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Sammanfattning Bakgrund Rehabilitering efter ett strokeinsjuknande ska påbörjas tidigt och vara målinriktad. För patienter som drabbats av mild till måttlig stroke rekommenderas i Socialstyrelsens riktlinjer vård på strokeenhet i kombination med tidig understödd utskrivning. Uppsatsen beskriver, analyserar och utvärderar ett förbättringsarbete där tidig understödd utskrivning med stöd av ett stroketeam prövades som arbetsmodell på en strokeenhet. Syfte Syftet med förbättringsarbetet var att patienterna skulle uppleva ett tryggt omhändertagande i samband med utskrivningen, samtidigt som strokeprocessen effektiviserades genom kortare vårdtid på sjukhus. Syftet med studien var att beskriva erfarenheter hos patienter, närstående och personal vid införandet av tidig understödd utskrivning från sjukhus med stöd av ett stroketeam för patienter med mild till måttlig stroke. Metod Förbättringsarbetet utvärderades genom mätning av vårdtider och mätning av patienternas upplevelse av trygghet i samband med utskrivningen. I studien av förbättringsarbetet insamlades data genom semistrukturerade intervjuer med patienter och deras närstående, samt i en fokusgruppsintervju med involverad personal. Nio patienter och sex närstående intervjuades. Vid fokusgruppsintervjun deltog två arbetsterapeuter, två sjukgymnaster och en sjuksköterska. Intervjuerna analyserades med kvalitativ innehållsanalys. Resultat Arbetssättet med tidig understödd utskrivning testades på tio patienter. Vårdtiden var något kortare, men osäkerhet finns i mätningarna och i den kvalitativa analysen framkom tveksamhet om vårdtiderna påverkades. Upplevelsen av trygghet i samband med hemgång var något högre bland deltagarna i projektet jämfört med baslinjemätningen. Vid intervjuerna med patienter framkom värdet av att erhålla rehabilitering i sin hemmiljö. Både patienter och närstående beskrev att teamet bidrog med kunskaper om stroke, rehabilitering och säkerhetsaspekter i hemmet, samt att kontinuiteten med samma personal var värdefull. Närstående beskrev också att de fått stöd av teamet i närståenderollen. Personalen framhöll vid fokusgruppsintervjun förbättrad kvalitet för patienterna, tidsbrist och svårigheter med prioriteringar samt en arbetstillfredställelse i nöjda patienter och att arbeta med förbättringar. Slutsats Tidig understödd hemgång med stöd av ett stroketeam upplevdes positivt av patienter, närstående och personal. Arbetssättet var engagerande men tidskrävande. Förhoppningen är att lärdomarna från detta projekt kan bidra till fortsatt utveckling av rehabiliteringsprocessen i samband med utskrivning.

Eine Vielzahl von Studien konnte den nützlichen Effekt einer Knochenmarkzelltherapie nach Schlaganfall an Ratten nachweisen. Diese Ergebnisse ließen sich jedoch in klinischen Studien nicht reproduzieren. Eine mögliche Ursache können die Unterschiede zwischen den eingesetzten Versuchstieren und Zellspendern sowie den Patienten im klinischen Bereich sein. Während die eingesetzten Tiere und Spender meist jung und gesund waren, ist der typische Schlaganfallpatient in der Regel älter und leidet an einer Vielzahl von Begleiterkrankungen. Ziel dieser Studie war es, die Auswirkungen von erhöhtem Alter und Begleiterkrankungen auf die Effektivität einer Knochenmarkzelltherapie des Schlaganfalles zu untersuchen. Zu diesem Zwecke wurde die Arteria cerebri media von 18 Monate alten spontan-hypertensiven Ratten operativ verschlossen. Nach 24 Stunden wurden entweder Zellen eines jungen oder eines alten Spender transplantiert. Tiere, die eine äquivalente Menge an PBS erhielten, dienten als Kontrolle. Im Anschluss wurden das neurofunktionelle Defizit und das Infarktvolumen über einen Zeitraum von 63 Tagen mittels verschiedener Verhaltenstest und magnetresonanztomographischer Bildgebung analysiert. Nach Induktion des Schlaganfalls kam es zu einer Abnahme der funktionellen Leistung in allen Verhaltensversuchen, die sich jedoch bis zu Tag 27 wieder erholte. Im MRT war im gleichen Zeitraum eine Reduktion des Infarktvolumens zu beobachten. In der zweiten Versuchshälfte kam es anschließend zu keinen weiteren Veränderungen, weder funktional noch morphologisch. Ein Einfluss der Therapie auf die Regeneration oder die Größe des Infarkts, war zu keinem Zeitpunkt feststellbar. Anhand dieser Ergebnisse muss in Frage gestellt werden, ob gealterte und komorbide Tiere durch einer Zelltherapie nach Schlaganfall profitieren können und ob sich Zellen älterer Spender als Therapeutikum für einer Knochenmarkzelltherapie des Schlaganfalls eignen.

