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.

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.

Research has shown that skeletal muscle, despite showing a high degree of specialisation, has a remarkable ability to modif,' its properties. Understanding these changes is important for optimal response to therapeutic intervention. These studies investigated alterations in neuromuscular performance of quadriceps femoris muscle in normal subjects, before investigating changes in muscle and neural mechanisms in the first six months following stroke. Muscle ftinction studies were conducted to monitor the effects of selected patterns of long term electrical stimulation (P1 - uniform 8 Hz, P2 - mixed frequency, and P3 random high and low frequency) on quadriceps femoris of2l healthy subjects. Stimulated muscles showed significant increases in strength, fatigue resistance and relaxation times after 3 weeks and in force-frequency output after 6 weeks. Significant changes were observed in the stimulated muscles in Groups P2 and P3 indicating that a mixed or random pattern of activation induced greater changes than a uniform 8 Hz pattern. These studies together with soleus H reflexes were used to study concurrent changes in quadriceps femoris and Ta spinal reflex pathways of stroke patients and age-matched controls (n=1O). One month following stroke, both paretic and non-paretic muscles were more fatiguable and weaker than the muscles of controls and disynaptic and presynaptic inhibition were reduced in the paretic limbs. In subsequent months, the paretic muscles regained strength and inhibitory effects were restored. Subjective analysis suggested that different patterns of recovery related to walking ability at six months. In patients taking less than 15s to walk lOm (Group 1 n=5), the paretic muscles became significantly stronger and less fatiguable over time whereas the muscles of patients who took longer to walk lOm (Group 2 n=5) remained weaker and more fatiguable. Reciprocal inhibition was regained by 1 month in Group 1 and by 6 months in Group 2. These findings provide insight into long-term recovery and rationale for therapeutic intervention following stroke.

Thesis (M.S.)--Boston University

The assessment of rehabilitation effectiveness in the post-stroke hemiparetic population has primarily focused on walking speed. Walking speed, however, may be improved through a number of mechanisms; increased speed can be achieved through a combination of increased propulsion (propelling the center of mass forward) and swing initiation (resulting in longer and faster steps) in either the paretic or nonparetic leg. Therefore the objective of this study was to use a detailed musculoskeletal model and forward dynamics simulations to identify the individual muscle contributions to forward propulsion and swing initiation following locomotor training in two post-stroke hemiparetic patients who had similar speed increases following training, one utilizing an “ankle strategy” (increases in ankle power generation to accelerate the trunk forward) and one a “hip strategy” (increases in hip flexor generation of the swing leg to accelerate the leg forward) to increase speed. Each subject participated in locomotor therapy training using a body weight supported treadmill modality. Strategy classification was based on inverse dynamics analysis pre- and post-training. The simulation analyses revealed that forward propulsion was achieved primarily through the uniarticular plantarflexors and the contralateral knee extensors in both subjects. The main difference between the two strategies occurred primarily in the hip muscle contributions to swing initiation. The “hip strategy” subject, in addition to using the hip flexors to accelerate the leg forward, had higher contributions from the contralateral non-sagittal plane hip muscles to generate energy to the leg to initiate swing. These results suggest that using either the “ankle strategy” or the “hip strategy” to increase speed post-training results in similar muscle function post-training walking with differences primarily occurring in the hip muscle contributions to swing initiation. Future studies analyzing both pre- and post-training may reveal changes in muscle function that correspond more with the strategy classifications. / text

No description available.

