Title: Kinesiological Analysis of the Rowing Stroke. Objectives: The aim of this thesis is to obtain, to analyse and process the data on the activity and involvement of selected measured muscles, working during one rowing stroke - in the drive part and in the recovery part. Methods: The work is processed by a kinesiological analysis of selected movement of the rowing stroke, based on the determination of muscle activation. Electromyography method was synchronized with the video recording. Results: Based on the sequences of the muscle activation was described their order and sequence in the actual shot of the rowing stroke (drive phase and recovery). We have proved that in the rigorous technical performance are always activated the same muscles in the exactly same order. Individual deviations from the correct technique in measuring appeared and thus enable their correction. Keywords: Electromyography, stroke, rowing, muscles.

Title: Kinesiological Analysis of the Rowing Stroke. Objectives: The aim of this thesis is to obtain, to analyse and process received data about the activity and involvement of the selected measured muscles, working throughout one cycle of the rowing stroke - in the course of the drive phase and during the recovery part of the stroke as well. Methods: The work is processed by a kinesiological analysis of selected movement of the rowing stroke, based on the determination of muscle activation. Electromyography method was synchronized with the video recording. Results: Based on the sequences of the muscle activation was described their order and sequence in the actual shot of the rowing stroke (drive phase and recovery). We have proved that in the rigorous technical performance are always activated the same muscles in the exactly same order. Individual deviations from the correct technique in measuring appeared and thus enable their correction. Keywords: Electromyography, rowing, muscles, stroke.

PARP-1 has been identified as a major player in apoptotic pathways. Its excessive activation causes mitochondrial dysfunction, permeability, and AIF mitochondrion-to-nucleus translocation. It has been suggested that PARP-1 interacts indirectly with Bnip3, a mitochondrial pro-apoptotic factor. However, the mechanistic linkage is still not well understood. Our lab has shown that cytosolic/nuclear NAD+ depletion is a hallmark for PARP-1 over activation and inhibition of sirtuin activity. Specifically in my project, we think that PARP-1 induced- NAD+ depletion and sirtuin inhibition causes hyperacetylation of the α subunit of the transcription factor HIF-1 allowing increased HIF-1 binding to Bnip3 upstream promoter, and increased Bnip3 expression. Indeed, our PARP-1 Knock out neurons, MNNG and PJ34 treatment, chromatin immunoprecipitation, and HIF-1α loss of function studies strongly confirmed the necessity of HIF-1 to increase Bnip3 expression in hypoxia. Overall, our research suggests a role for HIF-1 in increasing PARP-1 dependent Bnip3 expression in hypoxic models. / May 2016

Epidemiological studies report that infarct size is decreased and stroke outcomes are improved in young females when compared to males. However, mechanistic insight is lacking. We posit that sex-specific differences in glial cell functions occurring immediately after ischemic stroke are a source of dichotomous outcomes. In this study we assessed astrocyte Ca2+ dynamics, aquaporin 4 (AQP4) polarity, Sloop expression pattern, as well as, microglia morphology and phagocytic marker CD11b in male and female mice following 60 min of middle cerebral artery (MCA) occlusion. We reveal sex differences in the frequency of intracellular astrocyte Ca2+ elevations (F-(1,F-86) = 8.19, P = 0.005) and microglia volume (F-(1,F-40) = 12.47, P = 0.009) immediately following MCA occlusion in acute brain slices. Measured in fixed tissue, AQP4 polarity was disrupted (F-(5,F-86) = 3.30, P = 0.009) and the area of non-S100 beta immunoreactivity increased in ipsilateral brain regions after 60 min of MCA occlusion (F-(5,F-86) = 4.72, P = 0.007). However, astrocyte changes were robust in male mice when compared to females. Additional sex differences were discovered regarding microglia phagocytic receptor CD11b. In sham mice, constitutively high CD11b immunofluorescence was observed in females when compared to males (P = 0.03). When compared to sham, only male mice exhibited an increase in CD11b immunoreactivity after MCA occlusion (P = 0.006). We posit that a sex difference in the presence of constitutive CD11b has a role in determining male and female microglia phagocytic responses to ischemia. Taken together, these findings are critical to understanding potential sex differences in glial physiology as well as stroke pathobiology which are foundational for the development of future sex-specific stroke therapies. (C) 2016 IBRO. Published by Elsevier Ltd. All rights reserved.

