Diss. (sammanfattning) Uppsala : Uppsala universitet, 2009. / Härtill 4 uppsatser.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2010. / Härtill 4 uppsatser.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2010.

This thesis explores opportunities to bridge the gap between preclinical and clinical research in stroke through the conduct of three studies: a Network Meta-Analysis (NMA) and systematic review of preclinical stroke therapies, a systematic review and meta-analysis of C-C chemokine receptor type 5 (CCR5) antagonists co-designed with patient partners, and an assessment of patient engagement in the systematic review process. The first study identifies a number of potential therapies while also underlining the challenges in their translation to human trials. The second investigation highlights the promising efficacy of CCR5 antagonists in preclinical models and notes existing gaps towards demonstrating clinical effectiveness. The final study focusses on the integration of patient perspectives, revealing the potential to align research with patient relevant outcomes. Collectively, the work highlights the importance of methodological rigour, transparent reporting, and patient engagement in enhancing the relevance and translatability of preclinical findings to clinical practice in stroke research.

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.

The purpose of this study was to gain understanding of the early symptom experience of ischemic stroke in women. This is the only study of which the researcher is aware in which narrative inquiry was used to examine the period of time from symptom onset until emergency department arrival in women. Data collection was achieved by in-depth interviews during which participants’ stories of stroke were elicited. Individual narrative accounts were created and analyzed using within and across case techniques. The participants were nine women ranging in age from 24-86 years (average age 53). Four participants were Caucasian, three were Hispanic, one was African American and one woman was of mixed race. The participants experienced the onset of stroke as the inability to carry out accustomed activities in usual ways. There was a tendency to objectify the body. Only two participants considered stroke as a possible cause for their symptoms, and the other women attributed symptoms everyday bodily experiences and/or other health conditions. Most participants did not perceive themselves at risk for stroke although all but one woman had risk factors. The participants displayed a variety of responses to symptoms, including trying to continue with usual activities and seeking help as well as deciding not to tell anyone about their symptoms. Symptom response was related to women’s evaluation of and emotional response to symptoms. The actions taken by the participants in response to symptoms were informed by the meaning of the symptoms, and meaning was formed within the context of each woman’s life situation. Few women made the decision to seek medical care on their own, and in every case family members or co-workers were reported to take an active role in getting the participant to the hospital. Some family members were reported to consult with one another before making the decision to call EMS or transporting the participant to the emergency department. Consistent with what was expected from extant research the majority of the participants did not arrive at the hospital in time to be offered treatment with t-PA. Recommendations for future research, stroke education and practice were discussed. / text

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).

In rodent models of motor cortical stroke, skill learning with the non-paretic forelimb worsens rehabilitation outcomes of the paretic forelimb. The neural basis of this effect is not fully understood. A possible mechanism for this effect is activity-dependent synaptic competition between projections from remaining regions of the ipsi- and contralesional motor cortex, specifically from the ipsilesional rostral forelimb area (RFA) and the contralesional caudal forelimb area (CFA). Previous studies have found that this effect is negated by callosal transections or inhibition of the contralesional cortex, suggesting that the contralesional hemisphere plays a key role. The purpose of this study was to investigate the influence of differential forelimb experience on the cortical plasticity of callosal projections from the contralesional CFA, which is known to contribute to the reinnervation of peri-lesion cortex. Since axonal sprouting is activity dependent, one would expect animals trained with the non-paretic forelimb to have an increase in axonal fibers and bouton densities from the contralesional CFA. Adult male Long-Evans rats were trained to proficiency using their dominant (for reaching) forelimb on the single-pellet-retrieval skilled reaching task. Animals subsequently received unilateral cortical ischemic lesions in the CFA of the hemisphere contralateral to the trained forelimb. On post-infarct day five, rats began 15 days of reach training either with their non-paretic forelimb (NPT), their paretic forelimb (rehabilitation training, RT), or no-training control procedures (CTRL). On post-infarct day 23 all animals received an injection of biotinylated dextran amine (BDA) into the contralesional CFA to label callosal projections from the spared hemisphere into peri-infarct motor cortex. Contrary to the hypothesis, results indicate no significant differences in axonal fiber or synaptic bouton densities across any of the groups within any of the examined regions of peri-lesion cortex. This suggests that the mechanism behind the detrimental effects of NPT on the paretic limb does not involve a net change in densities of neural connections from the contralesional CFA. Future research should explore possible changes in the structure of synapses or variations in relative densities of excitatory and inhibitory post-synaptic cells as possible contributors to the neural basis of the deleterious effect of NPT. / text

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