Stroke is a common condition that can not only affect physical functioning, but also psychological and emotional wellbeing. In the literature review, a meta- synthesis of qualitative papers exploring the impact of stroke on self, identity or biography indicated, that although a person's sense of self can be significantly affected by the occurrence of a stroke, many people are able to maintain a sense of a sustained self. In particular, the review highlighted that the impact of stroke on self is complex and varied. Furthermore, it is dependent on a number of factors such as degree of physical impairment and the socio-political climate. A further review of the stroke literature indicated a lack of qualitative studies exploring the experiences of people that have had a stroke at a young age. Consequently, the present study aimed to explore and understand the experiences of coping and recovering from a stroke at a young age. Interpretative phenomenological analysis was used which demonstrated that young people have a sense of 'not belonging' post-stroke. In particular, participants felt that their age-related identities were affected, that they were not understood by others and that their concept of self was altered. Finally, in the critical review the researcher reflects on experiences of conducting the research and discusses clinical implications and suggestions for further research in more depth.

Stroke causes impairment of the sensory and motor systems; this can lead to difficulties in walking and participation in society. For effective rehabilitation it is important to measure the essential characteristics of impairment and associate these with the nature of disability. Efficient gait requires a complex interplay of muscles. Surface electromyography(sEMG) can be used to measure muscle activity and to observe disruption to this interplay after stroke. Yet, classification of this disruption in stroke patients has not been achieved. It is hypothesised that features identified from the sEMG signal can be used to classify underlying impairments. A clinically viable gait analysis system has been developed, integrating an in-house wireless sEMG system synchronised with bilateral video and inertial orientation sensors. Signal processing techniques have been extended and implemented, appropriate for use with sEMG. These techniques have focussed on frequency domain features using wavelet analysis and muscle activation patterns using principal component analysis. The system has been used to measure gait from stroke patients and un-impaired subjects. Characteristic patterns of activity from the ankle musculature were defined using principal component analysis of the linear envelope. Patients with common patterns of tibialis anterior activity did not necessarily share common patterns of gastrocnemius or soleus activity. Patients with similar linear envelope patterns did not always present with the same kinematic profiles. The relationship between observable impairments, kinematics and sEMG is seen to be complex and there is therefore a need for a multidimensional view of gait data in relation to stroke impairment. The analysis of instantaneous mean frequency and time-frequency has revealed additional periods of activity not obvious in the linear or raw signal representation. Furthermore, characteristic calf activity was identified that may relate to abnormal reflex activity. This has provided additional information with which to group characteristic muscle activity. An evaluation of the co-activation of gastrocnemius and tibialis anterior muscles using a sub-band filtering technique revealed three groups; those with distinct co-activation, those with little co-activation and those with continuous activity in the antagonistic pair across the stride. Signal features have been identified in sEMG recordings from stroke patients whilst walking extending current signal processing techniques. Common features of the sEMG and movement have been grouped creating a decision matrix. These results have contributed to the field of clinical measurement and diagnosis because interpretation of this decision matrix is related to underlying impairment. This has provided a framework from which subsequent studies can classify characteristic patterns of impairment within the stroke population; and thus assist in the provision of rehabilitative interventions.

People who have suffered a stroke can become housebound and miserable because they cannot access suitable transport. They can have difficulty getting to the shops, doctors and hospital and this can have an effect on their quality of life. Occupational therapists routinely aim to help these people overcome their outdoor mobility problems by providing information and verbal instructions but these interventions do not appear to be effective. The aim of this research was to design and evaluate a new occupational therapy outdoor mobility intervention. The intervention was modeled on travel training that is provided for other conditions and the outdoor mobility experiences and needs of people with stroke. Qualitative semi structured interviews were used to investigate 24 peoples experiences of both using transport and their outdoor mobility after they had suffered a stroke. It was found that people wanted to travel for a variety of reasons; shopping, work, getting to the doctors, social reasons, meeting friends, visiting family and just for the sake of traveling. People were prevented from traveling because of physical difficulties such as stepping onto the bus, psychological problems such as confidence and environmental barriers such as the weather or lack of information. The results were used to define the main components of an Occupational Therapy Outdoor Mobility Intervention. A randomised controlled trial was used to evaluate the effects of this Occupational Therapy Outdoor Mobility Intervention (OTOMI) by comparing it to the routine occupational therapy intervention. Participants with stroke in the last 36 months were recruited from primary care services and randomly allocated to receive either the OTOMI or the routine occupational therapy. Participants in the OTOMI received up to seven individualised occupational therapy sessions. The sessions aimed to increase confidence, encourage use of different types of transport and provided tailor-made information. Outcomes were measured by postal assessment 4 and 10 months after recruitment. The primary outcome measure was a yes/ no question, Do you get out of the house as much as you would like? Secondary outcomes included the number of journeys, mood, performance of activities of daily living and leisure. 168 participants who had had a stroke in the last 36 months were recruited into the study over eighteen months, 82 in the control group and 86 to the OTOMI group. 10 people were unable to provide follow-up information at the four month assessment and 21 people at the ten month assessment. Intention-to-treat analyses were undertaken. For the principal outcome measure, participants who were dead at the point of assessment were allocated the worst outcome, and for others lost to follow up their baseline or last recorded responses were used. For the other analyses all missing values were imputed using baseline values. Participants in the treatment group were more likely to get out of their house as often as they wanted at 4 months (RR 1.72,95% CI 1.25 to 2.37) and at 10 months (RR 1.74,95 Cl 1.24 to 2.44). The treatment group recorded more journeys outdoors in the month prior to assessment at 4 months (intervention group median 37, control group median 14, Mann-Whitney p<0.01) and at 10 months (intervention group median 42, control group median 14, Mann-Whitney: p<0.01). At 4 months the NEADL mobility scores were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. There were no significant differences in these measures at 10 months. The interview study demonstrated that participating in outdoor mobility is a major problem for people who have had a stroke. The randomised controlled trial demonstrated that a relatively simple and feasible, individualized, properly organised, focused and adequately resourced occupational therapy outdoor mobility intervention can increase participation in outdoor mobility activities, allowing people to get out of the house as much as they wish.

