The following dissertation analyses how users experience space with their different senses. And how we as designers can utilise this to improve rehabilitative designs’ responsiveness to cater to acute brain injury and post-operative neurological surgery patients. The medical field has shown a rapid increase in neurological development that changes the way doctors have been treating patients thus far. With the rapid growth in development, the associated disciplines need to react to the change in knowledge to provide a facility that accommodates new treatment methods that will always provide the patient with the best care. When dealing with specialised fields, the architectural design process is limited by the designers’ experience and knowledge, and when it comes to the medical field, it is almost always limited. The regulations and medical planning guidelines cater to the minimum requirements and systematic applications and not set to adapt to patient needs. Thus a multidisciplinary collaborative effort is needed to address the patient’s wellbeing properly. For the architectural profession to design responsive environments that help promote the patients’ passive recovery principles, we need to be able to identify the effect our spaces have on the brain. The research aims to broaden the philosophical approach to design to include rehabilitation principles to create more productive environments for patients. By studying the effect of the spaces on the brain, we know from the brain’s neuroplasticity that the constructive stimulation of the areas affected will increase its recovery rate. Once the principles have been identified, architectural drivers can be deduced from the data sets. If correctly implemented, the responsive design principles can help produce better rehabilitative methods that don’t have to rely solely on active rehabilitation applications. The end goal is to have this facility serve as a precedent for future projects with a multidisciplinary healthcare program that aims to incorporate responsible passive neurological treatments. / Mini Dissertation (MArch (Prof))--University of Pretoria, 2020. / Architecture / MArch (Prof) / Unrestricted

When adults with neurological conditions can access occupational therapy (OT) services, they have better outcomes. Unfortunately, many people who are living in the community with these conditions do not participate in OT services. This can compound deficits, lead to re-hospitalization, and negatively impact independence and quality of life. The issues with access for this population, specifically adults aged 18-65, can largely be attributed to lack of awareness of the role and scope of OT, lack of availability of specialized services, and issues with affordability. Evolve Occupational Therapy (Evolve OT) is a program designed specifically for this group, adults with neurological conditions aged 18-65 who have difficulty accessing OT services. This innovative approach to service delivery provides an alternative access pathway, treatment, and payment models that are intentionally designed to increase participation in and utilization of OT services. With this program, it is expected that patients will report increased satisfaction with participation, increased quality of life, and outcomes will hopefully effect change amongst policymakers.

Muscle weakness is one of the major causes of post-stroke disability. Stroke rehabilitation programs now often incorporate the same type of resistance training that is used for healthy subjects; however, the training effects induced from these training strategies are often limited for stroke patients. An important resistance training principle is that an optimal level of stress is exerted on the neuromuscular system, both during concentric (shortening) and eccentric (lengthening) contractions. One potential problem for post-stroke patients might be difficulties achieving sufficient levels of stress on the neuromuscular system. This problem may be associated with altered muscular function after stroke. In healthy subjects, maximum strength during eccentric contractions is higher than during concentric contractions. In individuals with stroke, this difference in strength is often increased. Moreover, it has also been shown that individuals with stroke exhibit alteration with respect to how the strength varies throughout the range of motion. For example, healthy subjects exhibit a joint specific torque-angle relationship that normally is the same irrespective of contraction mode and contraction velocity. In contrast, individuals with stroke exhibit an overall change of the torque-angle relationship. This change, as described in the literature, consists of a more pronounced strength loss at short muscle length. In individuals with stroke, torque-angle relationships are only partially investigated and so far these relationships have not been analysed using testing protocols that include eccentric, isometric, and concentric modes of contraction.   