A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2017 / This was a qualitative study design using in-depth caregiver interviews. Ethical clearance was applied for at the University of the Witwatersrand and permission was also obtained from hospital management where the study took place before the commencement of the research project. Interviews were conducted with the caregivers of patients discharged from the hospital where the study took place, who met the inclusion criteria. The interviews took place at the hospital three months post discharge. Verbal and written consent was obtained from all the stroke survivors and caregivers for participation and audio recording of the interviews. The researcher collected all the demographic data from the stroke survivors including BI score. The in-depth interview was conducted by the researcher using an interview schedule. The interview was informal, with open- ended questions, carried out in a conversational style in the participants’ choice of language Afrikaans, English or Setswana. Initially the interview started with structured questions and probing questions followed as necessary for more information or clarification thereof. Audio records and field notes were made during the interview by the researcher. The audio records were transcribed and translated word for word afterwards by the researcher. The data was analysed by the researcher and a second analyser using the general inductive approach and consisted of five main steps. Results: Seven interviews were conducted. The average age of the stroke survivors was 55.8 (±15.03) years, four were female and three were male, five had right sided strokes and two left sided. The average BI score was 47.1%. The average age of the caregivers was 47.8 years (±13.96) years, five were female and two were male all of them were closely related family members. Three were unemployed, two self-employed, one employed and one a pensioner. The most common enablers of adherence to home exercise programmes are: self –motivation, external motivation from friends and family, daily routine, spirituality, carers’ ‘attitudes and desire’ and knowledge. The most common barriers of adherence to home exercise programmes are: general health issues, other responsibilities, lack of family and social support, caregiver burden and stress, low self-efficacy and mood, and fear of falling. Conclusion: It is evident from this study that adherence to home exercise programmes is multifactorial and does not only relate to the stroke survivor alone. Caregivers have a lot of responsibilities and experience emotional strain and burden and this has an influence on stroke survivors’ adherence to home exercise programmes as they rely upon caregivers for assistance. When addressing adherence both the stroke survivor and the caregivers needs to be considered. Being aware of the potential enablers and barriers of adherence to home exercise programmes can give health care professionals insight in how to optimise adherence and possibly improve functional ability and the quality of life of stroke survivors. / MT2017

ABSTRACT Sub-Saharan Africa is thought to be undergoing a health (or epidemiological) and demographic transition, moving from a pattern of disease dominated by infection, perinatal illness and other diseases of poverty, to one dominated by noncommunicable disease, in particular vascular disease. If such a transition is occurring, then the burden of vascular disease including stroke will increase. Stroke is a heterogeneous condition and it is likely that the nature of stroke (pathological types, subtypes, and causes) will change during this transition. However, little is known about the burden and nature of stroke in Sub-Saharan Africa, as it is now. This information is essential to inform health services to appropriately plan and deliver health care for the future, to develop strategies for stroke prevention, and to test the theory of the health and demographic transition. My overall aim was to assess and compare the burden and nature of stroke in rural and urban South Africa, and to establish whether there is any evidence of a health transition. Specifically I aimed to: • review what is known about stroke in Sub-Saharan Africa; • establish the prevalence and nature of prevalent stroke in rural South Africa; • compare the nature of hospital-based stroke in urban and rural stroke patients; • compare the nature of urban hospital-based stroke in different population groups; and • validate two stroke scores in the urban stroke register to enable us to diagnose pathological stroke type in rural stroke patients who do not have access to brain imaging. Methods: The following methods were used to achieve these aims: • I systematically searched the literature for, and critically reviewed, studies of stroke from Sub-Saharan Africa (literature review). • The rural Agincourt Health and Population Unit demographic surveillance site was screened for stroke using two questions during the annual census. Anyone who screened positive for stroke was examined to decide whether they had had a stroke (stroke prevalence study). • The Tintswalo Hospital Stroke Register was established to ascertain and assess rural stroke patients over 20 months (rural hospital-based stroke), and • The Johannesburg Hospital Stroke Register similarly established to assess urban stroke patients over 23 months (urban hospital-based stroke). • The accuracy of the Siriraj and Guy’s Hospital stroke scores was compared to the CT brain scan “gold-standard” in the Johannesburg Hospital Stroke Register. Results: Using these approaches I found that: • Very little is currently known about the burden and nature of stroke in Sub- Saharan Africa. • The prevalence of rural stroke was about half that found in high-income countries, and double that found in Tanzania. However, disabling stroke was at least as prevalent as it is in high-income countries. • Both rural and urban black South Africans are probably in early phases of the health transition, and this is impacting on the nature of stroke, particularly the cause of cardioembolic stroke. • Neither the Siriraj nor Guy’s Hospital stroke score are sufficiently accurate for use in epidemiological studies or clinical management of stroke in Sub- Saharan Africa. Conclusion: There is already a heavy burden of stroke in Sub-Saharan Africa, and there is some evidence of a health transition in the black population. However, it is not possible to accurately assess the burden and nature of stroke without communitybased incidence studies using early brain imaging to distinguish ischaemic stroke from cerebral haemorrhage. Until we have these studies, we will never know the precise burden and nature of stroke, the effect of the health transition, or the optimal approach to preventing a stroke epidemic in our population.

