Little is understood about the process by which individuals maintain or lose a positive sense of wellbeing in the face of a chronic disabling condition such as stroke (Clarke, 2003). It appears that the impact of residual impairments and disabilities can pose significant problems for wellbeing in older adults, but the presence of such sequelae is not necessarily correlated with subjective wellbeing – some adapt well while others are devastated by minor sequelae (Clarke, 2003). Additionally, little is known about recovery in stroke survivors in relation to normal ageing processes (Green & King, 2007). Through narrative we bring a sense of order to the disorder in our lives, and gain a sense of temporal continuity as we define ourselves in the context of our experiences (Murray 2008). A qualitative study examined the narratives of a sample of six older people with stroke in the East of Scotland. Participants took part in an episodic interview exploring their experience of stroke and the impact it has had on them and their lives. Narrative analysis was used to explore these stories. A story analytic approach was used to examine the content and structure of stroke narratives. A performative analysis revealed that narrative anchors relating to health, relationships, activity and ageing were used by participants to make sense of stroke, while stroke itself was an anchor point in participants‟ ongoing life stories. These findings were interpreted in relation to theories of ageing, suggesting that a developmental approach may be helpful in understanding the experiences of stroke survivors entering frailty, rather than focussing on the active ageing strategies which benefit those in the younger-old age groups. An approach similar to that used in working with grief is proposed as a framework to help health and social care staff and service users understand the process of adjustment following stroke.

Sammanfattning Bakgrund: Stroke är den tredje vanligaste dödsorsaken i Sverige och en av våra största folksjukdomar. Cirka 30 000 personer drabbas årligen av stroke i Sverige. Stroke kan ge upphov till allvarliga konsekvenser som personerna måste leva med. Att kroppsförmågan försämras på grund av stroke är vanligt och leder till att personerna inte klarar av att utföra sina dagliga aktiviteter. Att inte klara av att utföra dessa aktiviteter leder till försämrad livskvalitet för personerna. Det är därför viktigt att sjuksköterskan har en insikt i personernas livsvärld. Syfte: Syftet med studien var att beskriva personers upplevelser av livet efter stroke.  Metod: Metoden som användes var en litteraturstudie bestående av sju stycken artiklar med kvalitativ design. Kvalitetsgranskning gjordes med hjälp av Willman, Stoltz och Bahtsevanis granskningsprotokoll för kvalitativa artiklar. Analys av artiklar genomfördes med Graneheim och Lundmans beskrivning av en innehållsanalys. Resultat: I resultatet framkom tre kategorier samt tre underkategorier. Kategorierna innefattade Konsekvenser av stroke, Relationella och sociala svårigheter och möjligheter och Motivation till ett bättre liv. Underkategorier som utformades var Att förlora sin identitet, Att vara beroende och förlora självständighet samt Att inte orka och vara oviss. Resultatet visade att stroke hade en negativ inverkan på personernas liv och gav dem en försämrad livskvalitet. Personerna kände att de hade förlorat sin identitet till följd av den förlorade förmågan att utföra de aktiviteter som de klarat av att utföra innan de drabbades av en stroke. På grund av handikappen var personerna tvungna att förlita sig på andra, vilket resulterade i en förlorad självständighet. I resultatet framkom även att de personerna som satte upp mål och hade framsteg i sin rehabilitering använde det som motivation till att bli bättre. Slutsats: Denna studie visar att personerna som drabbats av en stroke får en förändrad livsvärld och upplever en försämrad livskvalitet. Det är viktigt att sjuksköterskan får en inblick i personernas livsvärld för att kunna utveckla vården och förbättra situationen för de strokedrabbade personerna.

