Philosophiae Doctor - PhD / Background: Many patients with stroke feel ill-prepared for discharge from stroke rehabilitation, despite having undergone extensive periods of therapy. From the available research, there is clear evidence that disease specific self-management interventions (SMI) are effective at changing targeted behavioural outcomes, and ultimately improve patient participation restrictions, using self-efficacy principles. A stroke SMI, originally developed by the Bridges Organization to address participation restriction in patients living with stroke in the United Kingdom (UK); was successfully adapted and contextualized for the New Zealand stroke population. A similar stroke SMI could have equal positive benefits for the South African stroke population but would need to be contextually relevant. Aim: This study aims to adapt and contextualize the original UK Bridges stroke SMI workbook for implementation with the South African stroke population. Method: The qualitative, exploratory study is conducted in five phases. Thirteen healthcare professionals (Phase 1) and 12 patients with stroke (Phase 2) are engaged with by the researcher using focus group discussions to understand their views on the implementation of self-management intervention in the local context; and one-on-one interviews with local South African patients living with stroke are conducted to explore their experiences (Phase 3) and build contextually relevant local vignettes. The adaptation and contextualization process of the Bridges stroke SMI workbook to the South African context occurs using the participant feedback and built vignettes from Phases 1 to 3. Consensus on the adaptation of the workbook is then reached through the use of an expert panel for peer-review (Phase 4), and a final focus group discussion with local healthcare professionals in the field of stroke rehabilitation (Phase 5) to produce the final South African Bridges stroke SMI workbook. Phase 1 and 5 participants were conveniently selected; while purposive sampling was applied for Phases 2 and 3. Throughout the various study phases, a thematic analysis procedure is employed by the researcher to analyse and interpret the themes identified through the qualitative data collected. A deductive approach was employed by the researcher for the focus group discussion data of Phase 1, 2, and 5; and an inductive approach to the data from the interviews in Phase 3. The trustworthiness criteria of credibility, transferability, dependability, and confirmability were applied.

Cerebral small vessel disease (SVD) is a leading cause of stroke and vascular dementia. The majority of cases are sporadic, occurring in the elderly hypertensive population. However, there also exist patients with familial disease. The most common form is Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), caused by mutations in the NOTCH3 gene. In recent years, other genes have also been found to cause familial SVD, such as COL4A1/A2, HTRA1, FOXC1 and TREX1. Genome wide association studies (GWAS) have also revealed loci associated with sporadic SVD strokes and its related features. This thesis explores the genetic basis of SVD primarily from the angle of the 'one gene, one disease' hypothesis. We explore the phenotype of familial SVD using CADASIL as a prototype. We next adopt a candidate gene approach to rare variant discovery using high throughput sequencing (HTS) techniques in two forms: 1) a multi-gene sequencing panel to examine the presence of rare variants in a cohort of 993 presumed-sporadic, early-onset SVD stroke patients, and 2) whole genome sequencing in 118 pedigrees with suspected familial SVD. We also evaluate the prevalence of known disease-causing mutations in the general population using a cohort of whole genome sequenced non-SVD patients, and other control databases. We demonstrate that a few presumed-sporadic SVD stroke patients may in fact have familial disease that was not previously diagnosed. We show that known and novel rare variants in candidate genes are found in our cohort of familial SVD patients, and suggest a possible role for rare variants in genes associated with related phenotypes and sporadic disease in this cohort. Finally, we identify known disease-causing variants in relatively high frequencies in the population, and show that conclusions on the pathogenicity of variants based on allele frequency and functional analyses may sometimes be misguided, thus highlighting the current limitations we face in the clinical interpretation of variants identified on HTS. In recent years genetic studies have revealed that pathways in different familial diseases are likely to converge in the pathogenesis of sporadic disease. Further uncovering the genetic basis of undiagnosed cases of familial SVD may shed light on the mechanisms underlying the sporadic form of disease, and may in turn drive the identification of potential therapeutic targets.

No description available.

Extracting strokes from handwriting in historical documents provides high-level features for the challenging problem of handwriting recognition. Such handwriting often contains noise, faint or incomplete strokes, strokes with gaps, overlapping ascenders and descenders and competing lines when embedded in a table or form, making it unsuitable for local line following algorithms or associated binarization schemes. We introduce Intelligent Pen for piece-wise optimal stroke extraction. Extracted strokes are stitched together to provide a complete trace of the handwriting. Intelligent Pen formulates stroke extraction as a set of piece-wise optimal paths, extracted and assembled in cost order. As such, Intelligent Pen is robust to noise, gaps, faint handwriting and even competing lines and strokes. Intelligent Pen traces compare closely with the shape as well as the order in which the handwriting was written. A quantitative comparison with an ICDAR handwritten stroke data set shows Intelligent Pen traces to be within 0.78 pixels (mean difference) of the manually created strokes.

