INTRODUCTION: Impaired physical fitness may contribute to functional limitations and disability after stroke. Physical fitness (including cardiorespiratory fitness and muscle strength/power) can be improved by appropriate fitness training; this is of benefit to healthy people and patient groups but whether it is of benefit for people after stroke is unclear. The aim of this thesis was to determine whether physical fitness training is beneficial after stroke. OBJECTIVES: (1) Develop a rationale for fitness training by determining whether physical fitness after stroke is a) impaired, and b) associated with functional limitations and disability. (2) Develop and evaluate randomized controlled trial (RCT) evidence by a) determining the feasibility of a definitive RCT, and b) evaluating the benefits of fitness training after stroke. METHODS: (1) Systematic review of observational data and multiple linear regression of exploratory RCT baseline data determined the nature of fitness impairments and any associations with functional limitation and disability. (2) Systematic review and meta-analysis of RCTs established the effects of fitness training on disability, death and dependence. An exploratory RCT (‘STARTER’) compared the effects of a fitness training programme (cardiorespiratory plus strength training 3 days/week for 12 weeks) with an attention control (relaxation) on fitness, function, disability, mood and quality of life in 66 ambulatory people with stroke. RESULTS: (1) Systematic review of observational data showed cardiorespiratory fitness (peak oxygen uptake and economy of walking) and muscle strength were low after stroke; the impairments predicted functional limitation but links to disability were unclear. STARTER baseline data showed little impairment in economy of walking but lower limb extensor power was impaired (42-54% of values expected in healthy age and gender matched people) and this predicted functional limitation and disability. (2) The systematic review identified 12 RCTs (n=289) in 2003, and 24 RCTs (n=1147) when updated in 2007. The systematic reviews showed death was uncommon, and effects on dependence and disability were unclear. However training did improve fitness and cardiorespiratory training during rehabilitation improved ambulation. Most benefits resulted from task-related training. The STARTER fitness training intervention was feasible, with good attendance (>90%) and good compliance with intervention content (94-99%). At the end of the fitness training intervention there were small improvements in some cardiorespiratory fitness, physical function and quality of life outcomes compared with the control group, but these differences had diminished four months later. CONCLUSIONS: (1) Cardiorespiratory fitness, muscle strength and power are impaired after stroke, so there is scope to increase fitness, and there are plausible benefits. (2) Physical fitness training after stroke is feasible, it improves fitness and has some functional benefits, in particular for walking ability. Effects on disability, death and dependence are not known. Further research is required to determine the timing, mode, duration, frequency and intensity of fitness training for optimum benefits, and investigate how benefits can be retained in the long-term.

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

The main aims were to: optimise the method for extracting polyamine from food and blood products; study the effect of diet (after oral loading with orange juice – a food source rich in polyamines) on blood polyamine concentrations and urinary polyamine excretion; assess the concentrations of S100β protein, NSE, GFAP and polyamines in healthy control populations; study the time profile or kinetics of polyamines, NSE, S100β protein and GFAP after acute ischaemic stroke and their relationship with stroke severity and outcome using NIHSS, mRS and BI; and study the relationship between risk factor burden, aetiological mechanisms and clinical stroke sub-types and biomarker trends. Several steps were taken to improve the quality of the acid soluble extract from red blood cells.  This led to a highly reproducible and high quality extract for HPLC analysis.  Evidence gathered from the results confirmed the absorption of the content of orange juice but this did not reflect in changes in blood polyamine concentrations.  Spermidine and spermine show significant correlation with stroke severity and functional outcome comparable to S100β protein and better than NSE and GFAP. The number of participants involved in the study is the largest ever used for any clinical assessment of polyamines in stroke but still falls short for a thorough assessment of these markers.  Challenges posed by shortage of reagents for the HPLC run remained largely unresolved until recently. Limited follow-up in the stroke study restricted the evaluation of the polyamines to short term outcome measures.