This thesis investigates the torque-angle relationship of elbow flexors in subjects with stroke during all three modes of contractions – isometric, concentric, and eccentric ­– and the relative loading throughout the range of movement during a resistance exercise. In addition, this thesis studies possible central nervous system mechanisms involved in the control of muscle activation during eccentric and concentric contractions.   The torque-angle relationship during maximum voluntary elbow flexion was examined in stroke subjects (n=11), age-matched healthy subjects (n=11), and young subjects (n=11) during different contraction modes and velocities. In stroke subjects, maximum torque as well as the torque angle relationship was better preserved during eccentric contractions compared to concentric contractions. Furthermore, the relative loading during a resistance exercise at an intensity of 10RM (repetition maximum) was examined. Relative loading throughout the concentric phase of the resistance exercise, expressed as percentage of concentric torque, was found to be similar in all groups. However, relative loading during the eccentric contraction phase, expressed as the percentage of eccentric isokinetic torque, was significantly lower for the stroke group. In addition, when related to isometric maximum voluntary contraction, the loading for the stroke group was significantly lower than for the control groups during both the concentric and eccentric contraction phases. Functional magnetic resonance imaging was used to examine differences between recruited brain regions during the concentric and the eccentric phase of imagined maximum resistance exercise of the elbow flexors (motor imagery) in young healthy subjects (n=18) and in a selected sample of individuals with stroke (n=4). The motor and premotor cortex was less activated during imagined maximum eccentric contractions compared to imagined maximum concentric contraction of elbow flexors. Moreover, BA44 in the ventrolateral prefrontal cortex, a brain area that has been shown to be involved in inhibitory control of motor activity, was additionally recruited during eccentric compared to concentric conditions. This pattern was evident only on the contralesional (the intact hemisphere) in some of the stroke subjects. On the ipsilesional hemisphere, the recruitment in ventrolateral prefrontal cortex was similar for both modes of contractions.    Compared to healthy subjects, the stroke subjects exhibited altered muscular function comprising a specific reduction of torque producing capacity and deviant torque-angle relationship during concentric contractions. Therefore, the relative training load during the resistance exercise at a training intensity of 10RM was lower for subjects with stroke. Furthermore, neuroimaging data indicates that the ventrolateral prefrontal cortex may be involved in a mechanism that modulates cortical motor drive differently depending on mode of the contractions. This might partly be responsible for why it is impossible to fully activate a muscle during eccentric contractions. Moreover, among individuals with stroke, a disturbance of this system could also lie behind the lack of contraction mode-specific modulation of muscle activation that has been found in this population. The altered neuromuscular function evident after a stroke means that stroke victims may find it difficult to supply a sufficient level of stress during traditional resistance exercises to promote adaptation by the neuromuscular system. This insufficiency may partially explain why the increase in strength, in response to conventional resistance training, often has been found to be low among subjects with stroke. / Muskelsvaghet är en av orsakerna till funktionshinder efter stroke. I rehabiliteringsprogram för personer som drabbats av stroke förekommer det numera att styrketräning används i syfte att öka muskelstyrkan. Effekten av styrketräning