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Stroke is the principal cause of long-term disability. Hemiplegia affects up to 80% of people with stroke and a significant number will not recover use of the affected arm. People with profoundly-affected arm may experience pain, stiffness and difficulty with care activities. We cannot currently predict who is most at risk of these difficulties, and historically interventions have been designed without understanding the temporal evolution of impairment or disability. The International Classification of Functioning, Disability and Health (WHO, 2001) was used to develop a model of the consequences of the profoundly-affected arm on impairment, disability, and participation. A systematic review of thirty observational studies was undertaken and identified potential predictors of increased impairment in general populations of people with stroke. However, there was a paucity of evidence directed at people with profoundly-affected arm or regarding impact on passive care. The aim of this study was to test the feasibility of using an observational study design to develop a longitudinal profile of the profoundly-affected arm. Specific objectives of the feasibility study were to assess the processes of recruitment and follow-up, to review the sample characteristics, and to establish the acceptability and responsiveness of the predictor variables and outcome measures. Key tenets of the project were to involve people with cognitive and communication disability, and to use assessments that could be adopted by therapists working in a patient’s own home. Forty people with stroke and nine carers were recruited and followed up at three and six months post-stroke. Using enhanced communication techniques and personal consultees, it was possible to include people with severe cognitive and communication disability. The baseline demographic characteristics and the rate of loss to follow-up of participants reflect that expected in people more severely affected by stroke. Qualitative data suggest that participants affirmed the model of impairments and disabilities that had been developed. The predictor variables and outcome measures were considered acceptable to participants, and collected a range of data, generally performing in the manner expected. However, there were a number of exceptions. Cognitive and communication disability impacted on completion of the self-reported assessments, and may have affected performance on measures of mood and sensation/perception. In addition to this, measures of range of movement varied at each time point, in a manner not in accordance with expected change over time. The evidence from this thesis suggests the research design has potential to be used to develop a longitudinal profile of the profoundly-affected arm. Further work is required to improve carer recruitment, establish the best assessments for those with severest cognitive and communication disability, and review the method of measuring range of movement.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2015 / Introduction: In South Africa the prevalence of patients with stroke that need help with at least one activity of daily living is equal to that of high income countries. Care of persons with stroke is essential, as stroke can lead to neurological deficits which in turn lead to functional impairments. Functional recovery for a patient, who has suffered a stroke, begins with rehabilitation. It has been found that supervised rehabilitation in an institution or at home improves the patient’s quality of life and fitness. It may not be feasible however, for the physiotherapist to supervise all rehabilitation, especially in a home-environment. Therefore adherence to exercise programmes is important. Adherence to exercise programmes allows for a potential saving in treatment costs, may avoid morbidity and unwanted side effects. The mode of exercise prescription may affect adherence to a home exercise programme. There are studies that show that the use of verbal prescription with an added brochure (a written and pictorial home-exercise programme) improves adherence rates. However none of these studies have been conducted in patients with stroke. Aim: The aim of this study was to determine the effect of a written and pictorial home exercise prescription on adherence with a home-exercise programme in patients with stroke at the Chris Hani Baragwanath Academic Hospital (CHBAH). Method: A randomised controlled trial with a blind assessor. Ethical clearance was applied for at the University of the Witwatersrand and permission to conduct the study was also obtained from CHBAH physiotherapy department and the superintendent before the commencement of the research project. Written informed consent was obtained from the patient and the caregiver before being included into the study. Participant’s anonymity was kept. All participants’ and their caregivers’ demographic data was captured on the initial assessment. The control group received a verbal home-exercise programme only and the experimental group received a verbal home-exercise programme with written and pictorial instructions for the exercises. An exercise logbook was completed by the participant’s caregivers to monitor adherence for each group. The Modified Rivermead Mobility Index (MRMI) and Barthel Index (BI) were used to establish mobility and activities of daily living functional ability of the patients. The significance of the study was set at 0.05. Between group comparison for the categorical data was carried out using the Chi square test. The Wilcoxon sign rank test was used for the between group comparison for the continuous data, the non-parametric data from the functional outcome measures as well as the adherence rates. Lastly the Spearman’s rank correlation co-efficient was conducted to assess if there is a relationship between the level of adherence and functional outcome in patients with stroke. Results: The average age of the participants was 60.8 (SD: 15.5) years. The gender distribution of the study population was 52% male and 48% female. Majority (76%) of the caregivers were females. Majority of the study population was living with a stroke for one to three months. The average length of stay in hospital was 14.5 (SD: 8.3) days. Of the study population 64% received in-patient physiotherapy. There was no significant difference between the intervention and control group for functional change and adherence: MRMI (p = 0.4), BI (p = 0.65) and adherence (p = 0.53). In the intervention group there was a greater increase in the MRMI score compared to the control group. But for the BI score the increase was greater in the control group. The relationship between functional ability (MRMI and BI) and the level of adherence for both the control and intervention group was generally not statistically significant. However, there was a weak relationship (p = 0.05, r = 0.44) for the intervention group for adherence and BI scores. Conclusion: The adherence rates were similar for the two groups despite the intervention that was administered. Both groups benefitted from the exercise therapy despite the mode of exercise prescription. Therefore there is no need to change the clinical practice at CHBAH regarding mode of home exercise prescription. Instead focus needs to be placed on interventions that can improve adherence to home exercise programmes e.g. the implementation of a monitoring system such as an exercise logbook.

