Background: Goal setting is accepted ‘best practice’ in stroke rehabilitation however, there is no consensus about what the key components of goal setting interventions are, how they should be optimally delivered in practice and how best to involve stroke survivors in the process. This PhD by publication describes the development and initial evaluation of a theory-based goal setting and action planning framework (G-AP) to guide goal setting practice in community based stroke rehabilitation settings. Included studies: The Medical Research Council (MRC) framework for developing and evaluating complex interventions guided the development and conduct of a programme of research which included the following studies: (i) a review of the literature to identify theories of behaviour change with most potential to inform goal setting practice (Paper 1) (ii) a causal modelling exercise to map identified theoretical constructs onto a goal setting process and convening of a multi-disciplinary task group to develop the theoretical process into a Goal setting and Action Planning (G-AP) practice framework (Paper 2) (iii) a process evaluation of the G-AP framework in one community rehabilitation team (Paper 3) (iv) a United Kingdom (UK) wide survey to investigate the nature of services providing community based stroke rehabilitation across the UK and what goal setting practice is in these settings in order to understand the context into which an evaluation of the G-AP framework could be introduced (Paper 4) Main Findings: The review of the literature identified three theories of behaviour change that offered most potential to inform goal setting practice: Social Cognitive Theory, Health Action Process Approach and Goal Setting Theory. These theories contained constructs directly relevant to the goal setting practice: self-efficacy, outcome expectancies, goal attributes, action planning, coping planning and appraisal and feedback. The causal modelling and Task group exercise: (i) Informed development of the G-AP framework into a four stage, cyclical process that included (i) goal negotiation and setting (ii) planning and measuring confidence (iii) action and (iv) appraisal, feedback and decision making. (ii) Proposed mechanisms of action: successful completion of action plans resulting in incremental improvements in goal sub-skills and self-efficacy. (iii) Predicted outcomes G-AP was likely to impact on: goal attainment and improved rehabilitation outcomes. The process evaluation suggested that each stage of the G-AP framework had a distinct purpose and made a useful contribution to the overall process. Overall, G-AP was acceptable and feasible to use but implementation of novel aspects of the framework (coping planning and measuring confidence) was inconsistent and health professionals had concerns about the potential impact of unmet goals on patients’ wellbeing. Patient reports suggested that (i) the experience of goal non-attainment could facilitate adjustment to limitations resulting from stroke and (ii) feeling involved in the goal setting process can incorporate both patient-led and professional-led approaches. The survey findings highlighted the variability that exists in community based stroke rehabilitation services in the UK (e.g. the patients they see; the input they provide). Goal setting is reportedly used with all or most stroke survivors in these services; however, practice is variable and may be sub-optimal. Conclusions: G-AP is the first practice framework which has been explicitly developed to guide health professionals through a systematic, theoretically based and patient centred goal setting process in community based stroke rehabilitation. G-AP is a cyclical process that that has four key stages, proposed mechanisms of action and has shown promise as an acceptable, feasible and effective framework to guide goal setting practice. The complexity that exists within community based stroke rehabilitation services, and the variability in usual goal setting practice used within them, should be considered when designing a study to evaluate the effectiveness of G-AP in routine practice.