har dock ofta visat sig vara begränsad. En viktig styrketräningsprincip är att muskulaturen belastas tillräckligt nära maximal styrka under både koncentriska kontraktioner (när man lyfter en vikt) och excentriska kontraktioner (när man kontrollerat sänker en vikt). Ett potentiellt problem skulle kunna vara att personer med stroke inte belastas optimalt under träning på grund av förändrad muskelfunktion. Efter stroke är muskelfunktionen ofta förändrad såtillvida att styrkenedsättningen är mer uttalad under koncentriska kontraktioner. Därutöver har man funnit att styrkenedsättningen är mest uttalad när muskeln är i sitt mest förkortade läge. Detta fenomen har dock inte studerats för alla tre kontraktionstyper, det vill säga excentriska, koncentriska och isometriska kontraktioner, hos personer med stroke.   Denna avhandling undersöker sambandet mellan styrka och ledvinkel över armbågsleden hos personer med stroke under alla tre kontraktionstyper – excentrisk, koncentrisk och isometrisk, samt relativ belastning genom rörelsebanan under en styrketräningsövning. Därutöver undersöker denna avhandling också hjärnans aktiveringsmönster under excentriska och koncentriska kontraktioner.   Sambandet mellan styrka och ledvinkel undersöktes hos personer med stroke (n = 11), åldersmatchade (n = 11) och unga försökspersoner (n = 11). Jämfört med kontrollgrupperna var maximal styrka för personer med stroke mest nedsatt, samt även den oproportionerligt stora styrkenedsättningen vid kort muskelängd som mest uttalad, under koncentriska kontraktioner. Denna avvikelse var minst uttalad vid excentriska kontraktioner. Vidare studerades hur hög belastningen på muskulaturen var i jämförelse med muskelns maximala styrka under en styrketräningsliknande övning för armbågsflexorer vid en träningsintensitet på 10RM. Den uppmätta belastningen under den koncentriska fasen av styrketräningsövningen, uttryckt som procent av den genomsnittliga koncentriska styrkan, var densamma för alla grupperna. Under den excentriska fasen av övningen var dock belastningen, uttryckt som procent av den maximala excentriska styrkan, signifikant lägre för personer med stroke. Träningsbelastningen utgjorde också en lägre andel av den maximala isometriska styrkan för personer med stroke, både under den koncentriska och under den excentriska fasen.   Funktionell magnetresonanstomografi (fMRI) användes för att undersöka hjärnans aktiveringsmönster hos unga försökspersoner (n = 18) och hos individer med stroke (n = 4) när de föreställde sig att de utförde maximal styrketräning för armbågsflexorer (motor imagery). Resultatet visade att primära motorbarken och premotoriska barken var mindre aktiverade när unga friska försökspersonerna föreställde sig utföra maximala excentriska, jämfört med maximala koncentriska kontraktioner. Dessutom var en region i ventrolaterala prefrontala barken, som i tidigare studier visat sig vara inblandat i reglering och hämning av muskelaktivering, mer aktiverade under föreställda excentriska kontraktioner. Detta aktiveringsmönster i den prefrontala barken återfanns dock endast i den icke skadade hjärnhalvan hos personer med stroke.   Jämfört med kontrollgrupperna uppvisade försökspersonerna med stroke en förändrad muskelfunktion som bestod av en specifik nedsättning av styrkan under koncentriska kontraktioner samt också ett mer avvikande samband mellan styrka och ledvinkel under koncentriska kontraktioner. Den relativa belastningen under utförandet av en styrketräningsövning med en intensitet på 10RM var på grund av dessa avvikelser lägre för försökspersoner med stroke. Hjärnavbildnings-studierna indikerade att ventrolaterala prefrontala barken verkar vara involverat i ett kortikalt moduleringssystem som reglerar muskel-aktivering olika beroende på kontraktionstyp under maximala kontraktioner. Detta skulle kunna vara en underliggande mekanism bakom den hittills obesvarade frågan varför det är omöjligt att aktivera muskulaturen maximalt under excentriska kontraktioner. En störning av detta moduleringssystem hos personer med stroke verkar också kunna ligga bakom den förändrade regleringen av muskelaktivering som visat sig förekomma hos personer med stroke. Neuromuskulär funktion efter stroke är förändrad i flera avseenden vilket verkar medföra att muskulaturen inte belastas optimalt under konventionell styrketräning. Detta kan vara en delförklaring till varför styrkeökningen som svar på träning ofta är liten hos personer med stroke.

