SAMMANFATTNING Bakgrund Stroke är den andra vanligaste dödsorsaken i världen och den största orsaken till funktionsnedsättningar. Studier visar på att fler överlever stroke men att förekomsten i de lägre åldrarna blir vanligare, vilket kan innebära att fler måste leva med konsekvenserna av en stroke under en längre tid. Syfte Belysa hur det dagliga livet hos personer i yrkesverksam ålder kan påverkas av en stroke. Metod Litteraturöversikt av sju kvalitativa och nio kvantitativa studier i totalt 16 vetenskapliga tidskriftsartiklar från databaserna PubMed och CINAHL. Resultat Föreliggande studie resulterade i följande teman: En förändrad livssituation, Faktorer som påverkar livskvaliteten, Att vara beroende av andra, Arbetet och fritidsaktiviteternas betydelse, Att hantera en ny livssituation. Slutsats Resultaten tyder på att främjandet av egenvård hos patienter som har haft en stroke bör ha en central del i omvårdnaden för att dessa i ett senare skede inte ska känna sig vara i beroendeställning av andra.

Proprioception, the often forgotten sixth sense, is frequently impaired following stroke, with rehabilitationists addressing this loss within the therapeutic techniques presented to resolve motor problems. The aims of the current studies were to (i) establish the current clinical reality of somatosensory assessment undertaken by physiotherapists nationwide, (ii) how proprioceptive loss in particular was addressed, (iii) explore upper limb weightbearing within everyday activity, (iv) evaluate the proprioceptive response in normal subjects having differences in age and activity. Proprioceptive loss following brain insult has been shown to have an adverse effect on outcome (iv) undertake a series of single case-studies to explore the effect of therapeutic intervention of weightbearing. The findings showed that (i) there was a high degree of agreement in the clinical practice of somatosensory assessment undertaken, (ii) therapeutic intervention of weightbearing was found to be recommended for both motor and proprioceptive loss (iii) upper limb weightbearing was found to be a non-trivial component of everyday life, (iv) positive effects of upper limb weightbearing were found on the proprioceptive responses of stroke victims. The implications of this research are that upper limb weightbearing activities should be incorporated in therapeutic activities to re-establish and maintain proprioceptive control of both upper and lower limbs.

Stroke has the ability to chronically alter both a person’s understanding and or use of language. Aphasia is a term that represents the loss or impairment of language function as a consequence of brain damage caused by a stroke and current data reveal that at least 25% of all strokes result in aphasia. Spouses often play a pivotal role in a stroke patient’s journey towards recovery. For this reason, there is a dire need for increased knowledge regarding spousal psychosocial welfare and increased insight into the experiences of these individual’s altered life situations. This paper considers aphasia, by nature of its deficits, a family disorder. Additionally, the contents of this paper explore the significance of caregiver coping strategies and ongoing caregiver involvement in recovery as a mechanism towards increased well being. Evidence to confirm the effects of stroke on spouses, as well as to support involvement of spouses in speech-language treatment to facilitate living well with aphasia, was obtained through primary and secondary research. Primary research was compiled through a telephone interview with the spouse of a 62-year-old male with aphasia while secondary research was conducted through an extensive literature search from 2000 to 2011. / text

Little is known about the effects of protein-energy malnutrition (PEM) developing after stroke on brain recovery. The goal of this project was to develop two experimental models in the adult rat to allow evaluation of nutritional effects on post-stroke recovery: (1) a PEM model, and (2) a photothrombotic stroke model. Experiment 1 examined the hypothesis that a diet containing either 1% or 0.5% protein will produce an acute state of mild-moderate PEM in adult rats. Male, Sprague-Dawley rats (16 wk) were trained in the Montoya staircase before being randomized to diets containing 0.5% (n=8), 1% (n=8), or 12.5% protein (n=10 [CON]) for 31d. Both low protein diets increased liver lipid content (p< 0.001) and decreased food intake (p= 0.005) and body weight (p< 0.001) compared to the 12.5% protein diet. The 0.5% protein group best mimicked the stroke patient, as judged by decreased serum albumin (p= 0.018) and an acute decrease in mean (±SEM) body weight (g) by d7 (0.5%= 424±15; 1%= 428±14; CON= 477±10; p = 0.011). Increased concentrations of the positive acute phase proteins, alpha-2-macroglobulin and alpha-1-acid glycoprotein, were greatest in the 0.5% group (p< 0.001). No differences were observed in the Montoya test on d3, 15, or 30 (p= 0.26). Values on d30 were: 0.5%= 109.5±4.4% of pre-diet performance; 1%= 97.2±5.5%; CON= 98.5±10.2%. Experiment 2 tested the hypothesis that targeted laser irradiation and 30 mg/kg of rose Bengal injection will cause an infarct in the forepaw region of the cortex with accompanying functional deficits. Male adult rats trained in the Montoya staircase were randomized to ISCHEMIA (n=15) or SHAM (n=3) surgery. A cortical infarct occurred in 86% of rats, with some misplacement and variability in volume (5.7-12.8 mm3). Forepaw impairments were confirmed by decreased performance in the staircase at d3 (34.3±7.3 % of pre-stroke performance, p<0.001) and diminished use in the cylinder test (30.3±4.0% affected limb use versus 53.9±1.93% prestroke, p< 0.001). At d30, mean recovery was incomplete in the staircase (p< 0.001). These experimental models, with additional refinements, can be used to address the hypothesis that deteriorating nutritional status after a stroke interferes with brain recovery.

