. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a hereditary disease which causes CVD in young adults and middle-aged people, with migraine, stroke, psychiatric illness and dementia as clinical manifestations. The subject of this thesis is vascular function in stroke and CADASIL. Endothelium-dependent vasodilation (EDV) and arterial stiffness were investigated by different methods in stroke patients and CADASIL patients compared with healthy controls. Venous occlusion plethysmography with intra-arterial acetylcholine was used to evaluate EDV in the forearm resistance vessels. Flow-mediated vasodilation of the brachial artery was used to evaluate EDV in a conduit artery. Stroke patients displayed reduced EDV in resistance vessels compared with a healthy control group, but this reduction was not significant when, in a larger group of stroke patients, adjustments were made for blood pressure, antihypertensive treatment and other risk factors. Flow mediated vasodilation of the brachial artery was reduced in the stroke patients even after adjustment for risk factors. Compared with controls, the CADASIL patients showed similar EDV in the conduit artery, but reduced EDV in resistance vessels. Arterial compliance was evaluated by augmentation index from pulse wave analysis, by a ratio of cardiac stroke volume and pulse pressure, and by the distensibility of the carotid artery in relation to pulse pressure. Stroke patients and CADASIL patients did not display any significant increase in arterial stiffness when evaluated by these methods.

I Sverige flyttar de flesta av oss till ett ”boende” när vi blir gamla och behöver mer hjälp och vård. Där spenderar man sedan sin sista tid i livet och ses inte alltid som en person med förmåga att utvecklas. FMT – Funktionsinriktad musikterapi, kan användas för att ge personer med olika funktionsnedsättningar förutsättningar för att utvecklas. I detta examensarbete beskriver jag mitt arbete med en person med demenssjukdom och en person som lever med sviterna efter en stor stroke. De har båda förlorat sin verbala förmåga och har även stora fysiska funktionsnedsättningar. Syftet är att undersöka hur FMT kan bidra till ökad livskvalitet för dessa personer. Jag har funnit att FMT-metoden kan bidra till ökad livskvalitet genom sin tydliga struktur, sin ickeverbala kravlöshet och betoning på det egna initiativet och den egna lusten.

Att drabbas av stroke innebär ofta kognitiva funktionsnedsättningar. Betydelsen av en snabb bedömning av strokepatienters kognitiva funktioner i det akuta skedet efter en stroke betonas i flera studier. Syftet med den här studien var att med hjälp av en enkätundersökning kartlägga de kognitiva bedömningar som genomförs av arbetsterapeuter på landets strokeenheter. Undersökningsgruppen utgjordes av arbetsterapeuter på 58 strokeenheter. Det insamlade materialet bearbetades med beskrivande statistik. Av resultatet framkom att de vanligast förekommande bedömningsinstrumenten/observationerna var MMT, RBMT, DBF samt AMPS. En kombination av bedömningar gjordes på de flesta strokeenheter, typvärdet var 4 bedömningar. Resultatet visade även att arbetsterapeuternas kunskap om bedömningarnas reliabilitet och validitet var god. Någon avgörande skillnad har inte observerats när det gäller valet av bedömning hos de olika strokeenheterna med hänsyn tagen till sjukhusets storlek eller antalet arbetsterapeuter som arbetar på strokeenheten. Vår slutsats är att strokepatienter som vårdas på de strokeenheter som ingår i den här undersökningen bedöms med bedömningsinstrument/observationer av arbetsterapeuter på ett likvärdigt sätt oavsett var i landet de vårdas.