Purpose: The purpose of this research program was three-fold. First it aimed to determine the effectiveness of smoking cessation interventions in increasing cessation rates in smokers with cerebrovascular disease and whether smoking cessation reduces stroke recurrence. Second it aimed to determine the prognostic influence of smoking and its association with stroke severity, disability, length of stay in hospital and mortality. Third it aimed to identify multi-level correlates of smoking cessation in Canadians who reported stroke symptoms in a large population based survey. Methods: Two systematic reviews and meta-analyses were performed to achieve the first objective. For the second objective, a retrospective cohort study was undertaken using variables from the Registry of the Canadian Stroke Network. Finally, the third objective was achieved by analyzing respondents from the Canadian Community Health Survey. Results: There is a paucity of intervention studies examining the effectiveness of smoking cessation in smokers with cerebrovascular disease. Most intervention studies that were found, failed to employ evidence-based approaches to smoking cessation. No evidence was found in regards to the effect of smoking cessation on stroke recurrence. We found smokers had strokes at a younger age compared to non-smokers. We found that in transient ischemic attacks and intracerbral haemorrhage, smoking was a significant predictor of stroke severity, disability, length of stay in hospital and 1 year mortality. Correlates of smoking cessation among Canadians who have experienced symptoms of a stroke included: higher education and income, implementation of household and vehicle smoking restrictions, access to a general practitioner and the use of smoking cessation pharmacotherapies and counselling support. Co-morbidities such as depression and alcohol consumption reduced the likelihood of successful cessation. Conclusions: This three-phase research program elucidated the gaps in intervention research for this population along with co-morbidities that hinder success in cessation. Smoking negatively impacted outcomes such as disability, hospital length of stay and mortality in patients with transient ischemic attacks and intracerebral haemorrhage strokes. Future interventions should take into account modifiable smoking cessation correlates in order to increase cessation rates in smokers with cerebrovascular disease.

Physiotherapy for people with stroke has been found to be beneficial but details of the most effective interventions are unclear. Further development of the evidence base for stroke physiotherapy is limited by a lack of clinical practice models, sensitive clinically based outcome measures and effective stratification techniques to characterise homogenous groups of subjects. These issues are addressed here with regard to balance and posture. These aspects were chosen because they form a cornerstone of stroke physiotherapy as they are thought essential for the rehabilitation of functional activities. A systematic review of assessment methods in the literature revealed a lack of measurement tools which met the utility criteria: reliability, validity, sensitivity to short-term change, suitability for a wide range of abilities, ease of use and suitability for different settings. This prompted the development of a new measurement tool. Firstly, a model of the clinical assessment process was developed using an adapted focus group method with neurological physiotherapists. This informed the content of a new measurement tool which combined an ordinal scale with functional performance tests- the Brunel Balance Assessment. The tool was evaluated in a series of studies involving 92 stroke patients. It was hierarchical (coefficient of reproducibility= 0.99, coefficient of scalability = 0.69), reliable (100% agreement) and valid as a measure of balance disability (r=0.58-0.97). The psychometric properties of the individual functional performance tests were also tested and found to be reliable (ICCs =0.88-1) and valid (r=0.32-0.63). Measurement error ranged 0-40% and the minimum change needed to detect true clinical change was calculated for each test. Balance disability, measured with the Brunel Balance Assessment, is heterogeneous with sitting, standing and stepping balance forming distinct levels of ability (p<0.027). Consequently, the BBA could be used to stratify people with stroke according to balance ability. Weakness, sensation and age were significant independent contributors to balance disability (r2=82.7%). Balance ability was a strong contributor to independence in ADL (p<0.0001). The findings of this thesis address the issues that have limited research into stroke physiotherapy with regard to balance disability. In relation to clinical practice, a robust measurement and stratification tool has been developed.