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, 2014 / Stroke is a significant contributor to disease worldwide and is the second highest cause of death in both men and women. Importantly, stroke is not only a common cause or mortality but also morbidity. This increased risk of suffering a stroke could lead to an increased number of individuals with functional limitations. The main objective in stroke rehabilitation is seen as aiding the patient to achieve their highest physical and psychological performance, with the ultimate goal of a stroke survivor being one of functional independence allowing them to return to their home and reintegrate into their community. The aim of this study is to describe the differences in functional abilities between patients with stroke who are HIV positive and those who are HIV negative admitted to Witrand rehabilitation unit in the North-West province of South Africa. This is a retrospective longitudinal study utilizing the review of subject records. All subject files dating back to 21 April 2005 to December 2010 were analysed. Functional ability of patients with stroke was scored using the Beta assessment tool.The Beta assessment tool is one of three platform level tools designed by the South African Database for Functional Medicine (SADFM).It is an evidence – based scoring system which can convert a patient’s functional abilities and behaviour into quantifiable data. Scores on admission and discharge were recorded to determine the presence of change in functional ability after having received rehabilitation. Demographic information and clinical characteristics of subjects were captured using a self-designed questionnaire. Data were analysed using both a two sample t-test and descriptive statistical tests. Over the period, 2005 – 2010, 173 stroke survivors were admitted to the Witrand rehabilitation unit.Data from 32 patient files was excluded for not meeting the inclusion criteria; leaving data from 141 files to form our study group (n). The study group included 53.2% male and 46.8% female stroke survivors, with the mean age for stroke at 54.4 years and52.4 years for males and females respectively. Ischaemic strokes were more prevalent than haemorrhagic strokes (74.5% and 25.5% respectively) with hypertension asthe most common (31.9%) stroke risk factor. The mean age of stroke onset for a HIV positive individual was 39.6 years and 54.9 years for an individual without HIV.This study found that HIV positive individuals required on average 7.5 days less to rehabilitate than an individual with HIV. This discrepancy could be a result of the notably younger HIV positive group. After receiving rehabilitation from a multidisciplinary team, the HIV positive group improved with an average of 40 points and the individuals without HIV by 38 points. When performing the various statistical tests there were in fact no significant differences between the two different clinical groups. Despite the statistically insignificant findings when comparing the HIV positive and HIV negative group, when taking a closer look at the study groups demographics and clinical characteristics this study yielded interesting results. It could be argued that a majority of the HIV positive group were generally younger than the HIV negative group and perhaps the advantage of age on recovery could result in this group in gaining, on average, a similar number of points on the beta scale with those individual without HIV.Prior to their commencement of rehabilitation it should be taken into account that neurological recovery requires a degree of brain reorganization and that with age comes a certain degree of neuronal loss. Neuroplasticity is the ability of the central nervous system to respond to internal and external stimuli by reorganizing its structure, function and connections. Normal ageing is associated with a decline in and reduced plasticity. These negative changes can be experienced as reductions in processing speed, working memory and peripheral nervous system functions; all of which can be associated with poorer rehabilitation outcomes. Neural plasticity is crucial for functional recovery and this occurs more effectively and efficiently in younger individuals.However, in general the age for stroke onset was younger than that of developed countries thus stroke should no longer be considered an ‘old-age’ disease in developing countries. Keywords: Stroke; Human Immunodeficiency Virus (HIV); Functional abilities