Speech and language impairments after left hemisphere stroke are life altering. Neuroprotective interventions, such as tissue plasminogen activator, or tPA, are utilized to diminish the impact of the stroke on functional ability. The purpose of this study was to examine speech and language recovery in the first three months after stroke in individuals with aphasia and to further investigate any differences between individuals who did and individuals who did not receive tPA, using objective speech and language measures. Twenty-six individuals, thirteen of whom received tPA and thirteen who did not, suffering from first-ever left hemisphere stroke with resulting aphasia were enrolled and completed repeated speech and language assessments within 24 hours after stroke, at one and two weeks after stroke. A three month assessment also included an additional quality of life measure. Findings indicate that both individuals who did and those who did not receive tPA demonstrated significant gains in language skills. Results also suggest that the individuals who received tPA have better outcomes at three months compared to those who did not. This is clinically significant as it helps provide prognostic information about the use of tPA and informs decision making for speech pathologists within the acute care hospital.

Association between Smoking and Functional Outcome in Acute Ischemic Stroke Population Treated with Tissue Plasminogen Activator Iretioluwa Ajani1, Oluyemi Rotimi1, Olubunmi Kuku1, Ndukwe Kalu1, Olakunle Oni1, Nwabueze Christian1,Thomas Nathaniel2, Shimin Zheng1* 1Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614 2Department of Neurology, Department of Pharmacology, Physiology & Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29208 *Sponsoring faculty Background The effect of smoking on outcome in acute ischemic stroke patients treated with tissue plasminogen activator (TPA) is debatable. Based on the hypothesis that smokers may have more effective thrombolysis with TPA. Some clinical studies have demonstrated a favorable outcome while others have seen worse prognosis or no effect at all. This study seeks to determine the association between smoking and functional improvement in TPA treated and non-treated patients. Methods We analyzed data from the Greenville Health System (GHS) stroke registry on stroke patients between January 2010 and December 2013. Patients were divided into two groups: those treated with TPA and those not treated with TPA but presenting within 4.5 hours. Logistic regression analysis was conducted to assess if smoking was associated with improvement in ambulation. Results Of 1,446 patients, 595 (41.15 %) were treated with TPA (181 smokers (30.42%), 414 non-smokers (69.58 %) and 851 (58.85%) not treated with TPA (198 smokers (23.27 %), 653 non-smokers (76.73 %). In the multiple logistic models, smoking was not independently associated with favorable outcome in patients treated with TPA (OR = 0.84; 95% CI = 0.54 – 1.33; P = 0.46) and those not treated with TPA (OR = 0.96; 95% CI = 0.64 – 1.44; P-value = 0.85) though the bivariate models showed significant association. Conclusion There is no association between smoking and functional outcome in stroke patients regardless of TPA treatment. The effect of smoking on outcome in acute ischemic stroke patients treated with tissue plasminogen activator (TPA) is however stronger than those not treated with TPA.

Stroke is a major health problem in Taiwan often causing disability and dependence for elderly persons. Family caregivers shoulder major caregiving tasks while caring for their stroke survivors at home. Despite the availability of home healthcare service for family caregivers, the quality of care outcomes remain poor. According to role acquisition theory, sufficient preparation before discharge is positively related to quality of care. Caregiver education is proposed as the way to increase quality of care outcomes, yet current educational programs in Taiwan have not incorporated three fundamental learning determinants: readiness to learn, learning needs, and learning styles. The purpose of this descriptive qualitative study was to describe the experiences of Taiwanese family caregivers learning to caregiver for a stroke survivor during the first year after discharge. Participants included 16 stroke survivors cared for by 17 family caregivers and 11 foreign care attendants during at-home and in-hospital phases. Data collection included three formal interviews and one care activity observation. While still in the hospital, family caregivers took on the caregiver role. They sought out resources to learn caregiving. They learned some care skills and stated that they felt ready to go home prior to discharge. Yet, once at-home, they immediately described a sense of uncertainty -not knowing what to do in new care situations. Fifteen challenges were identified. The most common ones were diet preparation, elimination problems, transportation, breathing and sputum problems, and rehabilitation resources. Three time periods were identified as the time for readiness to learn: before discharge, the first month after discharge, and when facing new care situations. All of the family caregivers were unprepared for the new care situations before discharge because of problematic preparation and fragmented health care services. Recommendations include further studies on the three learning determinants, development of an organized and systemic discharge planning protocol, and increased in-home nursing and rehabilitation services.