Bakgrund: Stroke är en folksjukdom som leder till både motoriska och kognitiva funktionsnedsättningar som påverkar aktivitetsförmågan hos den drabbade individen. Arbetsterapeuten kan bidra till att klienten kan förbättra sin kapacitet till aktivitetsförmåga genom återtränade och kompensatoriska åtgärder. Tre åtgärdsmodeller som tillämpas i praxis är Bobathmodellen, den Uppgiftsorienterade modellen samt CI-terapi. Kunskapen om i vilken utsträckning dessa används i praxis är dock bristfällig. Syfte: Syftet med denna studie är att kartlägga tre arbetsterapeutiska åtgärdsmodeller som tillämpas inom slutenvården för individer med nedsatt hand- och armfunktion efter stroke. Metod: Studien hade en deskriptiv design där en kvantitativ metod användes. Datainsamlingen gjordes med hjälp av en enkät till arbetsterapeuter som arbetar inom slutenvården med klienter som drabbats av nedsatt hand- och armfunktion efter stroke. Enkätfrågorna berörde områdena bedömning, åtgärd klientcentrering samt utvärdering utifrån de tre åtgärdsmodellerna. Av 52 tillfrågade besvarade 32 arbetsterapeuter hela enkäten. Resultat: Majoriteten av de deltagande arbetsterapeuterna arbetade på en specifik strokeenhet. De flesta angav att de använde Bobathmodellen eller den uppgiftsorienterade modellen. Det vanligaste syftet med arbetsterapin var att återträna den affekterade armen eller handen och den vanligaste åtgärden var att återträningen skedde i en målinriktad aktivitet. Klientcentrering är en viktig aspekt i interventionen enligt alla deltagande arbetsterapeuter. Utvärderingen av interventionen såg olika ut beroende på vilken avdelning arbetsterapeuten arbetade. Slutsatser: Antalet deltagande arbetsterapeuter i denna studie är för få för att studiens resultat kan överföras till kliniska verksamheter. För en mer fördjupad förståelse skulle en kvalitativ studie kunna ge en mer korrekt bild av arbetsterapin. Slutsatsen av resultatet är att deltagarna använder mer än en modell vid arbetsterapi för individer med nedsatt hand – och armfunktion efter stroke. Ett nytt instrument som både inkluderar ett återtränande och ett kompensatoriskt syfte bör utformas.

Aufgrund der steigenden Prävalenz und der bisher unzureichenden Behandlungsmöglichkeiten ist der Schlaganfall Gegenstand intensiver Forschung. Ein vielversprechender therapeutischer Ansatz ist die Hemmung der überwiegend destruktiven Entzündungsantwort nach dem ischämischen Ereignis, zum Beispiel durch die Applikation von potentiell neuroprotektivem hyperbarem Sauerstoff (HBO). Die vorliegende experimentelle Arbeit am thrombembolischen Rattenmodell untersuchte die Einwanderung Makrophagen-artiger Zellen sowie längerfristige mikrogliale und astrozytäre Veränderungen nach akuter fokaler zerebraler Ischämie. Dabei erhielten die Tiere eine Monotherapie mit rekombinantem Gewebsplasminogenaktivator (rtPA), die einzige bisher zugelassene medikamentöse Therapieoption, oder eine Kombinationstherapie von rtPA mit HBO. Mit Hilfe des immunhistochemischen Nachweises gegen CD68 konnten einwandernde Makrophagen-artige Zellen erfasst und semiquantitativ ausgewertet werden. Verschiedene Immunfluoreszenz-Mehrfachmarkierungen und konfokale Laserscanningmikroskopie ermöglichten die simultane Detektion von mehreren Mikrogliapopulationen, Astroglia und Neuronen. Zwei bis vier Wochen nach Infarkt konnte in der rtPA + HBO-Gruppe eine abnehmende Tendenz akkumulierter Zellen nachgewiesen werden. In Tieren der Kontrollgruppe zeigte sich reaktive Mikroglia vor allem im Infarktkern, während Astrozyten im Randbereich des Infarktes eine zirkuläre Form annahmen. Die vorliegende Arbeit konnte einen Einfluss von HBO auf die Einwanderung von Makrophagen-artigen Zellen nachweisen sowie neue Erkenntnisse über regionale Unterschiede langfristiger Gliareaktionen liefern.

