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Systematic review Executive dysfunction is commonly reported following stroke with most research in this area focused on frontal lobe lesions. A systematic review was carried out to evaluate the evidence of executive dysfunction following stroke as compared to control groups. It was found that executive functions are consistently impaired following stroke and is not limited to frontal lobe lesions. Processing speed, mental flexibility, attention and working memory impairments were found to be the most common executive functioning impairments following stroke. Given the impact executive dysfunction may have on successful rehabilitation, relationships, return to work and quality of life, a comprehensive assessment of such difficulties is important following stroke to aid in the development of appropriate and effective rehabilitation strategies. Future research should use larger samples and a wide range of measures to assess different aspects of executive functioning. Introduction Mood disorders and psychological distress are common following stroke, and depression and emotional lability have been studied extensively. There has, however, been little research into difficulties in emotion regulation following stroke and whether this is associated with emotional or cognitive difficulties. The current study investigated emotion regulation difficulties following stroke and their relationship with quality of life, executive functions, anxiety and depression. Method Fifty participants who had suffered a stroke and forty five age matched controls completed the Difficulties in Emotion Regulation Scale, the Hospital Anxiety and Depression Scale, the World Health Organization Quality of Life assessment – Brief version and the National Adult Reading Test. In addition individuals with stroke completed four measures of executive functioning – Color Trails Test, Verbal Fluency, Brixton Spatial Anticipation Test and the Hayling Sentence Completion Test. Results Individuals with stroke had significantly greater difficulties in emotion regulation compared to age matched controls and this was significantly associated with lower self reported quality of life and increased levels of both anxiety and depression. No significant associations were found between emotion regulation and executive functions or between executive dysfunction and lower self reported quality of life. Discussion The current study found evidence that individuals who have suffered a stroke have more difficulties in emotion regulation than an age matched control group. This is clinically important as emotion regulation difficulties are found in mood disorders and it may be that such difficulties precipitate and/or maintain depression following stroke. The absence of an association between difficulties in emotion regulation and executive functioning suggests that other factors may influence such difficulties, such as the trauma of having a stroke. Future research should explore emotion regulation difficulties further following stroke, particularly investigating whether the course of these difficulties changes over time and if they are linked to type of stroke or lesion location.

Objectives: Reviews have suggested that stroke patients and family members frequently hold different impressions of the patient’s quality of life. Understanding such differences may be particularly useful for clinicians who wish to help clients adjust to the effects of a stroke. The aim of this study was to investigate how the responses of stroke survivors and their family members differ when indicating the stroke survivors’ quality of life, and whether such differences are associated with greater time elapsed since the stroke onset. Design and Method: A related-subject design and a correlational design were utilised in this study. People who had suffered a stroke within five years were compared with nominated members of their family. All participants indicated the perceived quality of life of the stroke survivor using the WHOQOL-BREF. The time elapsed since their stroke was recorded and the participants’ mood was assessed. Results: No significant differences were found between the stroke survivors and the family members’ views of the stroke survivors’ quality of life. However, agreement between these groups was found to be low in the Social domain of the WHOQOLBREF. Greater time since the stroke onset was found to correlate with greater discrepancy between groups in the Social domain, but not in the other domains. Conclusions: The results suggest that families’ adjustment to stroke does not conclude when improvement in function slows. Instead, a stroke continues to affect families years after the initial stroke. These findings may be interpreted within the context of quality of life response shift, where changes in the stroke survivors’ evaluation of their social lives may not be identified by their families. This may reflect a common trajectory following stroke. The methodological limitations of this study and suggestions for future research are discussed.