Background/Objectives: Gaps in care due to the movement of patients between health settings and/or practitioners, known as transitions of care (TOC), may contribute to second stroke or TIA events. The elements that impact TOC in the stroke/TIA population have not been fully elucidated. The purpose of this study is to identify key elements of a Doctor of Nursing Practice-led TOC model that could be used to develop and evaluate a TOC program for the stroke/TIA population. Design: A descriptive study was performed to 1) identify elements that may affect transitions of care using a stroke database and post-discharge phone surveys and 2) based on information from Aim 1, propose a DNP-led TOC model specific to the stroke/TIA. Setting: An urban primary stroke center in the southwest United States. Participants: All patients in the GWTG®-stroke database from May 1 - December 31st, 2012 and patients who consented at discharge from the stroke unit following a stroke or TIA. Measurements: Patient demographics including: length of stay (LOS), age, race, ethnicity, comorbidities, insurance, discharge status, thirty-day readmission rate, and follow up survey. Results: Patient data (n=276) from GWTG®-stroke database was obtained. Average LOS was 7.81 +/- 11.15 days. The majority of patients were greater than age 65 (59%); 53% relied on Medicare support; those age 50-59 (21%) were most likely to be uninsured (47%). Fifty-one percent were discharged directly home, 48% of those were referred to outpatient rehab services. Two-thirds received rehabilitation services during hospitalization. Eight patients experienced a subsequent hospital readmission; two of those had a repeat stroke event. Although patients reported understanding their discharge instructions, their perception of ongoing care was poor. Conclusion: Key elements of a TOC model specific to the stroke and TIA patient population could include: patient surveillance, comprehensive care planning, follow-up, stroke education and point of contact. Advanced practice nurses have been successful in leading such programs, and a DNP-led model providing continuity of care would support the transition of an effective model into clinical practice.

Intro/Aims: Differences in end-of-life decision-making among minorities have been well described. However, among Native Hawaiian and Other Pacific Islanders (NHOPIs), this has not been well studied. Aim 1: Determine if differences in time to withdrawal of life support (WOLS) exist between NHOPIs and non-Hispanic whites (NHWs). Aim 2: If differences in time to WOLS between races are found, examine factors that may contribute to these differences. Methods: A retrospective study was conducted on patients admitted to a primary stroke center in Honolulu with diagnosis of spontaneous intracerebral hemorrhage (ICH). Medical records were reviewed for occurrence of WOLS and time of WOLS. Unadjusted and multivariable logistic regression models were performed to determine associations between race and WOLS. Kaplan Meier analysis and Cox regression were performed to estimate survival time to WOLS and to compare these results between racial groups. Results: 396 patients with diagnosis of spontaneous ICH were studied. Mean time to WOLS after ICH was found to be similar between NHWs and NHOPIs (p = .925). Prevalence of WOLS was significantly lower in NHOPIs in univariate analysis (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.15, 0.80) and Kaplan Meier analysis predicted a significant difference in WOLS between NHOPI and NHWs within 30 days of ICH (p =<. 01). However, in multivariate analysis, race was no longer significant when adjusted for age (OR 0.59, 95% CI 0.25, 1.43) and when fully adjusted (OR 0.68, 95% CI 0.20, 2.39). NHOPIs were significantly younger at the time of ICH when compared to NHWs (p =<.001) although ICH severity and presentation such as initial Glasgow Coma Scale, presence of intraventricular hemorrhage and ICH volume were similar (p = .241; p = .604; p = .901, respectively). Conclusions: No difference in mean time to WOLS was noted between NHOPIs and NHW. However, secondary analysis showed WOLS was less prevalent after ICH in the NHOPI population compared to NHWs, although the significance of this finding was attenuated by age. NHOPIs in this population likely had a lower incidence of WOLS due to the fact that they presented with ICH at a significantly younger age, although small sample size also may have resulted in difficulty detecting variances between races.