Beim akuten ischämischen Schlaganfall ist die Größe der initialen DWI-Läsion (Diffusions-gewichtete Sequenz) in der zerebralen MRT zur Abschätzung der Prognose des Patienten umstritten. Die Beobachtung des Verlaufs der DWI-Läsion in den ersten Tagen nach einem Schlaganfall scheint hierfür besser geeignet. Hierbei zeigt sich, dass ein Infarktwachstum eher mit einem schlechteren klinischen Ergebnis korreliert. Ein mögliches Infarktwachstum vorherzusagen ist deshalb von großem Interesse. Bei nicht-lakunären Infarkten, die durch Verschlüsse größerer Arterien verursacht werden, ist die Ausbreitung des Infarktkerns in zuvor minderperfundierte Areale (d.h. in die Penumbra), als Ursache eines Wachstums anerkannt. Die Penumbra wird als die Differenz zwischen DWI- und PWI-Läsionen (Perfusions-gewichtete Sequenz) angesehen, was als PWI/DWI-Mismatch bezeichnet wird. Unklar ist, ob dieses Mismatch-Konzept auch auf lakunäre Ischämien (DWI-Läsionen < 2 cm Ø) angewandt werden kann. Ziel dieser prospektiven Studie war, den Zusammenhang zwischen dem initialen DWI/PWI-Mismatch und der Infarktentwicklung im kurzfristigen Verlauf bei 100 konservativ behandelten Patienten zu untersuchen. Das Patientenkollektiv war hinsichtlich der Infarktsubtypen (lakunäre und nicht-lakunäre) als inhomogen einzustufen. Am Tag der Aufnahme und an Tag 7 wurden anhand eines MRT-Schlaganfallprotokolls die Volumina der DWI und PWI-Läsionen, die Mismatch-Volumina, das Infarktwachstum, das relative Mismatch und das relative Infarktwachstum untersucht. Das Infarktwachstum zeigte einen engen Zusammenhang mit dem initialen DWI/PWI-Mismatch. Dies traf vor allem dann zu, wenn man die relativen Werte betrachtete. Hieraus ergibt sich, dass ein großes initiales Mismatch ein späteres Infarktwachstum wahrscheinlicher macht. Für die Zukunft könnte man daher davon ausgehen, dass das relative Mismatch, bezogen auf die relative Infarktentwicklung, einen besseren prognostischen Wert aufweist, als die absoluten Werte.

For those who have suffered a stroke, damage to the brain can result in a decreased ability to walk. The traditional therapy used for the recovery of walking, body weight supported treadmill training, has significant labour requirements that limit the availability of training to the larger stroke population. Thus, the conception and application of new, effective, and efficient rehabilitation therapies is required. To approach this, an understating of the intricate neural control behind walking is needed to form the principled foundation upon which locomotor therapies are based. Due to observations that the arms and legs are connected in the nervous system during walking, and that nervous system control is the same across rhythmic tasks, arm and leg (A&L) cycling training could provide an effective means of locomotor rehabilitation. Thus, the goal of this dissertation is focused upon exploring central nervous system control and interlimb coordination during rhythmic arm and leg movement and testing the extent to which A&L cycling training improves walking after stroke. The first objective of this dissertation was to provide further evidence of central nervous system control of walking. Through a literature review in Chapter 1 and experimental evidence in Chapter 2 of common subcortical control across rhythmic locomotor tasks, evidence for the existence of central pattern generating networks in humans is given. The second objective was to explore interlimb coordination during rhythmic movement. Results presented in Chapters 3 and 4 further our understanding of specific interlimb interactions during rhythmic arm and leg tasks. The third objective was to evaluate the effects of an A&L cycling training intervention in a post-stroke population. To support this objective, it was shown in Chapter 5 that a multiple baseline design is appropriate for use in intervention studies. In Chapter 6, it was determined that A&L cycling training can be used to improve walking ability. And in Chapter 7, it was shown that training induced plasticity in interlimb reflex pathways. Overall, results in this dissertation provide further knowledge on nervous system control and arm and leg interlimb interactions during rhythmic movements and their effect on locomotor recovery following a stroke. / Graduate / 2017-10-31

