There is a need for standardized clinically accessible measurements that would enable detection of the primary underlying deficit and a patient’s rehabilitation capacity after stroke. While a multitude of measures of neuromotor control exist, there is not a unified perspective on their complementarity versus redundancy for identifying the stroke-related impairments. This dissertation evaluates four measures of neuromotor control: the lower extremity portion of the Fugl-Meyer Assessment (FM-LE), plantarflexor central drive, the number of muscle synergies, and the dynamic motor control index. The first aim was to assess if the dynamic motor control index, which has not previously been used in a post-stroke population, could identify stroke-related impairments in neuromotor control, and how it compared to the number of muscle synergies. The second aim evaluated which measure(s) of neuromotor control were most indicative of biomechanics and functional outcomes. Twenty-two individuals post-stroke (60 ± 8 years old, chronicity 6 ± 4 years, 16 male, 10 right paretic) completed clinical assessments of the FM-LE and six-minute walk test, 90 seconds of fast treadmill walking during which force and muscle activity data were collection, and three burst-superimposition tests on the paretic limb for the calculation of central drive. The results of the first study concluded the dynamic motor control index was able to identify stroke-related impairments and may do so better than the discrete number of muscle synergies. The second study determined that the FM-LE, paretic central drive, and paretic dynamic motor control index are individually the best neuromotor indicator of propulsion asymmetry, endurance, and step time asymmetry, respectively, suggesting these measures are complementary for explaining post-stroke deficits. A multi-modal evaluation approach that combines these measures of neuromotor control with clinical and biomechanical evaluations provides the best opportunity to understand post-stroke walking impairment. Future work should focus on developing a single measure of neuromotor control that fully explains locomotor compensations and the primary underlying impairment, further enabling clinical accessibility and standardized assessments. / 2024-09-08T00:00:00Z

Background: In Canada, as acute ischemic stroke treatment advances and the population ages, more individuals are surviving stroke and returning home with minor deficits. Self-management education tailored to one’s health literacy level is a critical and overlooked aspect in minor ischemic stroke survivors’ recovery. During the first month after minor ischemic stroke, when the risk of recurrence is highest, minor ischemic stroke survivors experience numerous transitions and report unmet health information needs that place them at risk for poor health outcomes. Although minor ischemic stroke-specific data is lacking, American data suggests 59% of stroke survivors have marginal to inadequate health literacy at the time of hospital discharge. Low health literacy in stroke survivors has been associated with poor education retention; issues with medication administration, adherence and self-efficacy; reduced physical functioning; and depression. Increasingly it is recognized that health literacy should be considered a contextual entity. There is a need to better understand the level of health literacy and contextual factors associated with health literacy in minor ischemic stroke survivors to prevent poor health outcomes and health disparities. Purpose: This project aimed to determine the level of health literacy and contextual factors associated with health literacy in recent minor ischemic stroke survivors who were predicted to return to the community within 30 days after their stroke. Methods: This cross-sectional survey was grounded by Sorensen’s Integrated Model of Health Literacy (2012) and employed the HLS19-Q12 to measure health literacy. Contextual factors were assessed using a survey developed from a comprehensive literature review. Forty-two minor ischemic stroke survivors were recruited from the acute stroke unit and stroke rehabilitation unit and completed the questionnaires. Statistical analyses were completed in SPSS. Summary statistics of the HLS19-Q12 scores in minor ischemic stroke survivors were reported and compared with HLS19-Q12 scores of the general population published in the2019-2021 Health Literacy Population Survey. Contextual factors were reported as summary statistics and associations with health literacy were analyzed using Spearman correlation, Kruskal-Wallis tests, Mann-Whitney U tests and multiple linear regression. Results: The average HLS19-Q12 score was 76.3 and similar to the results obtained in the 2019-2021 Health Literacy Populations Survey. The need for information about financial support, a higher number of total barriers to health literacy and issues related to health care provider continuity, feeling uncomfortable asking a health care provider to explain something you didn’t understand (stigma) and memory were associated with lower levels of health literacy in recent minor ischemic stroke survivors. Discussion: Although the average level of health literacy was similar to that of the general population, many participants reported problematic (26.2%) or inadequate (16.7%) health literacy. This thesis is unique in its use of a contextual perspective to explore health literacy in minor ischemic stroke survivors. This perspective enabled the identification of personal, situational and societal/environmental factors that may be critical in promoting optimal health of recent minor ischemic stroke survivors. The results of this study suggest care continuity, the patient-health care provider relationship and financial support may be critical factors. Conclusion: This data can be used to inform future equity-focused research designs and holistic interventions to support recent minor ischemic stroke survivors with lower levels of health literacy who return to the community. These interventions have the potential to reduce the risk for poor health outcomes after a minor ischemic stroke / Thesis / Master of Science in Nursing (MSN)