Within rehabilitation research recovery from a stroke has been defined by health professionals as the improvement in the physical ability and task-related skills of an individual. The negative psychological consequences of a stroke for both individuals and their families have been recognised for several years, but are poorly understood. Within this thesis an alternative approach has been used to explore psychological consequences following a stroke. The focus of study has been the change in identity of individuals and their spouses, rather than the ability of an individual to carry out tasks. Ten consecutive couples were included following one partner's admission to hospital following a stroke. Separate narrative life history interviews were carried out with the stroke respondent and their spouse in hospital, and at six months and at one year after hospital discharge. Data collection and analysis was based on an interpretative phenomenological approach. A second concurrent study was carried out including 38 stroke respondents who were admitted to hospital following a stroke. While in hospital they were asked to complete a questionnaire including indices of physical ability, task-orientated ability, mood and self-concept. The questionnaire was administered again at six months and one year following discharge. Multivariate statistical procedures were carried out to describe the associations between the variables assessed. All respondents reported that they had experienced a fundamental change in their lives. They continued to report this fundamental change up to the final interview at one year, apart from one couple, where the stroke partner had made a complete physical recovery. The issue which appeared to dominate the stroke respondent's first year post-stroke was a split between their body and their physical and social self They could not maintain their prior identity within the capabilities of their new body. The spouses reported that they became totally responsible for not only their own lives but also the life of their partner. The issues of body-self split and total responsibility appeared to be hidden from others,making the situation of the respondents more challenging. Younger spouses reported more difficulty than older spouses in integrating the stroke into their life situation. Issues facing the respondents also varied depending on their own life histories and life goals. Within the quantitative analysis the mood of the stroke respondents was not highly correlated with physical ability or task-oriented improvement. Perceived difference between past and present self-concept was correlated to anxiety and depression at all assessment times even when the other indictors were taken into account. Exploration of identity change appears to be a useful framework for exploring the psychological consequences of a stroke.

Introduction: The number of stroke survivors living with post-stroke deficits is increasing worldwide. Although stroke rehabilitation can improve these deficits and promote the recovery of function when initiated early post-stroke, many survivors are not able to access rehabilitation because of a lack of resources. Early mobile tablet-based stroke rehabilitation may be a feasible means of improving access to recovery promoting therapies. Objective: To summarize and advance the knowledge of early mobile tablet-based therapies (MTBTs) for stroke survivors with regards to feasibility and barriers to care. Methods: This thesis is comprised of two major studies. (1) A scoping review summarizing the literature for MTBTs following stroke. (2) A cohort study testing the feasibility of a MTBT for post-stroke communication, cognitive, and fine-motor deficits. Results: (1) Twenty-three studies of MTBTs following stroke were identified. Most of these therapies targeted communication or fine-motor deficits, and involved patients in the chronic stages of stroke. Barriers to care were summarized. (2) A 48% recruitment rate was achieved and therapy was administered a median of four days post-stroke. However, therapy adherence was very low because of frequently encountered barriers to care. Conclusions: Stroke survivors are interested in using tablet technology to assist with their post-stroke recovery. However, early MTBT post-stroke may be challenging for some survivors because of encountered barriers to care. Regular patient-therapist communication using a convenient method of interaction appears necessary to minimize barriers and to help patients overcome barriers when they occur.

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.