Šio darbo tikslas: Įvertinti proaktyvios ir reaktyvios strategijų taikymo įtaką pusiausvyrai ir eisenos greičiui pacientams, patyrusiems galvos smegenų insultą. Tikslui pasiekti išsikelti uždaviniai: 1. Įvertinti pusiausvyrą ir eisenos greitį proaktyvios strategijos lavinimo grupės pacientams reabilitacijos pradžioje ir pabaigoje. 2. Įvertinti pusiausvyrą ir eisenos greitį reaktyvios strategijos lavinimo grupės pacientams reabilitacijos pradžioje ir pabaigoje. 3. Palyginti pusiausvyros ir eisenos greičio kaitą tarp grupių reabilitacijos metu. 4. Įvertinti pusiausvyros ir eisenos greičio sąsajas pacientams, patyrusiems galvos smegenų insultą. Metodika: tyrime dalyvavo 32 pacientai patyrę galvos smegenų insultą. Tiriamieji atsitiktine tvarka buvo suskirstyti į tiriamąją ir kontrolinę grupes. Tiriamųjų amžius svyruoja nuo 60 iki 70 metų. Tyrimas atliktas Kauno klinikinės ligoninės FMR skyriuje. Visiems pacientams kiekvieną dieną buvo atlikti du kineziterapijos užsiėmimai. Vieno užsiėmimo metu su visais pacientais dirbama pagal reaktyvią strategiją, o kitas užsiėmimas buvo orientuotas į eisenos ir pusiausvyros gerinimą; su kontroline grupe šio užsiėmimo metu dirbama taikant reaktyvią, o tiriamąja grupe – proaktyvią lavinimo strategiją. Visi tiriamieji prieš ir po reabilitacijos buvo įvertinti „Stotis ir eiti“ testu, pusiausvyros mėginiais pagal Schmitz ir Berg pusiausvyros skale. Apibendrinus rezultatus pateikiamos išvados: 1. Proaktyvi lavinimo strategija pacientams... [toliau žr. visą tekstą] / The aim of this work: to evaluate influence of proactive and reactive strategies towards balance and walking speed of the patients who suffered from the stroke. The tasks of the work: 1. to evaluate balance and walking speed of the patients in the group of proactive strategy at the beginning of rehabilitation and at the end. 2. to evaluate balance and walking speed of the patients in the group of reactive strategy at the beginning of rehabilitation and at the end. 3. to compare the change of balance and walking speed between groups during the rehabilitation. 4. to evaluate the links between balance and walking speed of the patients who suffered from stroke. Methodology: 32 patients who suffered from the stroke took part in the research. They were divided into analyzed and control groups in random order. The age of the patients is from 60 to 70 years. The research was carried out in FMR department Kaunas Clinical hospital. All patients had two physiotherapy periods every day. During one period they have been working according to reactive strategy. The other period was oriented towards the improvement of balance and walking. During the second period patients of control group have been working according to reactive strategy and patients of analyzed group have been working according to proactive strategy. All patients before and after the rehabilitation were evaluated according to “Stand and go” test and balance samples of Schmitz and Berg balance scale. Conclusions: 1... [to full text]