Prehospital care has developed dramatically the last decades with the implementation of new devices and educational concepts. Clinical decisions and treatments have moved out from the hospitals to the prehospital setting. In Sweden this has been accompanied by an increase in the level of competence, i.e. by introducing nurses in the ambulances. With some exceptions the scientific support for these changes is poor. This thesis deals with such changes in three different subsets of prehospital care: Cardiopulmonary resuscitation (CPR), the stroke chain of survival and trauma care. We assessed the performance of ambulance crews during CPR, using a mechanical compression device, as compared to CPR using manual compressions. There was a strikingly poor quality of compressions using the mechanical device compared to CPR with manual compressions. The result calls for caution when implementing a chest compression device in clinical practice and reinforce the importance of randomised controlled trials to evaluate new interventions. Careful attention should be given to the assurance of correct application of the device. Further implementation without evaluation of the quality of mechanical compressions in a clinical setting is discouraged. Among patients with a prehospital suspicion of stroke we analysed the ambulance nurses’ ability to select the correct patient subset eligible for a CT scan as a preparation for potential thrombolysis. The results do not support an implementation of a bypass of the emergency department, using ambulance nurse competence to select patients eligible and suitable for a CT scan without a preceding assessment by a physician. The association between the Prehospital Trauma Life Support (PHTLS) course and the outcome in victims of trauma was analysed in two observational studies. A study covering one county gave some support for a protective effect from PHTLS, but the estimate had a low precision. A nationwide study, covering all of Sweden, could not confirm those results. Although there was a reduction in mortality over time coinciding with the implementation of PHTLS, it did not appear to be associated with the implementation of PHTLS. Thus, we could not detect any clear beneficial impact of the PHTLS course on the outcome of trauma patients.

Purpose: The purpose of this research program was three-fold. First it aimed to determine the effectiveness of smoking cessation interventions in increasing cessation rates in smokers with cerebrovascular disease and whether smoking cessation reduces stroke recurrence. Second it aimed to determine the prognostic influence of smoking and its association with stroke severity, disability, length of stay in hospital and mortality. Third it aimed to identify multi-level correlates of smoking cessation in Canadians who reported stroke symptoms in a large population based survey. Methods: Two systematic reviews and meta-analyses were performed to achieve the first objective. For the second objective, a retrospective cohort study was undertaken using variables from the Registry of the Canadian Stroke Network. Finally, the third objective was achieved by analyzing respondents from the Canadian Community Health Survey. Results: There is a paucity of intervention studies examining the effectiveness of smoking cessation in smokers with cerebrovascular disease. Most intervention studies that were found, failed to employ evidence-based approaches to smoking cessation. No evidence was found in regards to the effect of smoking cessation on stroke recurrence. We found smokers had strokes at a younger age compared to non-smokers. We found that in transient ischemic attacks and intracerbral haemorrhage, smoking was a significant predictor of stroke severity, disability, length of stay in hospital and 1 year mortality. Correlates of smoking cessation among Canadians who have experienced symptoms of a stroke included: higher education and income, implementation of household and vehicle smoking restrictions, access to a general practitioner and the use of smoking cessation pharmacotherapies and counselling support. Co-morbidities such as depression and alcohol consumption reduced the likelihood of successful cessation. Conclusions: This three-phase research program elucidated the gaps in intervention research for this population along with co-morbidities that hinder success in cessation. Smoking negatively impacted outcomes such as disability, hospital length of stay and mortality in patients with transient ischemic attacks and intracerebral haemorrhage strokes. Future interventions should take into account modifiable smoking cessation correlates in order to increase cessation rates in smokers with cerebrovascular disease.