Background: Being close to a person who suffers from a disease can mean a burden, as these tends to disregard own needs in favor of the person who is sick. Aphasia is a disorder that affects communication skills and is one of the most common complications due to brain damage. Aim: The main purpose of this literature study was to illuminate relatives experiences of living with a person with aphasia. Method: Nine scientific articles were analyzed with a qualitative manifest content analysis which resulted in three themes with subthemes: Emotional reactions: The impact on well-being, Changing social and emotional relationships; A changed everyday life: Obstacles in communication, Decreased social interaction, Being able to handle everyday; Increased need for support: To get information about the aphasia; Deterioration of the economy and the need for financial support. Result: It was revealed that relatives felt left aside in the care of their relative with aphasia, resulting in an increased need for information, support and relief. Conclusion: Therefore conclusion was that relatives should be asked by nurses of how much involved in the care of their sick relative they want to be or can be and how much support they need to be able to handle that.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Ischaemic heart disease and stroke were the leading causes of death and disability globally, accounting for a combined 15 million deaths. Disability following a stroke is complex and multidimensional. Disability and functioning post stroke can be conceptualized within the framework of the International Classification of Functioning, Disability and Health (ICF). The involvement of the individual in their rehabilitation and recovery is essential. Therefore, it is a necessity for individuals, particularly in a low resource setting to engage in selfmanagement activities. Bandura’s social cognitive theory based on self-efficacy, forms the basis of self-management programmes. Self-management relates to one’s ability to manage one’s consequences post stroke, and self-efficacy has been proven to be pivotal in the management and improvement of long-term conditions. The aim of the study was to explore the self-management strategies employed by stroke survivors in the Western Cape, South Africa through an exploratory, qualitative design. Prior to the commencement of the data collection phase, ethical clearance was sought from the University of the Western Cape Research Ethics Committee. Participants were recruited from an urban and rural area in the Western Cape. An interview guide was developed based on previous literature. Interview questions were related to 1) what self-management strategies were adopted to address activity limitations and participation restrictions and 2) strategies used to address environmental challenges.

Die vorliegende Arbeit überprüft an einem nach Alter, Geschlecht, Barthel-Index und Mini-Mental-State-Test gematchten geriatrischen Patientenkollektiv mit erstmaligem Schlaganfall die Wirksamkeit einer vorausgegangenen Akutbehandlung an einer Stroke Unit (n=59) gegenüber einer allgemeinen (internistischen oder neurologischen) stationären Akutbehandlung (n=59) für die Prognose im Laufe einer nachfolgenden geriatrischen Rehabilitationsbehandlung. Hintergrund dieser Frage ist der erhöhte ökonomische Druck im Gesundheitswesen, der eine Effizienzprüfung einer personell, technisch und logistisch aufwändigeren und damit teureren Behandlung auf einer Spezialstation verlangt. Bei Anwendung zahlreicher funktioneller Skalen und Erhebung einiger sozioökonomischer Faktoren zeigte sich auf Signifikanzniveau, dass die auf Stroke Unit Vorbehandelten bei Aufnahme in die Rehabilitation motorisch schwerer beeinträchtigt waren (timed up and go-Test p=0,044, Lachs-Test p=0,34) und sich dann ausgeprägter (Transferleistung p=0,024) auf ein bei Rehabilitationsende