Walking is an essential task important to recovery after stroke. However, there is a limited understanding regarding the characteristics of walking in in-patients with stroke. The objectives of this thesis were to: 1) develop an instrument capable of acquiring temporal characteristics of everyday walking; 2) investigate the quantity and control of everyday walking; and 3) profile the task-specific link between walking and cardiorespiratory response. In study 1 we developed and validated a wireless monitoring system (ABLE system). Study 2 revealed low quantities of everyday walking (4816 steps; SD 3247) characterized by short bout durations (59.8s; SD 23.4) and asymmetric walking. In study 3 we observed a modest task-related response in HR(19.4% HRR); however, the intensity and duration of everyday walking did not approach the guidelines for aerobic benefit. Monitoring in-patient walking can help guide clinical decision making in developing methods to maximize recovery after stroke.

Functional recovery of the upper limb after stroke is influenced by many factors, one being amount of affected arm and hand use following stroke. In the healthy population, amount of hand use is influenced by degree of hand dominance. Depending on side of stroke and previous hand dominance, these preferences may be altered, consequently affecting the amount of upper limb use. Determining hand preference in patients after stroke, when measured, is commonly assessed with questionnaires; however, these reports are subjective and patients may have difficulty recalling from memory which hand they use for the numerous activities on the questionnaire. A preferential reaching task has been shown to correlate with the degree of hand dominance as determined by the Waterloo Handedness Questionnaire, providing an objective performance-based method to assess the continuum of hand dominance in healthy subjects. A modified version of this preferential reaching task, with varying degrees of proximal to distal control, was used to investigate the influence of impairment, pre-stroke dominance and task difficulty on affected arm reach percentage. Results of the study revealed that it is feasible to administer a modified preferential reaching task in the stroke population, as the test could be completed in less than 10 minutes with no adverse effects reported from the patients. Heterogeneity made it difficult to detect statistical effects of task difficulty and pre-stroke dominance on post-stroke preference; however, there were trends observed indicating that patients with their dominant arm affected may have greater preference for the affected arm compared to those with their non-dominant arm affected. This was despite similar impairment levels between these patient groups. Preference for the dominant arm (whether affected or unaffected) was stronger when the task was at midline or in contralateral space, and when tasks required the greatest degree of distal control. In future, the degree of hand preference measured with this tool will have important implications for identifying areas in therapy requiring greater focus as well as identifying individuals who would most benefit from therapies that promote affected arm use, such as constraint induced movement therapy

Thesis (M.S.)--University of Hawaii at Manoa, 2005. / Includes bibliographical references (leaves 48-49). / vi, 49 leaves, bound ill. 29 cm

Bakgrund: När en person drabbats av stroke är det i många fall även närstående som påverkas och måste anpassa sig till den nya situationen. Syfte: Syftet var att beskriva negativa respektive positiva upplevelser av att vara anhörigvårdare till en person som drabbats av stroke. Metod: Litteraturöversikt med granskning av 15 kvalitativa studier publicerade mellan åren 2006-2012. Resultat: Utifrån anhörigvårdarnas upplevelser av vårdarbetet framkom tio teman. Huvudresultatet var att de upplevde vårdarbetet som betungande, utmattande, bekymrande med brist på egentid och avlastning. De upplevde också brist på stöd från familj, vänner, samhälle och sjukvård. Anhörigvårdarna upplevde sig utlämnade och oförberedda i sin nya roll som vårdare och ansåg sig inte ha fått tillräcklig undervisning i vad rollen skulle innebära och vad de kunde förvänta sig. De positiva upplevelserna var att relationerna stärktes inom familjerna och anhörigvårdarna lärde sig att uppskatta saker som de tidigare tog för givet. De beskrev även att de använde olika copingstrategier för att hantera den nya situationen. Slutsats: Vårdpersonal måste bli bättre på att stödja anhörigvårdarna i sin svåra situation och i ett tidigt stadium ge anpassad och koordinerad information så att de känner sig trygga och kan få den hjälp de behöver.