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Stroke or cerebral vascular accident (CVA) is the 4th leading cause of mortality and the principle cause of long-term disability in the United States. Unfortunately, current reperfusion-based treatments (e.g. thrombolysis, tPA) cannot be administered to the majority of patients presenting with ischemic stroke. Accordingly, new treatments for ischemic stroke are desperately needed. Reactive astrocytes perform key roles in tissue repair and remodeling following stroke such as preservation and repair of the blood-brain barrier, modulation of immune cell invasion, glutamate uptake and neuroprotection, and glial scar formation. The proliferative subpopulation of reactive astrocytes found immediately adjacent to the infarct core after stroke (known as the peri-infarct area) is particularly important for protecting the brain parenchyma from ischemic damage and inflammation. Defining the signaling network that controls reactive astrocyte formation and function has potential to provide new treatment strategies for patients ineligible for reperfusion therapy. Notch1 signaling is required for the proliferation of peri-infarct reactive astrocytes after stroke. To identify downstream targets and potential functional effectors of Notch1 signaling in reactive astrocytes, we developed an ex vivo forward signaling screen. To generate large quantities of adult reactive astrocytes, we employed adult Reactive astrocyte-derived Neural Stem Cells (Rad-NSCs) isolated from the peri-infarct area of mice after stroke. Astrocytes re-differentiated from Rad-NSCs (AstroRad-NSC) were then exposed to immobilized Jagged-1, a Notch1 ligand. In response to Jagged-1, many genes involved in reactive astrocyte-mediated tissue protection, metabolic regulation, angiogenesis and glial scar formation were up-regulated. Of special interest, several genes for proteins that regulate with glutamate uptake and metabolism were increased by Jagged-1/Notch signaling, including the glial-specific GLutamate-ASpartate Transporter (GLAST). With loss-of-function experiments, we determined that deletion of Notch1 decreased GLAST transcript and protein levels in cultured AstroRad-NSC. Furthermore, we isolated reactive astrocytes directly from cerebral cortex after stroke and confirmed the effects of Notch1 on GLAST in vivo. Our results suggest that treatments designed to stimulate Notch1 signaling after stroke may promote glutamate uptake, thereby decreasing excitotoxicity and neuronal cell death. Binding of Endothelin peptides to the type B Endothelin receptor (ETBR) has been shown to alter cell proliferation. Investigating a possible relationship between Jagged-1/Notch1 and Endothelin signaling in reactive astrocytes, we determined that Notch1 signaling regulated ETBR indirectly, by activating STAT3, an unidentified transcriptional activator of ETBR. Using inducible transgenic astrocyte-specific conditional knockout (cKO) mice (GFAP-ETBR-cKO), we found that specific deletion of ETBR in reactive astrocytes phenocopied the defect in reactive astrocyte proliferation observed in our previous work with GFAP-Notch1-cKO mice. Notably, the Notch1-STAT3-ETBR axis we identified is likely to control reactive astrocyte proliferation in most, if not all, forms of CNS injury. The experimental results presented in this doctoral dissertation provide novel insight into signaling mechanisms that may someday be exploited to improve care for patients with stroke and other forms of CNS injury or disease.

In response to the potential benefits of task specific training in rehabilitation of gait after stroke and the need for affordable, simple ways to implement it, our group designed the elliptically based robotic gait trainer (EBRGT). A design review of the EBRGT, covering the design goals, an overview of the mechanical and electrical design, and a discussion of the novelty of the device and why it may be beneficial for individuals with hemiparesis secondary to stroke is discussed (Chapter 2). To characterize the new device, a study was performed to determine if the EBRGT produced a gait pattern that mimicked level surface walking in healthy adults (chapter 3). Sagittal plane kinematic analysis suggested the EBRGT produced joint movement patterns that are similar to level surface walking at the hip and knee with less similarity between activities at the ankle. Electromyography (EMG) revealed that the EBRGT induced a cyclic muscle firing pattern that had some similarities when compared to level surface walking. We also examined the feasibility of ambulatory individuals after stroke to use the EBRGT and if their movement patterns were similar to healthy adults walking on the same device (Chapter 4). All six participants were able to walk on the device with minimal assistance. These participants had joint kinematics and EMG similar to healthy adults, suggesting that individuals with hemiparesis perform a gait like movement when using the EBRGT. Lastly, a study was performed to determine if the EBRGT could improve gait parameters and function in ambulatory individuals with hemiparesis after stroke (chapter 5). Four participants walked on the EBRGT 3x/week for 4 or 8 weeks. After the intervention, all 4 participants increased their preferred gait speed. One participant had an improvement in gait speed that indicated functional gains. The results of this research suggest that the EBRGT can produce a gait pattern that has some similarities to level surface walking and that it is feasible for ambulatory individuals with hemiparesis to use the device. The device may also improve gait parameters in ambulatory individuals after stroke, but future studies with a control group need to be performed.

