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Objectives: The purpose of this work was to define and explore effects of one module of physical therapy treatment, known as 'mobilisation and tactile stimulation' (MTS) to improve sensory and motor function in the hemiplegic upper limb after stroke. Methods: Equipment to measure grip responses was designed and constructed and its validity and reliability established. Upper limb function (Action Research Arm Test (ARAT), Nine-Hole Peg Test (NHPT), touch/pressure sensory thresholds, grip response latency) following stroke was estimated from a longitudinal study, at six weeks, three months and six months post-stroke. Scores were compared with those obtained from a cross-sectional study of healthy volunteers. Using a modified nominal group technique, seven expert participants (senior clinical physiotherapists) defined and described techniques and interventions involved in MTS. Effects of this treatment on sensory and motor function were subsequently explored (ARAT, NHPT, Motricity Index, sensory thresholds, grip response latency) through a series of six replicated single case studies (A-BA design) following first ever stroke resulting in upper limb dysfunction. Results: Significant differences in sensorimotor performance were found in both hemiplegic and non-hemiplegic limbs compared to healthy limbs. A clinically validated treatment schedule was created that clearly defined and described MTS. All six subjects treated with MTS in the single case series improved in ARAT and Motricity Index scores, and sensory thresholds improved in four out of six subjects during the intervention phase, with minimal or no further improvements in performance on withdrawal of intervention. Conclusions: Both hemiplegic and non-hemiplegic upper limbs are affected by stroke. However, sensorimotor function in the hemiplegic limb can improve following a 6-week programme of daily MTS therapy. Further work is required to identify the optimum dose of MTS therapy and mode of delivery, and effects on specific clinical problems.

Background: Motor imagery (MI) has been shown to be beneficial if added to physical practice. It remained unclear, whether M I is effective in patients after stroke, whether MI techniques differ across disciplines, and whether MI can be applied to complex motor tasks (MTs) in patients after stroke. Methods and results: Two systematic reviews were conducted: firstly, to evaluate evidence of MI interventions. Four randomised controlled trials (RCTs) confirmed MI efficacy in patients after stroke if added to therapy. Secondly, characteristics of successful MI training sessions in different disciplines were reviewed. Totally 141 MI interventions were identified in education, medicine, music, psychology, and sports. Information describing 17 MI training elements and 7 temporal parameters were identified and compared. Prior to conducting a pilot RCT, two questionnaires to assess MI ability (KVIQ, Imaprax) were translated with associated validity and reliability testing. The single blinded pilot RCT compared two MI approaches: embedded (n=13) vs. added (N=13) MI vs. a control group (N=14) in patients after stroke. Primary outcome measure was time to perform a complex MT. Results revealed a significant change for all three groups from pre- to post-intervention but no group differences. A qualitative study evaluated MI experiences in patients from experimental groups using semi-structured interviews. Results showed that answers matched to MI framework questions where, when, what, why, and how to use imagery. Conclusions and contributions: MI is still under-researched in stroke rehabilitation. Conducted research showed that MI was beneficial if added to therapy and MI techniques varied across disciplines. Embedded and added MI supported patients similarly and could be applied to a complex MT. MI appeared spontaneously in patients after stroke and was used to practice simple movements. Furthermore, this thesis proposed steps towards consistent term usage and detailed MI intervention reporting, which is lacking in current Ml literature.

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Background: After a stroke, a considerable proportion of people experience upper limb (UL) impairments, which may affect their activities of daily living. Focal spasticity is common, for which botulinum toxin-type A (BTX-A) is used increasingly. However, published randomised controlled trials have not used valid outcome measures to assess the effects of BTX-A on spasticity and have hardly explored its impact on UL function. The primary aim of this thesis was to investigate whether task-specific UL practice in the form of an evidence-based, functional skill acquisition programme, administered after BTX-A, would have any differential effects on upper limb spasticity or functional UL activity in people more than six months after stroke. The prerequisites were to: 1) clarify the definition of "spasticity", 2) pilot a novel biomechanical spasticity measurement device, 3) standardise the assessment of arm function, 4) systematically review the literature on the effects of BTX-A and 5) compile an evidence- and theory-based skill acquisition programme. Methods: Design: randomised controlled feasibility study with four repeated measures and a blinded assessor. Fourteen participants (time after stroke: range 1.4 -11.0 years) gave informed consent and were randomised into either the experimental group (EG: BTX-A plus skill acquisition) or the placebo control group (CG: BTX-A plus inflatable arm splint). Outcome measures were: Action Research Arm Test, Canadian Occupational Performance Measure, grip force of the affected hand, Stroke Impact Scale, EMG of the elbow flexors, biomechanically measured resistance to passive movement and Ashworth scale. Outcomes were assessed at baseline and weeks 4, 7 and 13 following BTX-A injection. Differences in change between the two groups were analysed using the Mann-Whitney U-test. Applying the Bonferroni correction for three repeated measures yielded a critical p-value of 0.017. Results: At baseline, there were no significant differences between the two groups in any of the dependent variables. Compared to the CG, the EG improved in self-reported hand function between baseline and week 4 (median change 25%, range 0 to 30% vs. CG: median change 0%, range -10 to 0%; p=0.04). The EG also improved in arm function between baseline and week 7 (median ARA T change 4 points, range 1 to 8 points vs. CG: median change -1 point, range -3 to 0 points; p=0.003) as well as in self-reported ADL between baseline and week 13 (median change 11.3%, range 5 to 20% vs. CG: median change 0%, range -2.5 to 5%; p=0.02). Only the differential improvement in ARAT by the EG reached statistical significance. There were no significant differences between the two groups in any of the other outcome measures. Although the programme was perceived as intensive, most participants in the experimental group had found the intervention to be enjoyable. Conclusion: The main finding of this study was that people with severe and chronic upper limb spasticity may still improve in functional activity involving their affected arm, using a combination of BTX-A and a functional skill acquisition programme - without exacerbating spasticity. BTX-A alone did not improve upper limb activity in this study. Implications for clinical practice and research were discussed.