Stroke is the leading cause of disability in the United States. The majority of stroke survivors have persistent arm dysfunction, which impedes their daily task performance. Mirror therapy (MT) as an adjunct to occupational therapy (OT) has been shown to be effective in upper extremity (UE) recovery post-stroke. Two protocols, unimanual mirror therapy (UMT) and bimanual mirror therapy (BMT), have been used in OT practice; however, research specifically comparing these two intervention protocols is absent. The purpose of this study was to compare: (a) home-based UMT and BMT protocols, and (b) both MT protocols to home-based traditional occupational therapy (TOT) regarding upper limb recovery post-stroke. Twenty-two chronic stroke participants were randomized into one of three groups: UMT, BMT, or TOT. The Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), ABILHAND, grip strength, and the Stroke Impact Scale (SIS) were administered pre- and post-intervention. Participants received outpatient OT 2 days/week for 45 minutes, plus a home program 30 minutes a day, 5 days/week for 6 weeks. A repeated measure ANOVA, Kruskal-Wallis Test, and Wilcoxon Ranked-Signed Test were used to compare the three groups, and 95% confidence intervals (CI) and effect sizes were calculated. There was a main effect of time for all groups, except for SIS-strength and activities of daily living (ADL); however, no group differences were noted on any of the measures. When comparing UMT and BMT, the effect size for all measures, except for grip strength, favored UMT. In comparing both mirror groups to TOT, UMT had a moderate to large effect size on the ARAT, FMA, and ABILHAND, as compared to the small effect size for BMT. Furthermore, 95% CI data for the ABILHAND showed clinical significance in favor of UMT compared to TOT, but not for BMT. This study showed that all groups improved over time and UMT may be more beneficial for UE recovery in chronic stroke individuals, compared to either BMT or TOT. However, given the small sample size, future studies comparing the two mirror protocols are necessary for more definitive conclusions to better inform clinicians of the optimal mode of MT treatment.

Unilateral deficits resulting from stroke manifest as reduced velocity, decreased cadence and asymmetries in temporal, spatial and force parameters during ambulation. Gait asymmetries and compensatory strategies employed during gait result in a higher mechanical energy cost that limits activity and community participation. Despite conventional rehabilitation efforts, individuals often remain with chronic gait deficits after stroke. Robotic-based therapies have been developed as an alternative to conventional rehabilitation. These therapies offer the means to provide task-specific training at an intensity greater than that of conventional approaches; however, to date outcomes have been similar to that of conventional training. One factor potentially contributing to the limited efficacy of robotic training is the active-assist control strategy that is often employed. This type of training strategy reduces the users’ engagement in the learning process and limits skilled learning. The tethered pelvic assist device (TPAD) is a robotic device that employs actuated tethers at the pelvis to guide the user along a pre-set movement trajectory. While other robotic devices restrict movement to a fixed trajectory, the TPAD promotes shifting weight onto the paretic limb, but permits users to freely move the limb to navigate spatiotemporal aspects of training independently. This allows individuals to participate in the problem-solving process required for motor learning to occur, facilitating a more active role in the motor task itself, and thus promoting learning. Earlier work utilized the TPAD to reduce gait asymmetry in a population of individuals in the chronic phase after stroke in a single training session (Bishop et al., 2015; Vashista, 2015). Results demonstrated an increase in propulsive forces of the affected limb as a result of the intervention, but these gains did not transfer to overground gait. A follow up study explored the feasibility and efficacy of two different training strategies using the TPAD (Bishop et al., 2017). Both training strategies proved feasible and similarly efficacious. The current work examines the feasibility and preliminary efficacy of a five-day intervention using the TPAD with faded visual feedback and a short bout of task-specific overground training to reduce gait asymmetry in a population of individuals at least six months after stroke. Participants underwent a series of three Pre Test assessments within a one-week interval prior to initiating the intervention. Training occurred over five consecutive days, with a Post Test assessment administered on conclusion of Day 5 of training. A one-week Follow Up assessment was also recorded. Results demonstrated this intervention coupling TPAD training with additional tenets of motor learning including visual feedback and salient task-specific overground training was feasible in terms of safety, tolerance and adherence. Further, while participant’s load asymmetry was not significantly reduced on the treadmill from Baseline to Post Training (p >0.05), there was a significant improvement in stance symmetry during overground gait (F = 8.498, p = 0.002). These results suggest that the integration of motor learning tenets with robotic TPAD training was useful in facilitating gains to overground walking. Implications to the broader scope of robotic training suggest that creating an environment in which the user plays a more active role is useful at maximizing effects of robotic training. Future work should include comparison groups (TPAD treadmill training, overground training, and combined TPAD and overground training) with a more robust sample size for a longer duration of training to parse out contributing factors to overground gains. Future work should also consider a longer training and follow up interval in an effort to determine whether individuals are able to maintain improvements longer than the immediate post training period.