This thesis focuses on assistive and rehabilitation technology for restoring the function of the hand. It presents three different approaches to assistive technology: one in the form of an orthosis, one in the form of a brain-computer interface combined with functional electrical stimulation and finally one totally aiming at rehabilitating the nervous system by restoring brain function using the concept of neuroplasticity. The thesis also includes an epidemiological study based on statistics from the Swedish Hospital Discharge Register and a review on different methods for assessment of hand function. A novel invention of an orthosis in form of a light weight glove, the SEM (Soft Extra Muscle) glove, is introduced and described in detail. The SEM glove is constructed for improving the grasping capability of a human independently of the particular task being performed. A key feature is that a controlling and strengthening effect is achieved without the need for an external mechanical structure in the form of an exoskeleton. The glove is activated by input from tactile sensors in its fingertips and palm. The sensors react when the applied force is larger than 0.2 N and feed a microcontroller of DC motors. These pull lines, which are attached to the fingers of the glove and thus work as artificial tendons. A clinical study on the feasibility of the SEM glove to improve hand function on a group of patients with varying degree of disability has been made. Assessments included passive and active range of finger motion, flexor muscle strength according to the Medical Research Council (MRC) 0-5 scale, grip strength using the Grippit hand dynamometer, fine motor skills according to the Nine Hole Peg test and hand function in common activities by use of the Sollerman test. Participants rated the potential benefit on a Visual Analogue Scale. A prototype for a system for combining BCI (Brain-Computer Interface) and FES (Functional Electrical Stimulation) is described. The system is intended to be used during the first period of recovery from a TBI (Traumatic Brain Injury) or stroke that have led to paresis in the hand, before deciding on a permanent system, thus allowing the patients to get a quick start on the motor relearning. The system contains EEG recording electrodes, a control unit and a power unit. Initially the patients will practice controlling the movement of a robotic hand and then move on to controlling pulses being sent to stimulus electrodes placed on the paretic muscle. An innovative electrophysiological device for rehabilitation of brain lesions is presented, consisting of a portable headset with electrodes on both sides adapted on the localization of treatment area. The purpose is to receive the outgoing signal from the healthy side of the brain and transfer that signal to the injured and surrounding area of the remote side, thereby having the potential to facilitate the reactivation of the injured brain tissue. The device consists of a control unit as well as a power unit to activate the circuit electronics for amplifying, filtering, AD-converting, multiplexing and switching the outgoing electric signals to the most optimal ingoing signal for treatment of the injured and surrounding area. / <p>QC 20130403</p>

No description available.

Bakgrund I Sverige drabbas årligen 50 000 personer av förvärvad hjärnskada. Vanliga komplikationer är funktionsnedsättning i övre extremitet, skuldersmärta, spasticitet och sänkt livskvalitet. En fysioterapeutisk rehabiliteringsmetod som försöker minska dessa komplikationer, men som ännu inte utvärderats vetenskapligt är Vasa-konceptet. Syfte Att undersöka vilken effekt en fem veckor lång intervention enligt Vasa-konceptet hade på nämnda komplikationer hos tre personer med förvärvad hjärnskada. Metod   Studien har en Singel Subject Experimentell Design med AB-design för att kunna följa förändringsprocessen över tid hos tre individer. Utfallsmått var Reaching Performance Scale, Patient-Specifik Funktionell Skala, Numerisk Skala, Modifierad Ashworth Skala och Modifierad Short version of Stroke Specific Quality of Life Scale. Studien pågick under sex veckor. Data bearbetades med visuell analys av trender, lutning och stabilitet. Resultat Arm/handfunktionen ökade hos två av tre deltagare. Den självskattade arm/handfunktionen ökade hos samtliga deltagare. Skuldersmärtan slutade öka hos en deltagare och övriga hade ingen smärta under interventionen, förutom vid några enstaka tillfällen. Spasticiteten i armbågsflexorer ökade hos en deltagare och förblev oförändrad hos övriga. I handledsflexorer minskade spasticiteten hos två av deltagarna och var oförändrad hos en. Livskvaliteten ökade hos samtliga deltagare. Konklusion Interventionen i studien hade positiva effekter på arm/handfunktion, skuldersmärta och livskvalitet. Ytterligare studier krävs dock för att kunna bekräfta dessa effekter av Vasa-konceptet. / Background Each year 50 000 persons are affected by acquired brain injury in Sweden. Common complications include disability in the upper extremity, shoulder pain, spasticity and reduced quality of life. A physiotherapeutic rehabilitation method which tries to reduce these complications, but has not yet been evaluated scientifically is the Vasa-concept. Purpose To examine the impact of a five-week intervention with the Vasa-concept on the mentioned complications in three persons with acquired brain injury. Method The study has a Single Subject Experimental Design with an AB-design, focusing on changes over time in three individuals. Outcome measures were Reaching Performance Scale, Patient-Specific Functional Scale, Numeric scale, Modified Ashworth Scale and Modified Short version of Stroke Specific Quality of Life Scale. The entire study lasted for six weeks. Data were processed by visual analysis of trends, tilt and stability. Results Upper extremity function increased in two of three participants. Self-rated upper extremity function increased in all participants. Shoulder pain stopped to increase in one participant and did not occur in the remainders, except for a few occasions. Spasticity in elbow flexors increased in one participant and was unchanged in the remainders. In wrist flexors the spasticity decreased in two participants and was unchanged in one. Quality of life increased in all participants. Conclusion The intervention had positive effects on arm/hand function, shoulder pain and quality of life. Further studies are needed to confirm these effects of the Vasa concept.