Stroke is the leading cause of adult neurological disability. Novel markers of vascular disease progression, such as arterial stiffness and endothelial function, may provide early and sensitive stroke risk detection. However, measurement properties of these novel vascular risk markers have not yet been established in the post-stroke population, nor has the association between these risk markers and measures of physical function. Moreover, given that subclinical vascular disease may initially manifest as a decline in cognitive function, understanding vascular disease progression in older adults with and without cognitive impairment may provide information regarding early stroke risk. This study aimed to investigate 1) test-retest reliability and between-side differences in novel vascular risk markers in individuals with stroke, 2) differences in arterial stiffness and endothelial function between older adults without cognitive impairment, with cognitive impairment, and with stroke, and 3) relationships between novel vascular risk markers and physical function in individuals with and without stroke. Participants were 50-80 years of age, able to ambulate ≥10 meters, and for those with stroke, ≥1 year post-stroke. Carotid-femoral, carotid-radial, and femoral-foot pulse wave velocity (cfPWV, crPWV, and ffPWV, respectively) were used to quantify systemic arterial stiffness, and compliance and distensibility were used to quantify local carotid arterial stiffness. Flow-mediated dilation (FMD) was used to quantify endothelial function. Findings revealed almost perfect test-retest reliability of cfPWV (ICC>0.91, P<0.0001) and substantial test-retest reliability of FMD in individuals with stroke (ICC>0.70, P<0.01). There were no between-side differences in novel vascular measures, no differences in these measures across subgroups of increasing vascular risk, and a positive correlation between cfPWV and walking speed. Findings suggest that in the post-stroke population, cfPWV and FMD may be the most appropriate measures of vascular risk progression, that it may be more clinically feasibly to assess these measures on the unaffected side. / Thesis / Master of Science (MSc) / Novel measures of arterial health, such as arterial stiffness and endothelial function, may provide early stroke risk detection. This study aimed to assess the day-to-day reliability and between-side differences of these new arterial measures in people with stroke, and to also investigate relationships between these measures and cognitive function in older adults with and without stroke. Arterial stiffness was assessed using pressure sensors that measure the speed of the pulse waves, and endothelial function was assessed using ultrasound to measure the capacity of the arteries to expand following an increase in blood flow. Results found that the most well-established measures of arterial health were reliable and there were no between-side differences in any measures. No relationships were observed between arterial measures and cognitive function. Overall, this study increases knowledge surrounding novel measures of arterial health in older adults with and without stroke.

No description available.

No description available.