schließlich vergleichbares Leistungsniveau verbesserten. Die ursprünglich geplante Langzeiteffizienzbetrachtung im Gruppenvergleich scheiterte an Datenschutzbedenken. Gesundheitsökonomisch relevant ist, dass die Vorverweildauer im Akutkrankenhaus bei Stroke Unit-Patienten sechs Tage kürzer war, die Rehabilitationsdauer allerdings vier Tage länger. Weitergehende Kostenbetrachtungen scheiterten am Unwillen zur Leistungsoffenlegung verschiedener Beteiligter im Gesundheitssystem. Eine plausible Erklärung für diese positive motorische Leistungsweiterentwicklung nach Stroke Unit-Vorbehandlung kann in einer frühzeitigeren und effektiveren Anstrengung durch Krankengymnastik, Ergotherapie, Logopädie, aktivierende Pflege, „enriched environment“ gesucht werden, die sich positiv auf die Plastizität im Gehirn als wesentliche Bedingung zur Funktionswiedergewinnung auswirken könnte, was aber noch umstritten ist und Ziel weiterer Untersuchungen sein muss. / This dissertation compares 2 groups of geriatric patients during their stay in a rehabilitation clinic after they suffered a first apoplexy. The first group is a group a 59 patients who have been admitted in the hospital on a general ward after their stroke. In the second group (n=59), the patients have been admitted in a special stroke unit after the apoplexy. In order to study the profit of the stroke unit pre-treatment, the 2 groups have been compared under the following criteria: age, sex, barthel-index and mini-mental-state examination. A long term comparison of efficiency was impossible because of data protection. The stroke unit patients stayed 6 day shorter in the acute hospital but they had to stay 4 days longer during the rehabilitation treatment before leaving the clinic of rehabilitation. Le travail suivant examine l’efficacité d’un traitement d’urgence dans un service de stroke unit par rapport à un traitement d’urgence dans un service général stationnaire (médecine interne ou neurologie) sur le pronostique lors du traitement de rééducation gériatrique à venir. Afin de pouvoir établir une comparaison, un groupe de patients gériatriques ayant subi un premier AVC a été choisi et couplé selon les critères de l’âge, du sexe, de l’index de Barthel et du test « mini-metal-state ». L’intérêt de cette question est la forte pression économique dans le secteur de la santé qui exige l’examen de l’efficacité d’un traitement dans un service spécialisé dont les moyens personnels, techniques et logistiques sont plus élévés et plus chers. L’utilisation de nombreuses échelles fonctionnelles et le relevé de quelques facteurs socio-économiques ont permis de mettre en évidence de facon significative que les patients traités dans un service stroke unit étaient plus gênés sur le plan motorique lors de l’admission mais qu’à la fin de la rééducation, ils s’étaient améliorés de facon nette, atteignant finalement un niveau de performance comparable. L’observation de l’efficacité à long terme dans le groupe de comparaison initialement prévue, a finalement échoué en raison de doutes quant à la protection des données. En ce qui concerne l’aspect éco-sanitaire, il est flagrant que le séjour à l’hôpital avant la rééducation a duré 6 jours de moins chez les patients du groupe stroke unit, mais la durée de rééducation 4 jours de plus. Il a été impossible d’examiner les coûts plus en détail en raison du refus de différents acteurs du système sanitaire à mettre leurs données à disposition. Cette évolution positive de la performance motorique suite au pré-traitement stroke unit peut s’expliquer par les efforts très précoces fournis en matière de physiothérapie, d’ergothérapie, de logopédie et de soins de rééducation active (enriched environment) qui ont une influence positive sur la plasticité du cerveau, laquelle est une condition indispensable au regain de fonctions. Ceci est encore controversé et devra faire l’objet d’autres études.