Made available in DSpace on 2016-06-02T20:19:20Z (GMT). No. of bitstreams: 1 4910.pdf: 3408018 bytes, checksum: 4034688ddb3183a38d1f9c8b45afa4e8 (MD5) Previous issue date: 2013-02-22 / Universidade Federal de Sao Carlos / Muscle weakness is characterized as a significant cause of reduced physical capacity and functionality, this limitation is due to the decreased ability to produce voluntary contraction of the muscle groups in the affected hemisphere. It is a consequence of morphological and functional changes related to neural and muscular aspects. The aim of this study was to evaluate the neuromuscular performance, muscle volume and Growth Factor Insulin-like I (IGF-I) serum concentration (SC) and its Binding Protein, IGFBP-3, in subjects with chronic hemiparesis. For such, a cross-sectional study was designed. Fourteen subjects with chronic hemiparesis were evaluated for functionality performed by assessment tools Berg Balance Scale Test, Timed Up Go Adapted, Walk test 10 meters, Functional Reach Test, Fugl- Meyer Assessment, Barthel Index, Assessment of Quality of Life, Medical Outcomes Study- 36 Health Status Measurement. The subjects were allocated in the hemiparetic group (HG, 12 men). Healthy subjects (control group, CG) were paired for age, gender, height and body mass index with HG. Rectus femoris (RF), vastus medialis (VM), vastus intermedius (VI), vastus lateralis (VL), biceps femoris (BF) and semitendinosus / semimembranosus (SS) muscle volume was measured. The SC IGF-I and IGFBP-3 was quantified by ELISA. The peak torque (PT), work and power during concentric and eccentric contractions of knee extensors and flexors were evaluated using an isokinetic dynamometer at 60°/s, synchronously to record muscle activation RF, VM, VL, BF and semitendinosus (ST). For parametric data, the unpaired t test and ANOVA two-way followed by Tukey test were applied to identify statistical differences between groups and factors (dominance and condition; paretic limb: PL, non-paretic limb: NPL and control group CG). For nonparametric data was used the Mann Whitney U test followed by Bonferroni adjustment. The significance level of 5% was considered. The HG presented functional levels and CSs of IGF-I and IGFBP-3 reduced compared to the CG. The HG showed selective muscle atrophy of VM, VI, BF and SS, and also altered muscle activation between agonist and antagonist against the CG. There was a significant decrease in PT, work and power of the knee extensors and flexors for concentric and eccentric actions in the PL and NPL compared to the CG. In conclusion, hemiparetic group show weakness in the PL due to changes in neuromuscular performance, including decreased PT, power and work, and also due to changes in the agonist and antagonist muscle recruitment. These neural changes are accompanied by selective atrophy of quadriceps and hamstrings muscles and CSs decrease in IGF-I and IGFBP-3 serum concentrations. / A fraqueza muscular é caracterizada como uma importante causa da redução da capacidade física e funcionalidade, esta limitação ocorre devido à diminuição da capacidade de gerar contração voluntária dos grupamentos musculares no hemicorpo afetado. E consequência de alterações morfofuncionais relacionadas aos aspectos neurais e musculares. O objetivo deste estudo foi avaliar o desempenho neuromuscular, o volume muscular e a concentração sérica (CS) do fator de crescimento semelhante à insulina 1 (IGF-1) e de sua proteína ligante, IGFBP-3, em indivíduos hemiparéticos crônicos. Para tal, um estudo transversal foi delineado. Quatorze sujeitos com hemiparesia crônica foram submetidos a avaliações de funcionalidade realizada pelas ferramentas Escala de Equilíbrio de Berg,Teste Timed Up Go (TUG) Adaptado, Teste de caminhada de 10 metros, Teste de Alcance Funcional, índice de Desempenho Motor de Fugl-Meyer, índice de atividade de vida diária de Barthel, Escala de Avaliação da Qualidade de Vida, Medical Outcomes Study-36 Health Status Measurement. Foram alocados no Grupo Hemiparético (GH; 12 homens). Sujeitos saudáveis (Grupo Controle, GC) foram pareados por idade, gênero, altura e índice de massa corpórea com o GH. Foram