Bakgrund: År 2021 insjuknade 24 500 svenskar i stroke. En konsekvens av stroke är post-stroke fatigue (PSF). PSF är ett tillstånd som är förknippat med försvårad rehabilitering och återgång till arbetslivet, ökad dödlighet samt försämrad livskvalitet. Syfte: Syftet var att belysa personers upplevelser av fatigue till följd av stroke. Metod: En allmän litteraturstudie där 11 resultatartiklar granskades för vetenskaplig kvalitet och analyserades med kvalitativ innehållsanalys. Resultat: Innehållsanalysen mynnade ut i fyra kategorier. Kategorin upplevelser av fatigue som en utmaning, vilken belyser hur PSF upplevdes som oförutsägbart och begränsande. Kategorin upplevelser av fatigue och behov av att möta livet på ett nytt sätt belyser hur personerna behövde ändra på sättet de verkade och såg på sina liv. Kategorin upplevelser av fatigue och behov av kunskap belyste hur personerna upplevde informationen de fick av vården. Kategorin upplevelser av fatigue och förståelse från personer i deras närhet belyser upplevelsen av stöd från omgivningen. Konklusion: Personer med PSF och deras anhöriga var överens om att de hade ett gemensamt och omfattande behov av undervisning om PSF. Ett personcentrerat bemötande baserat på kunskap om PSF bör prägla sjuksköterskans arbete gentemot personer med PSF. Mer forskning kring effektiva behandlingar och omvårdnadsåtgärder vid PSF behövs. / Background: In 2021 24 500 persons in Sweden had a stroke. A consequence of stroke is post-stroke fatigue (PSF). PSF can be a hindrance to rehabilitation, return to work and have a negative effect on quality of life and mortality. Aim: The aim was to highlight person’s experiences of fatigue following stroke. Method: A general literature review where 11 articles were examined for scientific quality and analyzed with qualitative content analysis. Results: Four categories: Experiences of fatigue as a challenge, which highlights PSF as unpredictable and limiting. Experiences of fatigue and a need to face life in a new way highlights how the persons had to adapt how they lived their lives and viewed themselves. Experiences of fatigue and the need for knowledge highlights how the persons experienced the information from health care professionals. Experiences of fatigue and understanding from people close to them highlights the importance of a supporting social network. Conclusion: Persons with PSF and their social network has a mutual and extensive need of education about PSF. A person-centered approach based on knowledge should characterize the nurses work with persons with PSF. More research on how to better treat and care for persons with PSF is needed.

Introduction Post-stroke activity limitation secondary to upper-extremity motor impairment is common, and increasing. We do not currently have effective, globally applicable interventions to improve activity limitation. The burden of post-stroke disability is rising in low and middle-income countries, resulting in an immediate need for effective interventions that can be implemented throughout the world. Purpose This program of research was structured to address three important questions, 1) In all parts of the world, do people with stroke experience similar degrees of activity limitation secondary to upper extremity motor impairment? 2) Are there simple interventions that can be initiated by health care workers, but autonomously sustained by people with stroke, that can improve activity limitation secondary to upper extremity motor impairment? and 3) Are these interventions effective? Methods To address the first question, data from an international stroke study were used to quantify the amount of post-stroke upper extremity weakness and characterize the people. For the second question, a systematic review was conducted to identify current evidence on the effectiveness of simple, task-based practice. To address the third question a protocol was developed for an outcome study. Results Post-stroke upper extremity weakness is common throughout the world, ranging from 67.3% of those with stroke in high-income countries to 97.3% in low-income countries. There is inconclusive, but promising evidence on the effectiveness of simple, task-based practice to improve upper-extremity motor impairment. It is likely that multiple interventions are needed to address the problem and a two-by-two factorial design trial, evaluating simple, task-based practice or a motor enhancing pharmacological agent, implemented in all regions of the world, would be a novel and efficient means of addressing the question. Conclusions The answers to these questions have provided novel information that is a required next step to providing effective, globally applicable interventions for people with stroke. / Thesis / Doctor of Philosophy (PhD) / After having a stroke, more than half the people have difficulty moving their arm. This difficulty often results in difficulties doing every day tasks. Most of the information on what happens after stroke comes from developed countries and we do not know if these problems exist to the same extent in developed countries. We also do not know the most effective interventions to help improve arm function after stroke. Possible interventions could include rehabilitation strategies, drugs or a combination of both. This thesis describes the amount of arm weakness after stroke throughout the world, looks at the evidence for a simple intervention that could be used throughout the world, and describes the design of study that could look at the effectiveness of both rehabilitation and drug interventions throughout the world. This work provides information on the globally applicable interventions to improve arm function after stroke, which has not been considered in the literature to date.