A total of 188 patients completed data at twelve months (attrition rate: 29% over 12 months). The path coefficients show low functional ability (beta=0.51), more depressive symptoms (beta=-0.27), low state self-esteem (beta3=0.20), female gender (beta=0.13), older age (beta=-0.11) and living in a residential care facility (beta=-0.12) have a direct effect on participation restriction, and these variables accounted for 71% of the variance in explaining participation restrictions at 12 months. Repeated measures revealed significant decreases in overall levels of participation restriction and depressive symptoms from baseline to one year. However, no significant early changes in the levels of state self-esteem and depressive symptoms (from baseline to six months) and no significant late changes in both depressive symptoms and LHS scores were found (between six months and 12 months). / A total of 210 stroke survivors completed data at six months. Functional ability, state self-esteem, and number of strokes significantly accounted for 57% of the variance in participation restriction. Lower levels of functional ability, state self-esteem and social support satisfaction were associated with an increased likelihood of having depressive symptoms (z = 5.30, 34.12, and 5.51). / Aims. To gain understanding about the social, psychological and physical outcomes following inpatient stroke rehabilitation; to determine the variables predicting the level of participation and depressive symptoms of stroke survivors at baseline, six and 12 months following discharge from a rehabilitation hospital; to test a theoretical model of predictors of participation restriction at 12 months; and to determine the level over time for each of the outcomes. / Conclusion and implications. The findings in this study indicate that identification of stroke survivors at risk of high levels of participation restriction and low self-esteem will assist health professionals to devise appropriate interventions that target improving the psychological well being amongst person with stroke. Rehabilitation services need to continue to focus on restoring functional independence but also need to diagnose and treat depressive symptoms in order to minimise the restriction to participation in society. Assisting stroke survivors in redefining their identity after stroke could be an important aspect in stroke rehabilitation. (Abstract shortened by UMI.) / Chau, Pak Chun Janita. / Adviser: Shelia Twinn. / Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3426. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 237-276). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

Chan, Chun Kit. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2008. / Includes bibliographical references (leaves 147-161). / Abstracts in English and Chinese. / Chapter Chaper 1 --- Introduction --- p.1 / Chapter 1.1 --- General introduction to cerebral stroke --- p.1 / Chapter 1.2 --- Different types of cerebral stroke --- p.2 / Chapter 1.3 --- Statistics --- p.3 / Chapter 1.4 --- Symptoms of cerebral stroke --- p.4 / Chapter 1.5 --- Complications of cerebral stroke --- p.5 / Chapter 1.6 --- Risks and preventions of cerebral stroke --- p.6 / Chapter 1.7 --- Cerebral stroke treatment --- p.8 / Chapter 1.8 --- Post stroke rehabilitation --- p.11 / Chapter 1.9 --- Mechanisms of stroke --- p.15 / Chapter 1.9.1 --- Energy production failure and loss of ionic homeostasis --- p.15 / Chapter 1.9.2 --- Excitotoxicity --- p.16 / Chapter 1.9.3 --- Calcium ions mediated toxicity --- p.17 / Chapter 1.9.4 --- Passive neuronal cell death --- p.18 / Chapter 1.9.5 --- Oxidative stress --- p.19 / Chapter 1.9.6 --- Inflammation --- p.22 / Chapter 1.9.7 --- Apoptosis --- p.25 / Chapter 1.10 --- Potential therapeutic agents for cerebral stroke --- p.24 / Chapter 1.10.1 --- Anti-oxidative enzyme and free radical scavengers --- p.24 / Chapter 1.10.2 --- Ions channel blockers and glutamate