Master of Arts - Arts / Background: With the increasing prevalence of stroke in developing countries, like South Africa, the long-term care of stroke patients living with disabilities has substantial consequences for caregivers and their respective families. Method: This study investigated caregiver perceptions of their experiences, as well as familial implications due to the incidence of stroke within the family system. The assessment, in the form of a semi-structured interview, described the experiences post-stroke as perceived by six primary caregivers. It additionally addressed the challenges the South African context adds to these experiences. This was conceptualised within a systems and biopsychosocial framework, enabling the caregiver and family to be considered in a comprehensive and holistic manner. Results: Prominent themes associated with the caregiving of a stroke patient included: role changes, relationship disruptions within the family system, occupational and social implications, fatigue, anxiety, depression, as well as financial problems. An additional sub theme was that the emotional impact on the family system was greater in cases where younger children were involved. However, social support increased the caregivers’ ability to cope and this additionally assisted the rest of the family in their adjustment. Caregiver experiences were exacerbated by the inadequate support structures available within the South African context, with the lack of post-stroke education being an issue of great concern. Conclusions: Practical implications of this study are discussed, along with considerations of the limitations of the study and suggestions for future research.

PhD (Physiotherapy), Faculty of Health Sciences, University of the Witwatersrand / Despite the improvements that have been made in health care over the years, stroke remains a serious public health problem in low, middle and high-income countries. Post-stroke, there are many consequences that manifest and these include mortality, morbidity and socioeconomic, affecting not only the stroke survivor but also the caregiver. These consequences are felt hardest in low and middleincome countries because they are the least able to deal with health related setbacks to development. Pressure for beds and the need to reduce hospitalisation related costs have resulted in early discharge home of patients culminating in caregivers playing a more significant role post-stroke. The role played by caregivers has of late received much attention and is well documented in highincome regions. Informal caregivers are particularly important in low resourced settings. Caregivers play an important role in the rehabilitation process of the stroke survivor. The discharge home of patients with stroke to unprepared caregivers is associated with burden or strain, which negatively affects the quality of life of not only the caregiver but the stroke survivor as well. The effect of a structured, individualised caregiver training programme on patients with stroke and their carers has not been established in sub-Saharan Africa in general and South Africa in particular. With this in mind, the aim of the study was to establish the impact of caregiver education on the morbidity of the stroke survivors and on the quality of life of the stroke survivors and their carers. The specific objectives of the study were to establish the: physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital, effect of caregiver education on the mobility of the stroke survivors, effect of caregiver education on the health related quality of life of the stroke survivor and the caregivers, effect of caregiver education on the ability of the stroke survivor to socialise and participate in community issues and also the patient and caregiver characteristics associated with caregiver strain post-stroke. To achieve the first objective, a self designed questionnaire was used to establish the physiotherapy caregiver education programmes and associated content in use for managing patients with stroke at Chris Hani Baragwanath hospital from the physiotherapists at the hospital. For the rest of the objectives, a stratified randomised controlled trial using concealed allocation with a broad entry and blinded outcome assessment at baseline, three, six and 12 months was used for data collection. The participants for the study were first time ischaemic patients with stroke admitted to Chris Hani Baragwanath hospital, Soweto, Johannesburg, South Africa. A total of 200 patients and their caregivers participated in the study. These were randomly assigned to either the control group or the experimental group. The caregivers in the experimental group were subjected to an individualised training programme just prior to discharge of the patient with stroke and at the three month follow up. The assessor was blinded to the group allocation of the patients and caregivers until after completion of the study. From the study, the one-year case fatality was 38%. The mean hospital length of stay for patients with stroke was six days and the average number of physiotherapy contacts for the stroke survivors was one. The content of the rehabilitation programme of patients post-stroke was well structured and appropriate at Chris