The intent of the following research is to utilize task-specific, constraint-induced therapies and apply towards dynamic training for symmetrical balance. Modifications to an elliptical trainer were made to both measure weight distributions during dynamic stance as well as provide kinetic biofeedback through a man-machine interface. Following a review of the background, which includes research from several decades that are seminal to current studies, a design review is discussed to cover the design of the modified elliptical (Chapter 2). An initial study was conducted in a healthy sample population in order to determine the best visual biofeedback representation by comparing different man-machine interfaces (Chapter 3). Index of gait symmetry measures indicated that one display interface optimized participant performance during activity with the modified elliptical trainer. A second study was designed to determine the effects of manipulating the gain of the signal to encourage increased distribution towards the non-dominant weight bearing limb. The purpose of the second study was to better understand the threshold value of gain manipulation in a healthy sample set. Results analyzing percentage error as a measure of performance show that a range between 5-10% allows for a suitable threshold value to be applied for participants who have suffered a stroke. A final study was conducted to apply results/knowledge from the previous two studies to a stroke cohort to determine short-term carryover following training with the modified elliptical trainer. Data taken from force measurements on the elliptical trainer suggest that there was carryover with decreased error from pre to post training. For one participant GaitRite® data show a significant difference from pre to post measurements in single limb support. The results of the research suggest that visual biofeedback can improve symmetrical performance during dynamic patterns. For a better understanding of visual biofeedback delivery, one display representation proved to be beneficial compared to the others which resulted in improved performance. Results show that healthy human participants can minimize error with visual biofeedback and continue minimizing error until a threshold value of 10%. Finally, results have shown promise towards applying such a system for kinetic gait rehabilitation.

Background: One-in-three carers of stroke survivors experience depression with no psychological treatments tailored to meet their needs, such as barriers to attending traditional face-to-face psychological services. A cognitive behavioural therapy (CBT) self-help approach may represent an effective, acceptable solution. Methods: Informed by the MRC framework (2008) for complex interventions, six studies informed development, feasibility and piloting of a CBT self-help intervention for depressed carers of stroke survivors: Study One: Systematic review and meta-analysis of psychological interventions targeting depression and anxiety in carers of people with chronic health conditions; Study Two: Interviews to understand difficulties experienced by depressed and anxious carers; Study Three: Interviews to understand positive coping strategies used by non-depressed and non-anxious carers; Study Four: Drawing on results of Studies One to Three, iterative modelling to develop the CBT self-help intervention; Study Five: Feasibility randomised controlled trial to examine methodological and procedural uncertainties for a Phase III definitive trial; Study Six: Updated systematic review and meta-analysis. Results: Study One: 16 studies identified for inclusion yielding small and medium effect sizes for depression and anxiety respectively, with trends for individually delivered treatments over shorter session durations to be more effective for depression. Six additional studies were included in Study Six, replicating Study One results; Study Two: Depressed and anxious carers experience difficulties adapting to the caring role, managing uncertainty, lack of support and social isolation; Study Three: Non-depressed and non-anxious carers utilise problem-focused coping strategies to gain balance and adapt to caring role, use assertiveness, seek social support and positive reinterpretation; Study Four: Developed a theory-driven CBT self-help intervention; Study Five: Recruited 20 informal carers in 10-months, representing 0.08% of invited carers randomised with high attrition in the intervention arm. Lack of GP recognition, gatekeeping and barriers to accessing psychological support identified as reasons for poor recruitment. Conclusions: A greater appreciation is required concerning barriers experienced by informal carers of stroke survivors to accessing support for depression and type of acceptable psychological support.

Title: Differences in game acts at the baseline among youth and adult categories in tennis. Goals: The aim is to find out where on the court the players move in time of hitting the ball, if they "circle it" and to what extent. We'll compare the results through youth and adult categories. Method: Using a structured observation we observed the position of the players during the match on the court and the representation of single strokes during the game. Results: The results show the differences in game acts among all categories: the position of the player during the hit of the ball, the percentage of forehands and backhands in the game and success and effectiveness of strokes from the baseline. Key words: tennis, efficiency, success, stroke position