The present research aimed to assess the effects of a novel type of orthosis, the Dynamic Ankle Foot Orthosis (DAFO), on the balance and gait characteristics of hemiparetic subjects. The DAFO is a low splint with a custom-moulded insole, which is believed to support foot alignment, ankle supination-pronation and provide minimal restriction of the ankle joint flexion-extension. It was hypothesised that DAFOs improve motor behaviour after stroke involving the acquisition of standing balance (hypothesis I) and gait (hypothesis II) compared with using shoes. It was proposed that users' subjective opinions of DAFOs would support the findings of the device's ability to modify human performance such that they are beneficial when used as a part of rehabilitation management for stroke patients (hypothesis III). Twenty-two stroke subjects were randomly allocated to experimental (with DAFO and shoes-only) and control (using shoes-only) groups. Subjects followed twelve weeks of experimental trials comprising three data collections. The testing procedure was developed from preliminary work, which involved a pilot study and reliability tests. Standing balance was measured using forceplatform apparatus. The parameters investigated were: the velocity and sway index of the CoP, and F(mean), F(sd) and F(slope) of shear forces. Kinematic gait performance was assessed using a 3-D four-camera motion measurement system. The parameters studied were: the gait velocity, stride length, step length, cadence, and single stance phase, together with the minimum/maximum values of the angular displacement and velocity of the foot, shank, and thigh segments in the saggittal plane during two strides. An open questionnaire was used to evaluate subjects' opinions regarding the use of DAFOs. Overall, the quantitative studies did not identify consistent and statistically significant differences between the two experimental situations for these groups of patients. In the studies of balance, none of the parameter comparisons analysed within- and between- groups achieved statistical significance. In the studies of gait, statistically significant differences were identified for some (but not all) parameters. It is unknown whether any single or combination of balance and gait variables can be used to describe human gait entirely. On this basis, hypotheses I and II were rejected. However, these are tentative conclusions. Thus, difficulties in maintaining the stroke subject cohort number for these studies meant that the analyses probably lacked sufficient statistical power to detect small but potentially important differences in DAFO mediated actions. Furthermore, in several cases, clear differences in the magnitude of balance and gait parameters between DAFO and shoe users were apparent, and these differences were often consistent with nearer normal levels associated with use of the device (suggesting potentially beneficial influences). Thus, positive effects of the DAFO on lateral velocity of sway and variability of the spectral frequency were evident for some subjects. The gait velocity, stride length and single stance phase were also nearer normal values using DAFOs than without them. In addition, the maximum foot velocity value was improved in the middle of swing phase on the affected side, which may indicate improvement to the ankle dorsiflexion function using these devices. In contrast to the inconclusive balance and gait findings, the outcome of the questionnaire assessments was clear. The majority of subjects provided very positive feedback with regard to DAFO use. Most subjects expressed confidence in the splint, which they perceived as helpful for their walking ability in day life. Some difficulties were noticed with donning and doffing the DAFO, but the perceived benefits outweighed this consideration. These qualitative studies therefore provide the most convincing evidence to support the idea that DAFOs improve stroke patients' balance and gait, and that this type of orthosis may form a useful adjunct to rehabilitation strategies. However, as the proposals set out for this research were related, acceptance of hypothesis III requires that at least one of the preceding hypotheses be accepted. On this basis, hypothesis III was also rejected. In conclusion, although this work failed overall to demonstrate a significant effect of DAFOs on the rehabilitation of stroke patients, the anecdotal evidence obtained adds to knowledge in this field. The research identified some parameters of balance and gait, which might be influenced by the device in a beneficial manner. These parameters may be more useful to use in future investigations. The reasons for the discrepant outcomes of the quantitative and qualitative studies are unclear. However, it is suggested that there may be uncontrolled variables within either the patient group or in the DAFOs (or both) which mean that some DAFOs work better than others. It is proposed that further studies of the DAFO are warranted.