In contrast to cardiac rehabilitation (CR) programs, traditional stroke rehabilitation aims to maximize functional independence and does not have a strong focus on exercise training and risk factor modification. Given the parallels between stroke and heart disease in cardiovascular etiology and risk factors, CR may be suited to supplement stroke rehabilitation by providing opportunities to enhance fitness and manage stroke risk factors. The aim of this work was to 1) examine the use of a non-adapted CR program of care with individuals with stroke and/or transient ischemic attack (TIA) through a retrospective database review, 2) using a prospective trial, determine the feasibility and effects of an adapted CR program for people with mild to moderate impairment from stroke, and 3) explore characteristics related to degree of program response in aerobic and functional capacity through secondary data analysis. The results from Study 1 demonstrated that traditional CR is an underutilized service for individuals with stroke or TIA, yet improvements in aerobic fitness were comparable to their non-stroke counterparts. In Study 2, adapted CR was feasible for individuals with a range of stroke-related disability and effective in increasing aerobic capacity. The anticipated carry over to improved walking capacity was not observed. There were no changes in health-related quality of life or stroke risk factors. Study 3 identified subgroups of participants who improved or declined in aerobic and ambulatory capacity after the adapted CR program. There were no differences in baseline characteristics, indices of time, intensity or volume of exercise performed across the response subgroups. In summary, given the parallels between stroke and heart disease, the needs of the stroke population and dearth of community-based exercise programming available for them, the CR model of care may be applied for individuals with stroke to provide opportunities for exercise training and risk factor modification.

Stroke rehabilitation is to train the motor function of a patients limb. In this process, functional assessment is of importance, and it is primarily based on a patients task performance. The context of the rehabilitation discussed in this thesis is such that functional assessment is conducted through a computer system and the Internet. In particular, a patient performs the task at home in a haptic virtual environment, and the task performance is transmitted to the therapist over the Internet. One problem with this approach to functional assessment is that a patients mind state is little known to the therapist. This immediately leads to one question, that is, whether an elevated mind state will have some significant effect on the patients task performance? If so, this approach can result in a considerable error. The overall objective of this thesis study was to generate an answer to the aforementioned question. The study focused on a patients elevated fatigue state. The specific objectives of the study include: (i) developing a haptic virtual environment prototype system for functional assessment, (ii) developing a physiological-based inference system for fatigue state, and (iii) performing an experiment to generate knowledge regarding the fatigue effect on task performance. With a limited resource in recruiting patients in the experiment, the study conducted few experiments on patients but mostly on healthy subjects. The study has concluded: (1) the proposed haptic virtual environment system is effective for the wrist coordination task and is likely promising to other tasks, (2) the accuracy of proposed fatigue inference system achieves 89.54%, for two levels of fatigue state, which is promising, (3) the elevated fatigue state significantly affects task performance in the context of wrist coordination task, and (4) the accuracy of the individual-based inference approach is significantly higher than that of the group-based inference approach. The main contributions of the thesis are (1) generation of the new knowledge regarding the fatigue effect on task performance in the context of home-based rehabilitation, (2) provision of the new fatigue inference system with the highest accuracy in comparison with the existing approaches in literature, and (3) generation of the new knowledge regarding the difference between the individual-based inference and group-based inference approaches.

This qualitative study investigated the experiences of family caregivers who cared for a stroke survivor throughout weekend passes from an in-patient rehabilitation facility. Following a Husserlian phenomenological perspective, I interviewed 15 family caregivers of stroke survivors on two separate occasions: within one week after their first scheduled weekend pass, and again two weeks after their final transition home. Interviews followed a semi-structured interview guide, and were audio recorded. Interviews were transcribed verbatim, and analyzed using the principles outlined by Giorgi (1997). Analysis of the caregivers’ descriptions of their experiences led to five themes: (i) Caregivers feel overwhelmed throughout the weekend pass, (ii) Access to supportive resources influences caregiving experiences, (iii) Caregivers adjust to the weekend pass throughout its subsequent use, (iv) Caregivers feel a responsibility and a need to be included by health professionals in the care of their family stroke survivor, and (v) Caregivers describe the weekend pass as a means towards recovery. This study has implications for future health services. By appropriately training and supporting caregivers throughout the weekend pass health care professionals can increase the positive experiences of caregivers, and optimize the opportunity to prepare caregivers and stroke survivors for the eventual transition home.