Stroke remains a serious public health problem in low, middle and high income countries worldwide. In low and middle income countries there has been a greater than 100% increase in stroke incidence. The impact of HIV associated vasculopathy is recognized as contributing to the increased prevalence of stroke in younger patients (Tipping et al., 2007) and is an independent risk factor for stroke (Cole et al., 2004). The impact of this increased stroke incidence has not only resulted in an increase in death rates in the developing world, but has also resulted in increases noted in long term disability as a result of stroke. The available resources for stroke care and rehabilitation are lacking in developing countries including Africa, particularly in rural areas. It has also been noted that 80% of the population live in areas where factors such as limited resources and cultural practices limit access to stroke services (Poungvarin 1998). Currently patients with stroke are discharged from hospitals in the public healthcare sector within six to 14 days of having a stroke, because of the pressure for beds (Mudzi, 2009; Reid et al., 2005; Hale, 2000). As a result patients are not benefitting from rehabilitation services and this leads to suboptimal recovery post stroke and to a large number of persons living with disabilities in under resourced communities. Because the patients with stroke are discharged so acutely after their stroke, carers become a necessity to cope with the burden of care. These conditions result in increased stroke survivor dependence in South Africa compared to the USA or New Zealand. While 80% of stroke survivors who are initially unable to walk achieve independent walking (Jorgensen et al., 1995), at three months post stroke 25%-33% still require assistance or supervision when walking (Jorgenson et al., 1995; Duncan et al., 1994; Richards et al., 1993). Unfortunately these independent walkers seldom achieve walking speeds that are sufficient for community ambulation (Schmid et al., 2007; Lord and Rochester, 2005; Lord et al., 2004). Walking competency is a term used to describe a certain level of walking ability allowing an individual to participate in the community safely and efficiently (Salbach et al., 2004). It should also be noted that even those with mild and moderate strokes experience limitations with higher physical functioning which impacts on their quality of life and ability to return to work (Duncan and Lai, 1997). The cerebral cortex has the ability to undergo functional and structural reorganization for several weeks and even months in more severe cases post stroke. Rehabilitation post stroke facilitates this process and can shape the reorganization of the adjacent intact cortex (Green, 2003). Further, it has been concluded that to facilitate the best possible functional outcome for people post stroke, engagement in intensive task oriented therapy is necessary (Kwakkel et al., 2004; Van Peppen et al., 2004). Considering these findings it is extremely concerning that there is little or no rehabilitation provided to stroke survivors in the public healthcare sector in South Africa (Mudzi, 2009; Rhoda and Hendry 2003; Hale and Wallner, 1996; Stewart et al., 1994). With this in mind, the aim of this study was to determine if an out -patient based task oriented group training programme would promote improved walking competency more than the current progressive resistance strength group training programmes that are common practice in persons who have had an acute stroke in the public healthcare system in South Africa. The specific objectives of this study were to establish the effect of a low intensity, namely once a week (for six weeks), out- patient based task programme on: walking competency, walking endurance, gait speed and health status in terms of physical functioning in persons with sub-acute stroke. Due to the high incidence of post stroke survivors with HIV it was important to establish if the training programme produced comparable effects in HIV positive and HIV negative subjects. This study used a stratified blocked randomised controlled trial design. Where group allocation was concealed. In addition assessor blinded evaluations were conducted at baseline, post intervention and at six months after the intervention had ceased. A total of 144 persons who had a stroke were stratified according to their walking speed – mild (able to walk at a gait speed > 0.8m/s), moderate (able to walk at a speed of 0.4-0.8 m/s) or severe (able to walk at a speed < 0.4m/s) – and randomly assiged to one of three training groups. One group received task oriented group circuit training (task group), the second group received progressive resistance strength training (strength group), and the third group participated in one multidisciplinary education group training session (control group). The task and strength interventions included 6 sessions, of 60 minutes each for six to 12 weeks. While the control intervention group participated in one three hour education session, which included advice on the importance of exercise and a 20-minute exercise session. All subjects had been discharged from the public healthcare sector and were less than six months post stroke at inclusion into the study. The primary objective was walking competency, which included the measurement of walking endurance, gait speed, functional balance and mobility (Salbach et al., 2004). The task group showed an improvement that was significantly greater than that achieved by the strength and control groups in walking endurance, gait speed, functional mobility and balance at the follow-up. These findings demonstrate that the provision of as little as six sessions of task training (in a developing country, where persons with sub-acute stroke have had no previous rehabilitation) improves walking competency to a significantly greater extent than either a strength intervention of equal intensity, or a control intervention programme consisting of one three hour education visit in the sub -acute phase post stroke. While the strength group received a more frequent and intensive training compared with the control group, there were no significant differences in terms of walking competency between these two groups over the study period. The task group showed significantly greater