Student Number : 9100202J - MPH research report - School of Therapeutic Sciences - Faculty of Health Science / Background and purpose of the research The magnitude of disability observed in stroke survivors is believed to be dependent, in part, on the severity of neurological deficits incurred. As important, but less well understood, is the contribution of physical and environmental factors. The objectives of this study were to establish the degree of functional independence of patients who have had a stroke and to establish factors that influence functional independence post stroke. Research methods and procedures employed This was a quantitative research using a descriptive cross sectional study design. A sample of convenience was derived from patients who had a stroke more than six weeks previously from clinics and a hospital in Johannesburg. The Barthel Index was used to establish the degree of functional independence, and a self-designed questionnaire was used to establish factors that influence functional independence of patients who have had a stroke. Intra and inter rater reliability tests were done to validate the questionnaire. The questionnaire was interviewer administered. Caregivers were interviewed in cases where patients had receptive aphasia. Results: Ninety three percent of the patients were functionally independent post discharge. Younger patients had the highest likelihood of improved functional independence than the older age group (p = 0.003); married patients recovered functional independence faster than those who were single (p = 0.05). The following factors also improved chances of being functionally independent: having bowel continence (p = 0.003); staying in hospital for less than two weeks and more than six weeks; and participating in community (p = 0.02) and household activities (p = 0.01). Having a caregiver decreased the chances of regaining functional independence (p = 0.04). Factors which were found to have no influence on functional independence post stroke were: gender (p = 0.99); education level (p =0.78); duration of stroke (p = 0.58); side of stroke (p = 0.12); shoulder pain (p = 0.90); leg pain (p = 0.22); urinary incontinence (p = 0.53); financial role (p = 0.156); monthly income (p = 0.73); and depression (p = 0.30). Conclusion: Age, marital status, duration of hospital stay and the presence of a caregiver, as well as bowel continence are the factors that influence functional independence post stroke.

Aim: Endothelial microparticles (EMPs) are released from dysfunctional endothelial cells. We hypothesised that patients with unstable carotid plaque have higher levels of circulating microparticles compared to patients with stable plaques, and this may correlate with serum markers of plaque instability and inflammation. Method: Circulating EMPs and inflammatory markers were measured in twenty healthy controls and seventy patients undergoing carotid endarterectomy. EMPs were quantified using flow cytometry. Bioplex assays profiled systemic inflammatory and bone-related proteins. Immunohistological analysis detailed the contribution of differentially-regulated systemic markers to plaque pathology. Alizarin red staining showed calcification. Results: EMPs were significantly higher in patients with carotid stenosis (greater than or equal to 70%) compared to controls, with no differences between asymptomatic vs symptomatic patients. Asymptomatic patients with unstable plaques exhibited higher levels of EMPs compared to those with stable plaques, with a similar trend observed in symptomatic patients. CXCL9 and SCGF-β were significantly elevated in asymptomatic patients with unstable plaques, with IL-16 and macrophage inhibitory factor significantly elevated in the stable plaque group. CXCL9, CTACK and SCGF-β were detected within all plaques, suggesting a contribution to both localised and systemic inflammation. Osteopontin and osteoprotegerin were significantly elevated in the symptomatic vs asymptomatic group, while osteocalcin was higher in asymptomatic patients with stable plaque. All plaques exhibited calcification, which was significantly greater in asymptomatic patients. This may impact on plaque stability. Conclusions: Circulatory EMP, CXCL9 and SCGF-β levels are raised in asymp-tomatic patients with unstable plaques, which could be important in identifying patients at most benefit from intervention.

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.

Abstrakt Bakgrund: Stroke är ett globalt hälsoproblem som kan bidra till funktionsnedsättningar och många vårddagar. Detta tillstånd innebär att patienten får kämpa med sig själv och sin återhämtning för att bli bättre. Vårdpersonalens bemötande och kunskap har en betydande roll i återhämtningen, då mobilisering och rehabilitering bör ske snabbt inpå sjukdomsdebuten. Detta för att minska risken för att nedsatta funktioner kvarstår. Syfte: Syftet med studien var att beskriva patientens upplevelse av att leva efter stroke. Metod: Systematisk litteraturstudie utifrån nio artiklar med kvalitativ ansats. Artiklarna är kvalitetsgranskade och analyserade. Under analysprocessen framkom kategorierna: När kroppen sviker, vårdpersonalens roll i patientens vård samt återhämtningsprocessen. Resultat: Resultatet visade på att många strokedrabbade upplevde sorg, maktlöshet och oro inför framtiden. Att tappa kontrollen över kroppen kunde påverka självkänslan och deras sociala relationer. Vårdpersonalens bemötande kunde ha stor betydelse för den strokedrabbades återhämtning. Det var viktigt att vårdpersonalen hade kunskap och att de stöttade patienten med empati och god information om tillstånd och forsatt liv. Det visade sig även att hoppet var en stor drivkraft i återhämtningssprocessen. Slutsats: Återhämtning med individualiserad rehabilitering är viktigt för att återfå förlorade eller försämrade funktioner efter stroke. Vårdpersonalen bör arbeta utifrån personcentrerad vård för att patienten ska uppnå goda resultat i återhämtningsprocessen. Vi anser att vidare forskning bör inriktas på hur innehållsrik information kan nå patienten på bästa sätt.