Background: Rare genetic mutations cause familial early-onset stroke disorders, known as “Mendelian strokes”. The broader relevance of rare mutations in unrelated young stroke patients is uncertain. We hypothesize that rare mutations in known and novel genes are important risk factors for stroke. Methods: Exome sequencing was used to characterize rare disruptive protein-altering mutations in 185 young cases and 185 matched controls from INTERSTROKE, a large and globally representative stroke study. The major objectives were: 1) to precisely define the role of known Mendelian stroke genes and 2) to discover novel gene and pathway associations. Results: A focused assessment of known Mendelian stroke genes revealed a significant contribution from NOTCH3, the causal gene for Cerebral Autosomal Dominant Arteriopathies with Subcortical Infarcts and Leucoencephalopathies (CADASIL). CADASIL mutations were identified in six cases and no controls (P=0.03). The clinical presentation of CADASIL mutation carriers deviated from known symptomatology, consisting of small-vessel ischemic strokes (SVIS) accompanied by secondary features including migraine and depression. A novel role for non-CADASIL NOTCH3 mutations in ICH was also elucidated (OR=2.86; 95% CI, 1.13 to 7.93, P=0.02). Such mutations were present in 22% of ICH cases and 8% of matching controls. An agnostic evaluation of all genes did not reveal any genome-wide significant associations. However, NOTCH3 was among the top ICH genes out of 13,706 tested, and many others were also biologically relevant, notably, AARS2 and NBEAL2. A protective association was identified for the renin angiotensin system (P=8.1x10-4), whereas type II diabetes mellitus was associated with increased risk (P=1.9x10-2). Conclusion: Rare mutations influence risk of early-onset stroke. CADASIL mutations play an important role in unrelated stroke patients. Beyond CADASIL, a novel role was uncovered for other NOTCH3 mutations as common and significant risk factors for ICH. Novel biologically relevant genes and pathways may also affect stroke susceptibility. / Thesis / Master of Science in Medical Sciences (MSMS)

Bakgrund: Stroke är ett sjukdomstillstånd som skadar hjärnvävnaden. Tillståndet innebär stora konsekvenser för de drabbade. De patienter som drabbats av stroke känner oftast skam och förtvivlan med en förlorad livsglädje som resultat. Idag upptar sjukdomsgruppen flest antal vårdplatser på sjukhusen runtom i Sverige. Med ökad kunskap i omhändertagande i kombination med stöttning för patienten efter insjuknandet, kan känslan av förlorad livskvalitet minskas markant. Syftet: Syfte med denna studie var att belysa patienters erfarenheter av att drabbas av stroke. Metod: En litteraturbaserad studie där 12 kvalitativa artiklar har analyserats. Resultat: Ur analysen av datamaterialet framträdde tre kategorier: Tappat kontrollen över sin kropp, Hamnar i beroendeställning och Återfå ett liv som självständig med åtta underkategorier. Slutsats: Studien bidrar med kunskap om patienters erfarenheter efter att ha drabbats av en stroke. Det kan vara omtumlande känslor att bearbeta för dessa patienter. Behovet av stöd är nödvändigt för att patienterna ska finna livskvalité. Motivation, hopp och uppmuntran stärker patientens självförtroende och leder till ett ökat välbefinnande. Genom en ökad förståelse för patientens upplevelser efter insjuknandet kan sjuksköterskan främja patientens hälsa och välbefinnande.

The study evaluated whether the activity of the indoleamine 2,3 dioxygenase (IDO) enzyme is increased post-stroke and contributes to the development of post-stroke depression (PSD) via tryptophan (TRP) depletion and neurotoxic kynurenine (KYN) metabolite production. The activity of IDO was measured using the KYN/TRP ratio. Participants were assessed for depression severity using the Center for Epidemiological Studies Depression Scale (CES-D). Blood TRP, KYN, large neutral amino acids and cytokines were measured and compared. Fifty-four (mean age=69.9±15.2, male=52.7%, mean NIHSS=7.3±4.6) patients within 28.9±40.3 days of stroke were separated into two groups: non-depressed (n=38, CES-D=6.1±4.9) and those with significant depressive symptoms (n=16, CES-D=26.8±10.8). Higher mean KYN/TRP ratios were demonstrated in stroke patients with depressive symptoms (non-depressed=69.3±36.9 vs. depressive symptoms=78.3±42.0, F3,50=4.61, p=0.006) after controlling for LNAA (p=0.026) and hypertension (p=0.039). As the KYN/TRP ratio reflects decreased TRP and increased neurotoxic KYN metabolites, both mechanisms may play an etiological role in PSD.