Stroke is a serious disease that leaves many sufferers physically disabled. Treatment resources are limited, meaning stroke patients, are in many cases, discharged prior to reaching their full potential of physical recovery. The hypothesis of this research is that a system that enables regular guided and monitored therapeutic exercises in the home can provide a means for stroke patients to achieve a higher level of physical rehabilitation. This research is based on the design, build and testing of an experimental prototype system to allow this, with the aim of investigating the feasibility and potential value for such systems. Any system to assist rehabilitation in the home must clearly be low cost, safe and easy to use. The prototype system therefore aimed to achieve these features as well as focusing on the upper limb. Literature is reviewed in the fields of stroke, human anatomy and mechanisms, motor performance, feedback during motor learning, and existing systems and technology. Interviews are also conducted with stroke physiotherapists to gain input and feedback on concepts that were generated. Although systems exist with similar aims to those mentioned in the hypothesis, there are some areas where investigation is lacking. The prototype system measures movement using a novel combination of gyro sensors and flex sensors. The prototype system is designed with a focus on the method of interaction with patients and the provision of guidance and feedback that simulates that provided by a physiotherapist. The prototype system also provides a unique combination of quantitative information to patients of their personal improvements and graphical feedback of their movements and target movements. Finally, a novel categorisation of movement synergism (a form of movement coordination) is established and a novel method for detecting movement synergism is developed and tested. Performance of the prototype hardware is tested, and it is concluded that identified requirements have been met, although variability of recorded data is high. Tests also indicate that the prototype system is capable of detecting movement synergism. Finally, a controlled test involving healthy participants is performed to investigate the efficacy of the prototype as a whole. It was found that use of the prototype system resulted in a statistically significant improvement in conformance to target movements (p < 0.05). Findings are discussed in detail and the hypothesis is concluded as being supported overall. Recommendations for future research are made.

I Sverige drabbas cirka 30 000 personer av stroke varje år. Stroke kan vara ett livshotande tillstånd med hög mortalitet samt är den främsta orsaken till neurologiskt handikapp och kan innebära ett livslång lidande. Tidigare forskning visar att tiden från symtomdebut till trombolysbehandling har stor betydelse för att minska de neurologiska skadorna hos patienter som drabbas av stroke. Dock saknas det studier som undersöker tidsåtgången prehospitalt vad gäller ambulanssjukvårdens tid på plats hos patienten.  Studien syftade till att genom journalgranskning undersöka de dokumenterade åtgärderna och tiden på plats som ambulanssjukvården spenderat hos patienter med stroke. En kvantitativ ansats med retroperspektiv journalgranskning valdes som metod. Utgångsmaterial var uppföljningsprotokoll från röntgenavdelningen där 137 patienter fått trombolysbehandling under 2014 och 2015. Efter exklusionskriterier granskades 121 journaler. Med bakgrund av internationella riktlinjer valdes 15 minuter som riktvärde av tid på plats för jämförande. Resultatet visade att ambulanspersonalen i snitt spenderar 19,5 (2-54) minuter på plats hos patienter som drabbats av stroke och fått trombolysbehandling. Studien fann ingen signifikant skillnad av antal dokumenterade åtgärder hos patienter där sjuksköterskan spenderat mindre än 15 minuter respektive mer än 15 minuter. Utifrån medeltiden hos de granskade fallen i studien samt att det saknas specifika tidsmål i nationella riktlinjer ges rekommendationen att införa specifika tidsmål i riktlinjer samt att begränsa åtgärder på plats hos patienten till att säkra och stabilisera ABC samt att genomföra AKUT-test.

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Following unilateral stroke there is significant loss of function in the body side contralateral to the damage and a robust degenerative-regenerative cascade of events in both hemispheres. It is natural to compensate for loss of function by relying more on the less-affected body side to accomplish everyday living tasks (e.g. brushing teeth, drinking coffee). This is accompanied by a “learned disuse” of the impaired side thought to occur due to repeated experience with its ineptness. However, as investigated in these studies, it may also be due to brain changes instigated by experience with the intact body side. The central hypothesis of these dissertation studies is that experience with the intact forelimb, after unilateral sensorimotor cortex (SMC) damage, disrupts functional recovery with the impaired forelimb and interferes with peri-lesion neural plasticity. Following unilateral ischemic lesions, rats were trained on a skilled reaching task with their intact (less-affected) forelimb or received control procedures. The impaired forelimb was then trained and tested on the same skilled reaching task. Intact forelimb experience worsened performance with the impaired forelimb even when initiated at a more delayed time point following lesions. Intact forelimb training also reduced peri-lesion expression of FosB/ΔFosB, a marker of neuronal activation, and caudal forelimb motor map areas compared to animals without intact forelimb training. It was further established that it is focused training of the intact forelimb and not experience with this limb per se, as animals trained with both forelimbs in an alternating fashion did not exhibit this effect. Transections of the corpus callosum blocked the maladaptive effect of intact forelimb experience on impaired forelimb recovery, suggesting a disruptive influence of the intact hemisphere onto the lesion hemisphere that is mediated by experience. Together these dissertation studies provide insight into how experience with the less-affected, intact body side, can influence peri-lesion neural plasticity and recovery of function with the impaired forelimb. The findings from these studies suggest that compensatory use of the less-affected (intact) body side following unilateral brain damage is not advantageous if the ultimate goal is to improve function in the impaired body side. / text