antagonists --- p.26 / Chapter 1.10.3 --- Anti-inflammatory agent --- p.28 / Chapter 1.10.4 --- Anti-apoptotic agent --- p.28 / Chapter 1.11 --- Experimental model of cerebral ischemia-reperfusion --- p.29 / Chapter 1.11.1 --- In vitro model (oxygen and glucose deprivation model) --- p.29 / Chapter 1.11.2 --- In vivo model (Middle cerebral artery occlusion) --- p.31 / Chapter 1.12 --- Traditional Chinese Medicine (TCM) --- p.32 / Chapter 1.12.1 --- General Introduction to Traditional Chinese Medicine --- p.32 / Chapter 1.12.2 --- TCM and cerebral stroke --- p.33 / Chapter 1.12.3 --- Chinese compound formula --- p.34 / Chapter 1.12.4 --- Introduction to individual herb --- p.34 / Chapter 1.12.4.1 --- Astragali Radix (Pinyin name: Huangqi) --- p.34 / Chapter 1.12.4.2 --- Rhizoma Chuanxiong (Pinyin name: Chuanxiong) --- p.35 / Chapter 1.12.4.3 --- Radix Salviae Miltorrhizae (Pinyin name: Danshen) --- p.35 / Chapter 1.12.4.4 --- Cassia Obtusifolia Linne (Pinyin name: Jue Ming Zi) --- p.36 / Chapter 1.12.4.5 --- Radix Glycyrrhizae (Pinyin name: Gancao) --- p.37 / Chapter 1.12.4.6 --- Radix Angelicae Sinensis (Pinyin name: Dongquai) --- p.37 / Chapter 1.12.4.7 --- Paeoniae Veitchii Radix (Pinyin name: Chi Shao) --- p.38 / Chapter 1.12.5 --- Salvianolic acid B --- p.39 / Chapter 1.13 --- Aim of study --- p.40 / Chapter Chapter 2 --- Materials and Methods --- p.41 / Chapter 2.1 --- Materials --- p.41 / Chapter 2.1.1 --- Drug --- p.41 / Chapter 2.1.1.1 --- Herbal Medicine --- p.41 / Chapter 2.1.1.2 --- Herbal extraction of PSR --- p.42 / Chapter 2.1.1.3 --- Herbal extraction of individual herb --- p.43 / Chapter 2.1.1.4 --- Salvianolic acid B --- p.43 / Chapter 2.1.2 --- Chemical --- p.44 / Chapter 2.1.3 --- Animal --- p.48 / Chapter 2.2 --- Methods --- p.49 / Chapter 2.2.1 --- (AAPH)- induced erythrocyte hemolysis --- p.49 / Chapter 2.2.2 --- Cell Culture study --- p.51 / Chapter 2.2.2.1 --- Cell Line --- p.51 / Chapter 2.2.2.2 --- Cell differentiation --- p.52 / Chapter 2.2.2.3 --- In vitro model of ischemia - Oxygen glucose deprivation (OGD) experiment --- p.53 / Chapter 2.2.2.4 --- Cell viability assay --- p.54 / Chapter 2.2.3 --- In vivo Study --- p.54 / Chapter 2.2.3.1 --- Cerebral blood flow (CBF) measurement --- p.54 / Chapter 2.2.3.2 --- In vivo transient focal cerebral ischemia model - Middle cerebral artery occlusion (MCAo) --- p.55 / Chapter 2.2.3.3 --- Administration of PSR --- p.57 / Chapter 2.2.3.4 --- Administration of salvianolic acid B (SAB) --- p.59 / Chapter 2.2.3.5 --- Measurement of brain infarct volume --- p.60 / Chapter 2.2.3.6 --- In vivo anti-oxidative enzyme activity determination in the brain --- p.61 / Chapter 2.2.3.6.1 --- Brain tissue preparation --- p.61 / Chapter 2.2.3.6.2 --- Tissue homogenization and protein extraction --- p.61 / Chapter 2.2.3.6.3 --- Protein concentration determination --- p.63 / Chapter 2.2.3.6.4 --- Catalase activity determination in the brain --- p.63 / Chapter 2.2.3.6.5 --- Glutathione Peroxidase (GPx) activity determination in the brain --- p.64 / Chapter 2.2.3.6.6 --- The Superoxide Dismutase (SOD) activity determination in the brain --- p.65 / Chapter 2.2.3.7 --- Behavioral Evaluation --- p.66 / Chapter 2.2.3.7.1 --- Neurological behavioural test --- p.66 / Chapter 2.2.3.7.2 --- Shuttle box escape experiment --- p.67 / Chapter 2.3 --- Statistical analyses --- p.71 / Chapter Chapter 3 --- Results --- p.72 / Chapter 3.1 --- In vitro model of ischemia - Oxygen glucose and deprivation (OGD) experiment --- p.72 / Chapter 3.2 --- AAPH assay of PSR --- p.75 / Chapter 3.3 --- AAPH assay of individual herb --- p.77 / Chapter 3.4 --- Brain slices after middle cerebral artery occlusion (MCAo) experiment --- p.81 / Chapter 3.5 --- Brain infarct volume of single dose protocol --- p.83 / Chapter 3.6 --- Neurological behavioural test of single dose protocol --- p.85 / Chapter 3.7 --- Brain infarct volume of double doses protocol --- p.87 / Chapter 3.8 --- Neurological behavioural test of double doses protocol --- p.89 / Chapter 3.9 --- Determination of superoxide dismutase (SOD) activity in the brain --- p.91 / Chapter 3.10 --- Determination of glutathione peroxidase (GPx) activity in the brain --- p.93 / Chapter 3.11 --- Determination of catalase activity in the brain --- p.95 / Chapter 3.12 --- Brain infarction volume of Salvianolic acid B (SAB) treatment --- p.98 / Chapter 3.13 --- Neurological behavioural test of SAB treatment --- p.100 / Chapter 3.14 --- Shuttle box performance in training and testing series --- p.102 / Chapter 3.15 --- Change in shuttle box performance (% avoidance c.f. last day of training) in testing series --- p.104 / Chapter 3.16 --- Escape latency in testing and training series --- p.107 / Chapter 3.17 --- Change in escape latency (c.f. last day of training) in testing series --- p.109 / Chapter 3.18 --- Brain infarct volume of shuttle box escape experiment --- p.112 / Chapter 3.19 --- Neurological score in shuttle box escape experiment --- p.114 / Chapter Chapter 4 --- Discussion --- p.117 / Chapter 4.1 --- The protective effect of PSR in in vitro oxygen and glucose deprivation (OGD) on human neuroblastoma SH-SY5Y cell line --- p.117 / Chapter 4.1.1 --- OGD model and cell line --- p.117 / Chapter 4.1.2 --- Protective effect of PSR in OGD experiment --- p.118 / Chapter 4.1.3 --- Free radical scavenging property of PSR --- p.120 / Chapter 4.2 --- The protective effects of PSR in in vivo middle cerebral artery (MCAo) model --- p.121 / Chapter 4.2.1 --- The shortcomings of in vitro OGD model --- p.121 / Chapter 4.2.2 --- Development of in vivo MCAo model and TTC staining --- p.122 / Chapter 4.2.3 --- Protective effect of PSR in MCAo experiment (single dose protocol) --- p.124 / Chapter 4.2.4 --- Protective effect of PSR in MCAo experiment (double doses protocol) --- p.125 / Chapter 4.2.5 --- The effect of PSR toward neurological deficits --- p.127 / Chapter 4.2.6 --- Anti-oxidative effects of PSR in MCAo model --- p.128 / Chapter 4.3 --- The protective effects of SAB in in vivo middle cerebral artery (MCAo) model --- p.130 / Chapter 4.3.1 --- Free radical scavenging property of different herbs --- p.130 / Chapter 4.3.2 --- Selection of pure compound that used to treat stroke --- p.131 / Chapter 4.3.3 --- Protective effect of Salvianolic B in MCAo experiment --- p.132 / Chapter 4.3.4 --- The effect of SAB toward neurological deficits --- p.133 / Chapter 4.4 --- The effects of PSR and SAB on stroked rats' performance in shuttle box escape experiment --- p.134 / Chapter 4.4.1 --- Establishment of shuttle box escape experiment --- p.134 / Chapter 4.4.2 --- Effects of PSR and SAB on avoidance performance --- p.135 / Chapter 4.4.3 --- Effects of PSR and SAB on escape latency --- p.138 / Chapter 4.5 --- Assessment on the contribution of SAB to the protective effect of PSR --- p.140 / Chapter 4.6 --- Comparison of acute and chronic testing --- p.140 / Chapter 4.6.1 --- The protective effect of the drugs (Histopathological examination) --- p.140 / Chapter 4.6.2 --- The severity of motor deficit (Neurological score) --- p.141 / Chapter Chapter 5 --- Conclusion and Future prospect --- p.143 / Chapter 5.1 --- Conclusion --- p.143 / Chapter 5.2 --- Future prospect --- p.144 / References --- p.147

The majority of daily living tasks necessitate the use of bimanual movements or concurrent cognitive processing, which are often more difficult for elderly adults. With the number of Americans age 65 and older expected to double in the next 25 years, in-depth research and sophisticated technologies are necessary to understand the mechanisms involved in normal neuromuscular aging. The objective of the research is to understand the effects of aging on biological signals for motor control and to develop a methodology to classify aging and stroke populations. The methodological approach investigated the influence on correlated activity (coherence) between electroencephalogram (EEG) and electromyogram (EMG) signals into senior age. In support of classifying aging and stroke populations, the methodology selected optimal features from the time, frequency, and information theory domains. Additionally, the use of cepstral analysis was modified toward this application to analyze EEG and EMG signals. The inclusion and optimization of cepstral features significantly improved classification accuracy. Additionally, classification of young and elderly adults using Gaussian Mixture Models with Minimum Classification Error improved overall accuracy values. Contributions from the dissertation include demonstration of the change in correlated activity between EMG and EEG with fine motor simple and complex dual tasks; a quantitative feature library for characterizing the neural control of movement with aging under three task conditions; and a methodology for the selection and classification of features to characterize the neural control of movement. Additionally, the dissertation provides functional insight for the association of features with tasks, aging, and clinical conditions. The results of the work are significant because classification of the neural control of movement with aging is not well established. From these contributions, future potential contributions are: a methodology for physiologists to analyze and interpret data; and a computational tool to provide early detection of neuromuscular disorders.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Neuromuscular electrical stimulation (NMES) has been shown to be effective for recovery of motor function following injury or pathology, however, NMES can impart rapid fatigue and the specific parameters of stimulation that maximize force output and delay the onset of fatigue remain unclear. Frequency, intensity, and pulse pattern are a few of the parameters that can be manipulated to achieve desired outcomes. Strong evidence supports the use of higher frequencies of stimulation to maximize performance of fatigued or paralyzed muscle. Likewise, several studies advocate the use of varied pulse patterns, rather than constant pulses, to maximize force output as well. Much of the research literature regarding NMES use with a pathological population involves spinal injured individuals. Much less is known about the effect of NMES on motor recovery, especially when delivered through varied pulse patterns, in the post-stroke population. The three studies contained herein addressed these issues. In Study 1, submaximal and supramaximal intensities of two variable frequency stimulation patterns and one constant frequency pattern were applied to the thenar muscles of a young healthy population. Results showed marked differences in force output between the two intensities. Submaximal stimulation enhanced the effect of the variable pulses and a greater force response was produced. In Study 2, the same three patterns were applied to the thenar muscles of a post-stroke group and an age-matched able-bodied group at submaximal intensities. Again, differences in force output were evident between the healthy and pathological group, and the variable pulses may have further depressed already weakened hemiplegic muscle. Study 3 compared the effects of a NMES rehabilitation program using a high (40 Hz) and a low (20 Hz) frequency to determine if task-specific improvements were related to frequency used. Results showed that those in the high frequency condition demonstrated greater improvements in strength, dexterity and force accuracy; those in the low frequency condition showed improvements in motor endurance. The results of this work suggest that the intensity, frequency and stimulation pattern of NMES used have a significant impact on the resultant muscle contraction and functional skills gained following stroke and should be carefully considered when implementing a clinical regimen for motor recovery.