Background: Stroke affects 15 million people worldwide each year. The rehabilitation should be equal everywhere but that is not the case. Most evidence comes from research in high income countries and those circumstances may not be applied everywhere in the world.  Aim: The aim of this study was to investigate the views of important elements of rehabilitation after stroke in clinical working physiotherapist and in lecturers in physiotherapy education in Thailand. Design: This study had a qualitative exploratory research design due to collection of data through six individual semi-structured in-person interviews. The data analysis was preceded by a content analysis and had an inductive approach.  Result: The analysis terminated in eight categories and 30 subcategories that reflected what the interviewees considered important. Examples on these categories were physiotherapeutic modalities, education, cooperation and patients’ characteristics. It was of high importance the care was individualized and planned together with the patient. Education throughout the carrier were crucial to be able to give the patients the best care possible.   Conclusion: This study showed that physiotherapists in Thailand perceived many different important elements in stroke rehabilitation in Thailand. The outcome was not just depending on the treatment itself, but on several factors that surrounded the patient and the rehabilitation. These studies need to be done to be able to see the variations in treatment and the approach the health-care have on stroke rehabilitation in different countries. / Bakgrund: Stroke drabbar ungefär 15 miljoner människor världen över varje år. Alla ska ha samma chans till rehabilitering och lika vård vart man än bor i världen, detta är dock inte fallet. Mycket utav den evidens som finns idag är framtagen i höginkomstländer och situationen där kan inte appliceras globalt.  Syfte: Syftet med denna studie var att undersöka åsikter hos thailändska kliniskt arbetande fysioterapeuter och lärare inom fysioterapeutisk utbildning angående viktiga element vid rehabilitering efter stroke.  Design: Studien bestod av sex individuella semistrukturerade intervjuer och hade en kvalitativ explorativ forskningsdesign. Insamlad data analyserades genom innehållsanalys med en induktiv inriktning.  Resultat: I databearbetningen framtogs åtta kategorier och 30 subkategorier som speglade de intervjuobjekten ansåg var viktigt. Exempel på kategorier var fysioterapeutiska modaliteter, utbildning, samarbete samt patientens tillgångar. Det var av yttersta vikt att behandlingen var individualiserad och planerad tillsammans med patienten. Utbildning genom det yrkessamma livet var viktigt för att ge den bästa möjliga vården för patienten.  Konklusion: Studien visade att fysioterapeuter i Thailand anser att det finns många viktiga element inom strokerehabilitering. Utfallet på rehabiliteringen berodde inte endast på själva behandlingen utan även på en mängd andra faktorer som fanns i patientens omgivning samt inom rehabiliteringen. Fler studier inom ämnet behövs för att se hur synen på rehabilitering och vården samt hur själva rehabiliteringen skiljer sig mellan olika länder.

<p>Att drabbas av stroke innebär ofta kognitiva funktionsnedsättningar. Betydelsen av en snabb bedömning av strokepatienters kognitiva funktioner i det akuta skedet efter en stroke betonas i flera studier. Syftet med den här studien var att med hjälp av en enkätundersökning kartlägga de kognitiva bedömningar som genomförs av arbetsterapeuter på landets strokeenheter. Undersökningsgruppen utgjordes av arbetsterapeuter på 58 strokeenheter. Det insamlade materialet bearbetades med beskrivande statistik. Av resultatet framkom att de vanligast förekommande bedömningsinstrumenten/observationerna var MMT, RBMT, DBF samt AMPS. En kombination av bedömningar gjordes på de flesta strokeenheter, typvärdet var 4 bedömningar. Resultatet visade även att arbetsterapeuternas kunskap om bedömningarnas reliabilitet och validitet var god. Någon avgörande skillnad har inte observerats när det gäller valet av bedömning hos de olika strokeenheterna med hänsyn tagen till sjukhusets storlek eller antalet arbetsterapeuter som arbetar på strokeenheten. Vår slutsats är att strokepatienter som vårdas på de strokeenheter som ingår i den här undersökningen bedöms med bedömningsinstrument/observationer av arbetsterapeuter på ett likvärdigt sätt oavsett var i landet de vårdas.</p>

<p>I Sverige flyttar de flesta av oss till ett ”boende” när vi blir gamla och behöver mer hjälp och vård. Där spenderar man sedan sin sista tid i livet och ses inte alltid som en person med förmåga att utvecklas. FMT – Funktionsinriktad musikterapi, kan användas för att ge personer med olika funktionsnedsättningar förutsättningar för att utvecklas. I detta examensarbete beskriver jag mitt arbete med en person med demenssjukdom och en person som lever med sviterna efter en stor stroke. De har båda förlorat sin verbala förmåga och har även stora fysiska funktionsnedsättningar. Syftet är att undersöka hur FMT kan bidra till ökad livskvalitet för dessa personer. Jag har funnit att FMT-metoden kan bidra till ökad livskvalitet genom sin tydliga struktur, sin ickeverbala kravlöshet och betoning på det egna initiativet och den egna lusten.</p>