Pre-existing dementia is associated with poorer functional outcome after stroke. It is unclear however whether this is due to lack of access to, or inequality in, stroke rehabilitation. This PhD used mixed methods to understand whether pre-existing dementia is a factor considered by clinicians when referring/admitting patients for rehabilitation, when providing rehabilitation interventions, and whether there is a difference in rehabilitation received by patients with and without pre-existing dementia. A background literature review informed the first study, which was a systematic review examining factors influencing clinical decision-making about access to stroke rehabilitation. The systematic review suggested that pre-stroke cognition influenced referrals/admission to rehabilitation, however, no studies examined this specifically. The qualitative study therefore used interviews (n=23) to explore clinicians experiences of decision-making about rehabilitation for patients with pre-existing dementia/cognitive impairments. The findings highlighted that clinicians own knowledge influenced their decision-making, with a common perception that people with pre-existing cognitive impairment lack potential to benefit from rehabilitation. The third study, a prospective cohort study, examined differences in rehabilitation received by patients with and without pre-existing cognitive impairments (n=139). People with pre-existing cognitive impairments received less rehabilitation than those without, particularly physiotherapy and referral to community therapies and more non-patient facing occupational therapy. This PhD identified that people with pre-existing dementia/cognitive impairment receive less rehabilitation when compared to those without. This may be, in part, due to clinicians decision-making about which patients should receive stroke rehabilitation. These findings have multiple clinical implications, particularly around the number of patients in stroke services with undiagnosed pre-existing cognitive impairment. Decisions can become more equitable by ensuring clinicians have access to relevant education, training and skills to work alongside patients with pre-existing dementia/cognitive impairments.

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.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Zambia is undergoing epidemiological changes from communicable diseases to NCDs as a result of demographic transition and hence Stroke is an emerging NCD in the country. The process of care of stroke in Zambia as country is unknown. Exploring the process of care of stroke in Zambia, could help understand the gaps in service delivery thereby helping to create interventions to improve stroke service delivery. The purpose of this study was to determine and explore the process of care of stroke in Zambia. As there is no information regarding stroke care in Zambia, the study aimed to explore and determine the process of care and explore the conditions under which diagnosis and management of stroke is done in Zambia and are the factors influencing stroke diagnosis and management in Zambia. The study was conducted in Zambia’s five general hospitals which were selected conveniently. The study consisted of both quantitative and qualitative methods. The quantitative part consisted of stroke patients’ medical records reviews, who were admitted to general hospitals between 1st January to 3oth October 2014. A sample of 80 medical records was selected randomly from each general hospital, making the total of 400 medical records from all the hospitals. Data was collected using a checklist which was specifically design for the study after literature review and contained stroke care processes including diagnosis, medical management, rehabilitation, lifestyle management and community linkage. Analysis of quantitative data was done using Statistical Package for Social Science (SPSS) version 22. The qualitative part consisted of individual in-depth interviews with a purposefully selected sample of three health workers from each hospital making 15 health workers. The in-depth interviews were based on predetermined themes including staffing levels, multidisciplinary team action, treatment guidelines, clinical capacity, planning and budgeting and technical environment. All the interviews were audio-taped, transcribed verbatim and the predetermined themes were analysed using content analysis. Ethical clearance to conduct the study was obtained from the University of the Western Cape Faculty Board Research and Ethics Committees and Senate Research Committee and ERES Converge in Zambia. Permission to conduct the study in Zambia was obtained from the Ministry of Health, Zambia. Informed consent was obtained from the health workers who took part in the study. The study found that the stroke process of care in Zambia ranged from diagnosis through to physical rehabilitation and lifestyle management. The stroke process of care was challenged in the area of diagnosis using biochemistry, haematology, CT scan, MRI and Angiography etc. The process of care in rehabilitation was challenged by lack of gadgets and space to use in rehabilitation. Community linkage, speech therapy and social welfares services were not part of the stroke process of care in Zambia as the study as established. Staff shortages, busy schedules, no treatment guidelines, poor clinical capacity, lack of resources and poor technical environment impacted negatively on the stroke process of care according to this study. Diagnosis and management of stroke was made with no treatment guidelines, poor clinical capacity and poor technical environment. The same were the factors which were influencing diagnosis and management namely staff shortages, no multidisciplinary teams due to busy schedules of health workers, lack of treatment guidelines, poor clinical capacity by health workers, lack of resources for stroke and poor technical environment. Using the Chi-square association of variables, the study showed that CT scan was associated with definitive diagnosis with the p-value of 0.000. Equally, Chi-Square test showed that Diagnosis was not associated with medical management (p value=0.058).