mensurados o volume dos músculos reto femoral (RF), vasto medial (VM), vasto intermédio (VI), vasto lateral (VL), bíceps femoral (BF) e semitendinoso/ semimembranoso (SS). A CS de IGF-I e IGFBP-3 foi quantificada pelo método de ELISA. O pico de torque (PT), trabalho e potência concêntricos e excêntricos, dos flexores e extensores do joelho, foram avaliados em dinamômetro isocinético a 60o/s, de forma sincrônica ao registro da ativação dos músculos RF, VM, VL, BF e semitendinoso (ST). Para dados paramétricos, o teste T não pareado e Anova two-way seguida de Tukey foram utilizados para identificar diferenças estatísticas entre grupos e fatores (dominância e condição; membro parético: MP, membro não parético: MNP e membro controle: MC). Para dados não paramétricos foram utilizados o teste U de Mann Whitney seguido do ajuste de Bonferroni. O nível de significância de 5% foi considerado. O GH apresentou níveis funcionais e as CSs de IGF-I e IGFBP-3 reduzidos em relação ao GC. O GH apresentou atrofia seletiva dos músculos VM, VI, BF e SS e também demonstrou a ativação muscular alterada entre agonistas e antagonistas em relação ao GC. Houve uma diminuição significativa do PT, trabalho e potência dos flexores e extensores do joelho em ações concêntricas e excêntricas no MP em relação ao MNP e ao MC. Em conclusão, indivíduos hemiparéticos apresentam fraqueza no MP decorrente de alterações no desempenho neuromuscular, incluindo diminuição do PT, potência e trabalho, e também devido a alterações no recrutamento de músculos agonistas e antagonistas do movimento. Estas modificações neurais são acompanhadas por atrofia seletiva de músculos do quadríceps e dos isquiotibiais e por menores CSs de IGF-I e IGFBP-3.

Sammanfattning Den här vetenskapliga essän handlar om arbetsterapeutens arbete med neurologisk rehabilitering. Jag gestaltar ett möte med en patient som har drabbats av en stroke och beskriver hur anhöriga påverkar rehabiliteringsprocessen. Problem uppstår när jag inte har lyckats skapa en god relation och samarbete med den anhöriga. Jag funderar över begreppet rehabilitering, kring krisbearbetning och vad det kan innebära att drabbas av en hjärnskada och relaterar det till ett existentiellt och ett relationellt perspektiv. Jag reflekterar över ansvarsfördelningen i vården och hur den fördelas mellan patient, anhörig och arbetsterapeuten i vårdmötet. Mina tankar och reflektioner från mötet med patienten och anhöriga utforskar jag med hjälp av filosofer och andra författare. Min slutsats är att anhöriga spelar en stor roll för att rehabiliteringen ska lyckas och deras behov av stöd behöver beaktas i större utsträckning. Jag behöver skapa förtroendefulla relationer och ha en dialog med patienten och anhöriga för att utveckla ett bra samarbete. Patienten och arbetsterapeuten har ett delat ansvar över rehabiliteringen och det stöd som anhöriga ger är viktigt för att främja tillfrisknandet. / Abstract This scientific essay is about the occupational therapist's work in neurological rehabilitation. I am portraying a meeting with a patient who suffered a stroke and describe how relatives affect the rehabilitation process. Problems arise when I have not managed to create a good relationship and cooperation with the relative. I discuss the concept of rehabilitation, about crisis management and what it can mean to suffer a brain injury from an existential and a relational perspective. I reflect on the division of responsibilities in health care, as well as how it is distributed between patient, relative and the occupational therapist in the patient care meeting. I explore my thoughts and reflections from the meeting with the patient and relatives with the help of philosophers and other writers. My conclusion is that relatives play a major role in the success of rehabilitation and the need for their support needs to be considered to a greater extent. I need to create trusting relationships with both the patient and relatives to develop a good collaboration. The patient and the occupational therapist have a shared responsibility for the rehabilitation and the support provided by relatives is important to facilitate recovery.