Hani Baragwanath. However, there was no caregiver involvement or training during in-patient rehabilitation. The barriers to caregiver involvement included perceived high workload by therapists, short hospital length of stay, poor referral systems between clinicians and therapists of patients post-stroke and caregivers being unavailable during working hours for training purposes. Using the Barthel Index (BI) scores, 78% of the patients were functionally dependent at 12 months post discharge. None of the patients were fully independent in mobility and stair climbing. The experimental group had better mean BI scores at the three and 12 month follow up periods (p = 0.01 and p = 0.05 respectively) when compared to the control group. Caregiver education had the effect of improving the BI scores by one and 0.7 at the three and 12 months follow ups respectively. However, the functional abilities of the patients from both groups were still low at 12 months with averages of 13.3 and 12.6 for the experimental and control groups respectively (out of a possible 20). The overall patient mobility scores as measured on the Rivermead Mobility Index were low over the study period with averages of 9.1 and 8.5 for the experimental and control group respectively (out of a possible 15). However, the experimental group had slightly better Rivermead Mobility Index (RMI) scores, which were not statistically significant. Caregiver education had the effect of reducing the risk of death by 27% relative to that occurring among the control group patients. The health related quality of life of the stroke survivors was generally poor over the study period. The baseline means from their EQ-5D scores (for health related quality of life) were 42.4 and 43.7 for the control and experimental groups respectively, which rose to 67 and 68.8 at 12 months respectively post discharge. Caregiver education had the effect of improving patients’ EQ-5D scores by a factor of three and this was only at 12 months. The caregivers’ quality of life generally declined over the 12 months of the study period (more in the control group than the experimental group) from averages of 92 and 93 at three months (for the control and experimental groups respectively) to 83 and 86 (respectively) at 12 months. However, the experimental group had better mean EQ-5D scores (health related quality of life) than the control group (p = 0.001). Caregiver education had the effect of improving EQ-5D scores by factors of 3.4 and 3.6 at the six and twelve month follow up period. The ability to socialise and participate in community issues was poor. None of the participants could carry out single and multiple tasks without assistance at 12 months post discharge. More than 87% of the patients had mild to moderate difficulty with walking at 12 months post discharge and they were all unable to lift and carry objects, have fine hand use and move around with equipment without assistance. None of the patients was able to carry out domestic activities without any difficulty and consequently they could not prepare meals and do housework without assistance from helpers. All of the participants had mild to moderate and severe to complete difficulty in basic interpersonal interactions, complex interpersonal interactions and formal relationships. They all had mild to moderate difficulty engaging in recreation and leisure activities while 27% of the control group and 25% of the experimental group had severe to complete difficulty with community life at 12 months post discharge. The design, construction and building products and technology for both public and private use were cited as barriers to community participation. More than 50% of the patients also cited friends as being barriers to community participation but acquaintances, colleagues, neighbours and community members were cited as being facilitators together with personal care providers (caregivers). Transport services, systems and policies were also cited as barriers by more than 80% of the participants. Caregiver education did not seem to influence patients’ ability to participate in community issues given the similarities in percentages between the control and experimental groups. At three months post discharge, 89% of the caregivers in the control group and 92% of those in the experimental group were strained from caregiving duties. However, these percentages declined to 78% and 43% respectively at 12 months, showing the effectiveness of caregiver education. Caregiver education had the effect of reducing strain by a factor of 2.6 at 12 months. The patient characteristics that were associated with caregiver strain were the dependency levels in transfers, mobility, dressing, bathing, poor activities of daily living scores, patient anxiety/depression, pain and poor perceived health state. The only caregiver characteristic that influenced caregiver strain was the level of education. The reduced hospital length of stay, pressure for beds and possibly inadequate rehabilitation personnel levels means that its possible that some caregivers are not adequately trained to meet patient needs, although this needs to be confirmed with further controlled research. The current pressure on in-patient services at Chris Hani Baragwanath hospital is