improvements in walking endurance, comfortable and maximum gait speed than the strength and control groups immediately post intervention. While post intervention, the task training led to superior gains in functional mobility and balance compared to the control group, it was not superior to the strength group. For subjects, with a moderate gait disability at baseline, the improvements in walking endurance and in comfortable and maximum walking speed in the task group were significantly more than the strength and control groups. For subjects with a severe gait deficit at baseline, the task group improved significantly more than the control group on all measures of walking competency but not significantly more than the strength group. There were no significant differences among the groups for subjects with a mild gait deficit at baseline. All three treatment intervention groups improved their score on the stroke impact scale 16 (SIS 16) over the course of the study period. The task group improved significantly more than the control group’s health status in terms of physical functioning measured by the SIS16. There were no significant differences among the groups in the change scores for the measures of walking competency between the HIV positive and HIV negative subjects throughout the study period. The results of this study demonstrate that an extremely limited number of task training sessions resulted in significantly greater improvements in walking competency than progressive strength training or a multidisciplinary education training approach. However, these results must be interpreted with caution, remembering the context of the sample population who had not received a period of inpatient rehabilitation prior to their inclusion into the study and were 10-15 years younger than subjects in numerous other studies. This appears to be the first study conducted with such a limited rehabilitative intervention post stroke. As a result, further research to evaluate the effectiveness of limited intensity task oriented training interventions for non -ambulant stroke survivors in the developing world where resources are limited, needs to be conducted. It is important to explore the benefits of different group based rehabilitative interventions for stroke survivors to alleviate the burden as a result of disability as much as possible. Key words: Stroke, Task Oriented, Rehabilitation, Walking, Walking Competency

M.Sc.(Med.), Faculty of Health Sciences, University of the Witwatersrand, 2008 / Introduction It is widely recognised that stroke is a multi-factorial disorder in which platelets play a crucial role in thrombus formation resulting in ischaemic stroke. Platelet adhesion and aggregation are initiated by the interaction of various platelet glycoproteins (GP’s) such as GPIbα, which binds to von Willebrand Factor and GPIIb/IIIa a fibrinogen receptor. Recent studies have shown that the GP’s are polymorphic and the polymorphisms described within GPIbα such as Kozak- 5T/C, the variable number of tandem repeats (VNTR) and the Human Platelet antigen 2 (HPA2), have been implicated in the development of stroke, while the PIA polymorphism of GPIIb/IIIa was found to contribute to “aspirin resistance”. Therefore, these polymorphisms may be potentially important for early detection and early intervention and thus setting the need to provide for a high volume genotype testing at health care centres. One of the most used techniques to determine platelet function is platelet aggregometry. However, the major disadvantages of platelet aggregation is that it is influenced by a number of environmental factors and its access is limited to tertiary health centres. Platelet aggregation measures the functional expression of platelets, which is known to deteriorate over time. It is for this reason that new methods at molecular level such as polymerase chain reaction (PCR) are needed to explore the role of genotypic expressions, which are not influenced by environmental factors. Currently, conventional PCR is used to detect platelet polymorphisms in the research settings and has limitations as a routine diagnostic test. Furthermore, it is time consuming and is prone to contamination. With the recent advances in real-time PCR it is possible to genotype large sample batches rapidly without compromising on the quality, accuracy and precision of results. This study aims to adapt conventional PCR methodology onto a real-time platform for detecting platelet polymorphisms that have been implicated in both stroke and aspirin resistance. Materials and methods A total of 60 caucasian patients classified as having ischaemic stroke by virtue of MRI and Doppler analysis from the Stroke Clinic at the Johannesburg Hospital were enrolled for this study. Healthy caucasian individuals (38), age and gender matched were enrolled as controls. DNA samples were extracted from all the subjects and the prevalence of the Kozak –5T/C, HPA-2, VNTR and GPIIIa PIA polymorphisms were determined first by using conventional PCR and then the real-time LightCycler TM PCR method. Results The frequency of the unfavourable alleles ( the PIA2 allele for the GPIIIa PIA polymorphism, the T allele for the Kozak –5T/C polymorphism, the B allele for the HPA-2 polymorphism and the C allele for the VNTR polymorphism) of the different GP’s were higher in the stroke patients when compared to the control subjects but did not reach statistical significance. There was complete statistical agreement between the results obtained for the conventional PCR as compared to the results obtained for real-time PCR except for the VNTR polymorphism, due to the difficulty in designing and the unavailability of probes for the real-time PCR assay. However, it is important to note that adapting the real-time PCR as a new methodology would greatly benefit both the patients and the clinicians by providing early detection and the possibility of early therapeutic intervention. Conclusion Therefore in conclusion, it is possible to perform not only conventional PCR for platelet polymorphism but also real-time PCR on a large scale without compromising on the quality, accuracy and precision on platelet polymorphisms that play a significant role in stroke and aspirin resistance. However, a larger population based study needs to be performed to confirm the findings.