I denna vetenskapliga essä beskriver jag två möten med personer som drabbats av stroke. I reflektion kring dessa möten redogör jag för dilemman i min yrkesvardag. Jag försöker att beskriva vikten av att förståelse uppnås mellan mig som sjukgymnast i neurologisk rehabilitering och de personer jag möter. Detta för att rehabiliteringen ska bli bra. Mitt ansvar är att göra personen engagerad i rehabiliteringen och personens ansvar är att aktivt delta. Problem uppstår när personen på grund av sjukdom inte har autonomi och därmed inte kan ta ansvar för sig själv. Kring begreppen praktisk kunskap, möte, ansvar och reflektion redogör jag för filosofers och andra författares tankar och reflekterar vidare kring dessa begrepp kopplat till de möten jag beskriver. Min slutsats är att jag behöver både teoretisk kunskap och praktisk kunskap i mitt arbete. Den praktiska kunskapen är ofta tyst kunskap. Reflektion är viktig för att jag ska kunna utföra mitt arbete så bra som möjligt och samla erfarenhet och praktisk kunskap. Trots att jag försöker att göra etiska val i min yrkesutövning ingår att jag ibland misslyckas. I reflektion och besvikelse över dessa misslyckanden bygger jag mer erfarenhet. / This scientific essay depicts two encounters with individuals who have suffered stroke. While reflecting about these encounters I describe dilemmas in my professional everyday work. I try to describe the importance of understanding between me as a physiotherapist working with neurological rehabilitation and the individuals I encounter. The purpose is achieving good rehabilitation. My responsibility is to make sure the individual feels invested in the rehabilitation and thus actively participate. Problems arise when the person as a result of disease do not have autonomy and consequently is unable to take responsibility. Philosophers’ and other authors’ thoughts and opinions about practical knowledge, encounters, responsibility and reflection as well as my own thoughts about the encounters I have had are described and analyzed. My conclusion is that both theoretical and practical knowledge are needed in my work. The practical knowledge is often tacit knowledge. Reflection is essential for me to be able to do my work as well as possible and to earn experience and practical knowledge. Even though I try to make ethical choices in my occupation I am not always successful. It is when reflecting and feeling disappointed about these failures that I emerge a more experienced professional in my field.

Due to physical, cognitive and emotional impairments, many individuals are unemployed or under-employed following a traumatic brain injury. The research evidence links the rigour of a vocational evaluation to future employment outcomes. Despite this link, no specific guidelines exist for vocational evaluations. Using the research evidence and a diverse panel of clinical and academic experts, the primary objective of this doctoral research was to develop an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. The objective of the guideline is to make explicit the processes and factors relevant to vocational evaluation, to assist evaluators (i.e. clients, health and vocational professionals, and employers) in collaboratively determining clients’ work abilities and developing recommendations for work entry, re-entry or vocational planning. The steps outlined in the Canadian Medical Association's Handbook on Clinical Practice Guidelines were utilized to develop the guideline and include the following: 1) identifying the guideline’s objective/questions; 2) performing a systematic literature review; 3) gathering a panel; 4) developing recommendations; 4) guideline writing; 5) pilot testing. The resulting guideline includes 17 key recommendations within the following seven domains: 1) evaluation purpose and rationale; 2) initial intake process; 3) assessment of the personal domain; 4) assessment of the environment; 5) assessment of occupational/job requirements; 6) analysis and synthesis of assessment results; and 7) development of evaluation recommendations. Results from an exploratory study of the guideline’s implementation by occupational therapists in their daily practices revealed that clinicians used the guideline to identify practice gaps, systematize their evaluation processes, enhance inter-professional and inter-stakeholder communication, and re-conceptualize their vocational evaluations across disability groups. Statistically significant improvements were also noted in clients’ participation scores on the Mayo-Portland Adaptability Inventory–4 following guideline use. This guideline may be applicable to individuals with TBI, clinicians, health and vocational professionals, employers, professional organizations, administrators, policy makers and insurers.