Sze Kai-hoi, Frank. / "February 2002." / Thesis (M.D.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (p. 280-301). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest Information and Learning Company, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web.

The majority of people with stroke regard walking in their community as very important (Lord et al 2004). Walking in the community is limited by slow walking speeds and poor walking capacity (Lord et al 2004; Patterson et al 2007). Slow walking speeds and poor walking capacity are identified sequela in people with stroke (Hill et al 1997). By the end of rehabilitation approximately 80% of people with stroke achieve independent walking (Dean & Mackay 1992; Hill et al 1997). However, less than 10 percent are able to easily walk in their community (Hill et al 1997). Optimal motor learning requires task-specific practice (Carr & Shepherd 2003). Treadmills offer the opportunity for repetitive practice of complete gait cycles (Shepherd & Carr 1999), potentially providing greater intensity and longer duration walking practice than usual physiotherapy rehabilitation. Recently there has been some suggestion that high-intensity interventions may improve walking in people with stroke (Moseley et al 2005). Low levels of cardiorespiratory fitness in people with stroke have been shown to impact on walking, in particular walking capacity (Kelly et al 2003). Treadmills, commonly used to retrain cardiorespiratory fitness in the healthy population, have been used to implement high-intensity interventions, improving cardiorespiratory fitness in people with chronic stroke (Macko et al 2005). Therefore it is possible that exercise aimed at improving cardiorespiratory fitness may improve walking in people with stroke. The aim of these four studies was to investigate in those following stroke if walking on a treadmill at high-intensity during inpatient rehabilitation could improve walking capacity without compromising pattern and quality. The first study determined, in an Australian setting, the duration and intensity of usual physiotherapy rehabilitation. Study 2 compared walking pattern immediately following overground and treadmill walking practice at the same intensity. Study 3 examined the effect of treadmill walking at intensities high enough to influence cardiorespiratory fitness on walking pattern and quality. The final study, investigated the feasibility of implementing a high-intensity treadmill intervention in addition to usual physiotherapy rehabilitation in people following stroke able to walk undergoing inpatient rehabilitation. Intensity in all studies was calculated using heart rate reserve or the Karvonen method. Heart rate is a valid, accurate and stable indicator of exercise intensity due to its relatively linear relationship with oxygen consumption (ACSM 2006). For those people taking beta-blocker medication, the heart rate-lowering effect of this type of medication was accommodated. A target intensity of 40% heart rate reserve was used; as this is the minimum required improve cardiorespiratory fitness (ACSM 2006). Walking pattern and quality were measured in Studies 2-4. Walking pattern was measured by linear kinematics using GAITRite (CIR Systems, Clifton, NJ, USA) and angular kinematics using a 2-dimensional webcam application. Walking quality was determined by observation of the webcam footage and scored using the Rivermead Visual Gait Assessment, Wisconsin Gait Scale and a vertical visual analogue scale by blinded assessor. The first study found that people with stroke spent an average of 21 (SD 11) minutes participating in standing and walking activities that are associated with reaching the target intensity during physiotherapy rehabilitation. Those who could walk spent longer in these activities (25 minutes, SD 12) compared to those would couldn’t walk (17 minutes, SD 9). However, the intensity of these activities was low; walkers reached a maximum of 30% heart rate reserve and non-walkers reached 35% heart rate reserve. Using the treadmill as a mode of task-specific physiotherapy rehabilitation, the second study in this thesis found that walking pattern was similar following 10 minutes of treadmill and overground walking practice at the same intensity. The third study found that during walking on the treadmill at intensities high enough to influence cardiorespiratory fitness (up to 60% heart rate reserve), many of the linear and angular kinematic parameters moved closer to a more normal pattern and walking quality was not compromised. The final study in this thesis, a randomised controlled trial, found that a 6-week high-intensity treadmill walking intervention was feasible in people with stroke able to walk who were undergoing rehabilitation. Participants attended 89% of the treadmill sessions, reaching an average duration of more than 20 minutes and an intensity of 40% heart rate reserve after two weeks. The intervention also appeared effective with significant improvements in walking speed and capacity following the treadmill walking intervention. Improvements in walking speed were maintained at 3 months. In summary, these studies found that usual physiotherapy in people with stroke was of low intensity. In addition, it was found that treadmill walking was safe and feasible as a means of increasing the intensity of physiotherapy rehabilitation, without compromising walking quality and pattern. Therefore, it may be possible to improve walking in people with stroke using high-intensity treadmill walking.