Bakgrund: Stroke är den vanligaste orsaken till funktionsnedsättning i Sverige och den diagnos som kräver flest vårddagar i hemmet. Antalet särskilda boende- och sjukhusplatser har minskat på grund av besparingsskäl, vilket har lett till att behov av vård i hemmet har ökat.  År 2000 vårdade cirka 83 000 personer sina anhöriga hemma. Anpassningen till den nya livssituationen är inte problemfri, varken för den drabbade eller för anhöriga som vårdare. Syfte: Syftet med studien var att belysa anhörigas upplevelser av att vårda strokedrabbade och deras upplevelser av stöd från sjukvården. Metod: Systematisk litteraturstudie av kvalitativa artiklar vilka analyserades med en kvalitativ innehållsanalys. Resultat: Anhöriga upplevde en förändrad livsvärld vid stroke. Stroke kom som en chock och de blev tvungna att anpassa sig genom att omstrukturera sina liv, förändra relationer, ta ökat ansvar, hitta strategier för att orka vårda och hämta kraft. Framtiden var oviss och beroende på hur sjukdomen utvecklades. Anhöriga upplevde bristande information och stöd från sjukvården. Slutsats: Anhöriga mår psykiskt dåligt och en effektivare hjälp från sjukvården var önskvärt. Anhöriga ville få information om en strokes fysiska/psykiska effekter, behandlingsalternativ och vilka rättigheter den sjuke och anhörige har. Stöd efterfrågas i form av avlastning och kontinuitet i vården.

Bakgrund: I Sverige drabbas varje år cirka 30 000 personer av stroke. En stroke innebär att en hjärninfarkt eller blödning uppstår i hjärnans blodkärl vilket leder till syrebrist. Många patienter som drabbats av stroke får sin rehabilitering och återhämtning i hemmet istället för på sjukhus. De uppger att behovet av stöd från sin partner är stor.Syfte: Studiens syfte var att beskriva partners upplevelser efter att den andra partnern drabbats av stroke.Metod: En litteraturstudie genomfördes med deskriptiv design. Systematiska sökningar har genomförts i databaserna Cinahl, Pubmed och Svemed+ som resulterade i tio vetenskapliga artiklar. Dataanalysen genomfördes med inspiration av innehållsanalys.Resultat: I resultatet framkom tre olika kategorier; Livsförändringar handlar om förändrad relation samt hinder och möjligheter i vardagen, Bristande stöd handlar om bristande socialt stöd och bristande stöd från hälso- och sjukvården och kategorin Känslomässiga reaktioner tar upp partners upplevelser av oro, rädsla, depressiva upplevelser, stress och undantryck av känslor.Slutsats: När en anhörig drabbats av stroke upplevde partners att livssituationen förändrades och känslor som oro, rädsla och stress präglade partners vardag. Partners upplevde att informationen var bristfällig, det var viktigt att sjukvården gav bra information. Möjligheten att besöka stödorganisationer var viktigt för partners.

The factors that influence gait velocity post-stroke are not clearly understood. This thesis sought to uncover the factors associated with gait velocity, particularly those related to maximum velocity. The first of two studies investigated the associations between physical factors and preferred and maximum gait velocity. Analysis revealed that individuals with stroke were able to increase gait velocity from preferred and that this increase, along with the achieved velocity, were related to functional balance. The second study characterized the strategy individuals used to increase gait velocity, and compared between the stroke and healthy population. It also probed the relationships between cadence, step length, strategy, and post-stroke impairment. This study demonstrated that individuals with stroke rely more on cadence than step length to increase gait velocity. These results revealed the role of balance control on limiting gait velocity and the need for specific measures of impairment in research to direct clinical practice.

The factors that influence gait velocity post-stroke are not clearly understood. This thesis sought to uncover the factors associated with gait velocity, particularly those related to maximum velocity. The first of two studies investigated the associations between physical factors and preferred and maximum gait velocity. Analysis revealed that individuals with stroke were able to increase gait velocity from preferred and that this increase, along with the achieved velocity, were related to functional balance. The second study characterized the strategy individuals used to increase gait velocity, and compared between the stroke and healthy population. It also probed the relationships between cadence, step length, strategy, and post-stroke impairment. This study demonstrated that individuals with stroke rely more on cadence than step length to increase gait velocity. These results revealed the role of balance control on limiting gait velocity and the need for specific measures of impairment in research to direct clinical practice.