This study is concerned with the impact of stroke, and in particular, the experiences of patients and carers following the return of the survivor to the home environment.

Background and Purpose Caregivers of patients with stroke are central in providing for the patient‟s needs, facilitating participation of the patient in their daily functional ability, maintaining functional improvements gained in rehabilitation and the long-term well-being of stroke survivors. The strain and ultimate decrease in quality of life of the caregiver can lead to breakdown in the support they provide to the patient. The well-being and quality of life of the caregiver is therefore of vital importance in the rehabilitation of the patient with stroke. It is therefore necessary to evaluate relevant factors in the South African context that affect the quality of life of the caregiver, so as to foresee and prevent possible breakdown in the support provided by the caregiver to the patient with stroke. The objectives of the study are to establish the functional level of patients six to 36 months post-stroke, the level of strain and quality of life of the caregiver six to 36 months post-stroke, and the influence of demographic factors, caregiver strain and patient‟s functional ability on quality of life of the caregiver. Method A cross-sectional study was performed on 35 patients six to 36 months post-stroke and their primary caregiver, obtained from a sample of convenience from six local clinics/hospitals in the Johannesburg area. Demographic information was gathered from both patient and caregiver by means of a questionnaire. The Barthel Index (BI) was used to assess the patients‟ functional ability at the point of interview. Caregiver strain and caregiver quality of life were measured using the Caregiver Strain Index (CSI) and EQ-5D and EQ-5D VAS respectively. Results Of the 35 patients with stroke, 19 (54.3%) were male, and 16 (45.7%) were female, with the mean age of 55.9 years. Of the 35 primary caregivers, 6 (17.1%) were male, and 29 (82.9%) were female, with the mean age of 50.7 years. Sixty percent of patients ranged from being independent in functional ability to being moderately dependent on the caregiver for their functional ability. Seventy seven percent of caregivers reported severe strain as a result of caring for the patient with stroke. Thirty one percent of caregivers reported midrange (50/100) quality of life using the EQ-5D VAS. No association was established between patient‟s functional ability and caregiver quality of life (Pearson x²=0.59). Negative association was established between caregiver strain and quality of life (Kendall‟s Tau-b=-0.23), however it was of marginal significance (Pearson x²=0.06). Logistic regression showed caregivers under severe strain were 1.6 times of higher odds to experience a decrease in quality of life than caregivers with less strain. Caregiver age showed a negative correlation with caregiver quality of life (Kendall‟s Tau-b=-0.48; Pearson x²=0.009). Logistic regression showed older caregivers were 0.19 times of higher odds to experience a decrease in quality of life than younger caregivers. Conclusion There is no association between the patient‟s functional ability and the quality of life of the caregiver six to 36 months post-stroke. A negative association is shown between caregiver strain and caregiver age, and caregiver quality of life. The realm of caregiver quality of life is both dynamic and contextual. Knowledge of the effects of the contextual factors enables the health services and professionals to respond appropriately to assist in foreseeing and alleviating those factors that negatively affect caregiver quality of life. As it is understood that caregivers provide support for the patient with stroke, promoting the caregiver‟s well-being in turn will promote patient care and their ultimate well-being.

Faculty of Health Sciences School of Public Health 9501477y maharaja@therapy.wits.ac.za / THE ENERGY EXPENDITURE OF DRESSING IN PATIENTS WITH STROKE. This study aimed to understand the physical demands of upper and lower body dressing in 23 stroke survivors and 23 control subjects. Measurement of the energy expenditure and time take was done by means of a triaxial accelerometer. The amount of active movement present in the limbs was also documented. Activities health was measured in the experimental group. Results indicated that significantly more energy was expended in dressing the upper body in the experimental group (p<0.05). No significant differences were found in the energy expenditure in dressing the lower limbs. There were significant differences found in the perception of difficulty of the tasks. Patients with stroke took four times longer to dress than controls. Despite having motor ability, stroke survivors were not able to use this in activities of daily living (ADL). Patients with stroke were unsatisfied and spent excessive amounts of time in their day in sedentary, unconstructive activity. Recommendations include increased endurance training in patients with neurological disorder in order to reengage them into ADL.