The majority of people with stroke regard walking in their community as very important (Lord et al 2004). Walking in the community is limited by slow walking speeds and poor walking capacity (Lord et al 2004; Patterson et al 2007). Slow walking speeds and poor walking capacity are identified sequela in people with stroke (Hill et al 1997). By the end of rehabilitation approximately 80% of people with stroke achieve independent walking (Dean & Mackay 1992; Hill et al 1997). However, less than 10 percent are able to easily walk in their community (Hill et al 1997). Optimal motor learning requires task-specific practice (Carr & Shepherd 2003). Treadmills offer the opportunity for repetitive practice of complete gait cycles (Shepherd & Carr 1999), potentially providing greater intensity and longer duration walking practice than usual physiotherapy rehabilitation. Recently there has been some suggestion that high-intensity interventions may improve walking in people with stroke (Moseley et al 2005). Low levels of cardiorespiratory fitness in people with stroke have been shown to impact on walking, in particular walking capacity (Kelly et al 2003). Treadmills, commonly used to retrain cardiorespiratory fitness in the healthy population, have been used to implement high-intensity interventions, improving cardiorespiratory fitness in people with chronic stroke (Macko et al 2005). Therefore it is possible that exercise aimed at improving cardiorespiratory fitness may improve walking in people with stroke. The aim of these four studies was to investigate in those following stroke if walking on a treadmill at high-intensity during inpatient rehabilitation could improve walking capacity without compromising pattern and quality. The first study determined, in an Australian setting, the duration and intensity of usual physiotherapy rehabilitation. Study 2 compared walking pattern immediately following overground and treadmill walking practice at the same intensity. Study 3 examined the effect of treadmill walking at intensities high enough to influence cardiorespiratory fitness on walking pattern and quality. The final study, investigated the feasibility of implementing a high-intensity treadmill intervention in addition to usual physiotherapy rehabilitation in people following stroke able to walk undergoing inpatient rehabilitation. Intensity in all studies was calculated using heart rate reserve or the Karvonen method. Heart rate is a valid, accurate and stable indicator of exercise intensity due to its relatively linear relationship with oxygen consumption (ACSM 2006). For those people taking beta-blocker medication, the heart rate-lowering effect of this type of medication was accommodated. A target intensity of 40% heart rate reserve was used; as this is the minimum required improve cardiorespiratory fitness (ACSM 2006). Walking pattern and quality were measured in Studies 2-4. Walking pattern was measured by linear kinematics using GAITRite (CIR Systems, Clifton, NJ, USA) and angular kinematics using a 2-dimensional webcam application. Walking quality was determined by observation of the webcam footage and scored using the Rivermead Visual Gait Assessment, Wisconsin Gait Scale and a vertical visual analogue scale by blinded assessor. The first study found that people with stroke spent an average of 21 (SD 11) minutes participating in standing and walking activities that are associated with reaching the target intensity during physiotherapy rehabilitation. Those who could walk spent longer in these activities (25 minutes, SD 12) compared to those would couldn’t walk (17 minutes, SD 9). However, the intensity of these activities was low; walkers reached a maximum of 30% heart rate reserve and non-walkers reached 35% heart rate reserve. Using the treadmill as a mode of task-specific physiotherapy rehabilitation, the second study in this thesis found that walking pattern was similar following 10 minutes of treadmill and overground walking practice at the same intensity. The third study found that during walking on the treadmill at intensities high enough to influence cardiorespiratory fitness (up to 60% heart rate reserve), many of the linear and angular kinematic parameters moved closer to a more normal pattern and walking quality was not compromised. The final study in this thesis, a randomised controlled trial, found that a 6-week high-intensity treadmill walking intervention was feasible in people with stroke able to walk who were undergoing rehabilitation. Participants attended 89% of the treadmill sessions, reaching an average duration of more than 20 minutes and an intensity of 40% heart rate reserve after two weeks. The intervention also appeared effective with significant improvements in walking speed and capacity following the treadmill walking intervention. Improvements in walking speed were maintained at 3 months. In summary, these studies found that usual physiotherapy in people with stroke was of low intensity. In addition, it was found that treadmill walking was safe and feasible as a means of increasing the intensity of physiotherapy rehabilitation, without compromising walking quality and pattern. Therefore, it may be possible to improve walking in people with stroke using high-intensity treadmill walking.