resulting in suboptimal exposure to rehabilitation of patients post-stroke. There is insufficient organised caregiver education at present. Structured individualised caregiver training has the effect of positively influencing the health related quality of life of the patients especially at six and 12 months post discharge. Caregivers for patients with stroke suffer from physical, financial and psychological problems, which negatively affect their health related quality of life. Currently, high levels of caregiver strain persist poststroke. Caregiver education however has the effect of reducing the decline in caregiver health related quality of life over time. Caregiver training did not positively influence patient mobility and this is most probably because the patients had very low or poor functional ability levels at discharge from hospital. However, structured and individualised caregiver training has the effect of improving patients’ quality of life and can help reduce deaths among stroke survivors. The patient ability to socialise and participate in community issues post-stroke is currently poor. This mainly stems from the poor functional ability levels, which necessitate dependency on caregivers. Compounding the low functional ability levels are the transport systems, services and policies, attitudes of friends and the design, construction and building products and technology for both public and private use, which are barriers to community participation. The high patient dependency levels result in caregivers being highly strained. The patient characteristics that influence caregiver strain are dependence in transfers, grooming, mobility, dressing, poor activities of daily living, patient anxiety/depression, pain and poor perceived health state (health related quality of life). The only caregiver characteristic that was associated with caregiver strain is the level of education. The early discharge home with little caregiver training calls for provision of community rehabilitation services preferably through domiciliary visits. Caregivers of patients with stroke should be assessed and treated for depression given its high prevalence among this cohort. The referral system between the local community health centres and the discharging hospital need to be strengthened to ensure access to rehabilitation by all patients post discharge from hospital. The referral to social workers during in-patient and out-patient rehabilitation also need to be strengthened to ensure processing of social grants to alleviate financial strain as is appropriate. Caregiver strain is a complex and multifaceted problem with no single causation or solution. As a result, further research is needed to establish the reasons for poor rehabilitation service provision post-stroke for patients and caregivers and find solutions to these. It is important to explore different methods of caregiver education programmes so that the method that yields the best results for both patients and caregivers can be established in our setting and internationally.

Remote ischemic conditioning (RIC) is a noninvasive procedure where blood flow to a limb is repetitively reduced, sometimes called an “exercise memetic”. RIC delivered before (pre-RIC) or after (post-RIC) stroke is reportedly neuroprotective in preclinical stroke models. A review of the preclinical RIC literature revealed that studies almost exclusively use male subjects and a single stroke model (MCAO) that produces a large injury (~34% of hemisphere). To improve clinical translation, efficacy should be demonstrated in multiple stroke models and both sexes. Furthermore, the restorative potential of RIC (delivered past the neuroprotection window) to improve stroke recovery remains to be investigated. In male and female Sprague-Dawley rats (n=129) a standardized session (5min inflation, 5min deflation, 4 repetitions) of RIC was delivered using a pressurized cuff on the hindlimb. RIC was either delivered once 18h before, once 4hr acutely after or daily for 28 days beginning day 5 after endothelin-1 (ET-1) stroke. Infarct volumes were assessed 24hrs after stroke using MRI. To determine if RIC efficacy varied across stroke size, a hierarchical cluster analysis was used to divide rats into subgroups based on stroke size (small/large). RIC was effective in ET-1 which produced smaller strokes (“small”:5.2%, “large”:18.0% of hemisphere) than MCAO (~34%). This is more comparable to injury sizes seen clinically (4.5-14.0%). “Small” (42±4mm3) strokes were reduced by 39% (p=0.010, d=0.29) and “large” (146±8mm3) strokes were reduced by and 35% (p<.00001, d=1.41). Pre-RIC reduced infarct volume by 41% (p=<0.0001, d=0.92) versus 29% (p=0.009, d=0.43) in post-RIC. Interestingly, RIC is more effective in males, with double the infarct volume reduction of 46% (p<0.0001, d=0.94) compared with 23% (p=0.013, d=0.42) in females. Although RIC did not show restorative potential to improve motor stroke recovery, RIC is neuroprotective now with stronger clinically relevant evidence. RIC is effective across stroke models, stroke sizes and sex. Application of RIpreC to prevent stroke following a transient ischemic attack or recurrent stroke (especially in males with “large" strokes) would have the greatest potential.