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Diffusion Tensor Magnetic Resonance Imaging (DTI) is a recently-developed technique that can image in vivo the white matter pathways of the central nervous system. This study used 12-direction diffusion-weighted MRI data from nine stroke patients acquired as part of a three-year stroke rehabilitation study coordinated by the Movement Neuroscience Laboratory at the University of Auckland. DTI was used to investigate corticospinal connectivity. From the FA maps, it is found that in those patients whose motor connectivity has been compromised by the stroke to the extent that no motor evoked potential (MEP) can be elicited from a selected affected muscle group, the asymmetry in mean FA values in the posterior limbs of the internal capsules (PLICs) is correlated with functional recovery as measured by the Fugl-Meyer clinical score. Using probabilistic tractography in the contralesional hemisphere produced CST location and somatotopy results that were consistent with those of previous studies. However, in the ipsilesional hemisphere, connectivity results were highly variable. A measure of change in symmetry of mean connectivity is found to correlate with functional recovery as measured by change in FM score. This supports previous work which has correlated CST integrity and functional improvement and it supports the theory that functional recovery after stroke depends on the extent to which motor CNS symmetry can be regained in the new post-stroke architecture. It also suggests that the movement of the fMRI activations occurs in such a way as to make the most of the preserved white matter connectivity.

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This thesis provides new insights about how the brain controls skilled movements, through the study of limb apraxia in two major neurological disorders: Stroke and Corticobasal Syndrome (CBS). Limb apraxia is a cognitive-motor deficit characterized by impairment in the performance of skilled movement. The Conceptual-Production systems model, used as framework in this thesis, proposes that skilled movement is under the control of three systems: a sensory/perceptual system, a conceptual system and a production system. Deficits in any of these systems produce limb apraxia, and depending on which system is affected, a distinct pattern of apraxia emerges. This information processing approach was used to evaluate performance levels, study brain asymmetries and discern patterns of deficits in each population. In addition, longitudinal assessments in sample subsets revealed patterns of recovery after stroke and of progression in CBS. The first study examined acute-subacute and chronic stroke patients with left (LHD) and right hemisphere damage (RHD) for their ability to pantomime and imitate transitive and intransitive gestures. The results indicated that LHD and acute-subacute were more severely impaired. Concurrent deficits in pantomime and imitation were most common, especially after LHD. Since acute-subacute patients were more severely impaired, in the absence of any therapies, it is likely that some degree of recovery occurs over time. The second study study examined longitudinal recovery in a series of transitive gestures tasks among stroke patients and indicated that patients significantly recovered in all tasks, except in Action Identification, a conceptual apraxia task which probes knowledge of actions. Finally, two comparative studies were conducted in CBS, a neurodegenerative disorder in which apraxia is common, making this one of the first studies that evaluated patient performance on a complete limb apraxia battery. The first study found that patients were often impaired on all gesture production tasks, while conceptual knowledge of gestures and tools was usually preserved. A case series constituted the second study, which documented the progression of apraxia in CBS demonstrating that, while deficits in gesture production usually are present at first examination, deficits in conceptual knowledge are infrequent and in many cases do not develop at all. Study limitations were discussed and it was suggested that future research should expand on our findings for recovery in stroke and progression in CBS.

<p>Lack of knowledge about stroke in general and specific knowledge of the risk factors, signs, and symptoms of stroke results in the late presentation of patients at hospital. The aim of this study was to determine the knowledge of stroke among hypertensive patients in the Tanga region of Tanzania. To investigate this, a cross-sectional survey using a quantitative research design was used.</p>

Background. The Swedish government states that participation and influence are among the most fundamental prerequisites of public health. Mobility services provide professional and high quality information, advice, and assessment to individuals with a medical condition or recovering from an accident or injury that may affect their ability to drive, access, or egress a motor vehicle. Although Swedish physicians must report drivers with medical conditions, rehabilitative training for driving licenses following injury or severe medical conditions does not exist within contemporary Swedish healthcare systems. Aim. This study aimed primarily to describe and compare two driving assessment models, i.e., the model used by Traffic Medicine Center (TRMC) Stockholm in 1998 and the model provided by Mobilitetscenter.se (MC.se) Gothenburg in 2007. The study also sought to determine the context of the changed provision of driving assessments and identify the significant components of this change. Method A literature review, synthesised with the author’s research and complemented by practice-based evidence, provided the knowledge base and starting point of this essay. Action research paired with intervention propelled the changes in the provision of mobility services in Sweden between 1998 and 2007. The author used John Ovretveit’s identification of significant change components to illuminate the complex change process that occurred.  Selection of an appropriate list of variables to compare the two assessment models derived from FORUM of Mobility Centres, the umbrella organization of British Mobility Centres that developed national guidelines for driving ability assessments in the UK; the QEF Mobility Centre was a member of that organization. The author used a questionnaire and a semi-structured interview to gather relevant data from the compared centers. Results TRMC aims primarily to provide services for society through its contributions to road safety. A Mobility Center focuses on providing assessment and rehabilitation services, optimizing impaired drivers’ mobility potential and minimizing collision risks. Cognitive assessment at TRMC accounted for a large part of this study’s time allotment. MC.se’s practical driving test in a suitably modified car provides the most significant difference between the two models.  In addition, MC.se has replaced physicians and psychologists with occupational therapists. Conclusion TRMC aims to ensure that current drivers comply with medical driving laws and regulations. MC.se provides assessments that maximize mobility potential and also ensure low collision rates. Thus, safety is balanced against the right to mobility. The study also explores coping strategies, training, adaptations, and choice of vehicle. / <p>ISBN 978-91-85721-58-0</p>