Bakgrund: Stroke innebär en stor omställning för personen som har insjuknat men också för anhöriga. Sjuksköterskan ska finnas där som stöd till anhöriga för att de enklare ska kunna hantera den nya livssituationen. Dagens sjukvård har inte tillräckligt med kunskap om anhörigas informationsbehov, vilket leder till att anhöriga inte får det stöd de behöver.  Syfte: Syftet var att belysa anhörigas informationsbehov när en familjemedlem insjuknat i stroke. Metod: En litteraturstudie baserad på åtta vetenskapliga artiklar med kvalitativ ansats där artiklarna analyserades med en manifest innehållsanalys. Resultat: I resultatet framkom det att anhöriga var intresserade av att erhålla information som var anpassad till deras situation och som kunde hjälpa dem individuellt. Informationen gav även anhöriga en bättre förståelse för vad som hade hänt och på vilket sätt de kunde stödja deras familjemedlem. Det framkom även att anhöriga ville ha allmän information för att kunna förbereda sig inför vad som skulle komma efter sjukhusvistelsen och för att hantera sin vardag bättre. Slutsats: Det framkom att anhöriga hade ett stort informationsbehov, men de upplevde att den information de fick av sjuksköterskan ofta var både begränsad och irrelevant gällande deras unika situation. Detta resulterade i att anhöriga kände sig tvungna att söka information på egen hand. Det framkom att anhöriga inte var intresserade av att få information som inte berörde dem utan de önskade att få individanpassad information. Anhöriga var även i behov av att få allmän information med syfte att få förståelse för den nya livssituationen och för att känna sig förberedda inför att deras familjemedlem skulle skrivas ut till hemmet.

Stroke is a leading cause of death and the most common cause of disability in adults in the United Kingdom. Several treatments are effective in preventing stroke in the long term after TIA and minor ischaemic stroke, including aspirin, other antiplatelet agents, and blood pressure lowering drugs, statins and anticoagulation in atrial fibrillation. However, failure of secondary prevention to prevent recurrent vascular events is still a major clinical problem, as is the risk of bleeding associated with antiplatelet agents and anticoagulants. This thesis determines the risks associated with urgent secondary prevention in the acute phase after TIA and minor stroke, particularly the reduction in risk of early recurrent stroke, the risk of bleeding with combination of aspirin and clopidogrel in the acute phase and whether or not there is a rebound increase risk of ischaemic stroke or recurrent TIA after withdrawal of a short course of clopidogrel. I have shown that urgent and early treatment of ischaemic stroke with secondary prevention leads to an 80% reduction in recurrent stroke. I have also shown that an increased bleeding risk exists among aspirin naïve patients treated with combination antiplatelet medications compared to those already treated with aspirin. My work has also shown that discontinuation of clopidogrel following treatment for 30 days or more does not lead to a rebound increase in ischaemic stroke. Bleeding events are a frequent complication of antiplatelet treatment in TIA and ischaemic stroke. I have shown that the long term risk of bleeding in a population study treated with antiplatelets is 6% per 100 person years. Using this information I identified risk factors for bleeding to develop a clinical baseline bleeding model to identify those at higher risk of bleeding. Age was identified as a significnant risk factor for both bleeding and recurrent ischaemic risk. In addition, bleeding events are associated with higher rates of fatality and disability in the older population. Finally, I have shown that the time trends in stroke recurrence differ depending on the presenting event i.e TIA or stroke. Stroke recurrence risk after minor stroke is delayed compared with TIA, and remains high during the late phase despite current best medical treatment. Blood pressure control and atrial fibrillation are risk factors for late stroke recurrence identifying the unmet need for better detection and treatment potentials to reduce late recurrent stroke.

Purpose: Many patients suffer from depression after a stroke. The aims of this feasibility study were to: examine the recruitment process of community dwelling stroke survivors in a study using an interactive computer program (Cognues®), determine the ability to assess cognitive function and depression status in subjects using Cognuse® and ascertain the usability of the Cognuse® program from the perspective of eight study participants. Methods: Stroke survivors in two community support groups and personal contact referrals were provided a research flyer and study synopsis, including background and study participation explanation. Eight stroke survivors agreed to take part in study. Each participant completed a depression and cognitive scale, three weeks of online computer exercises assigned by the PI, then a post-exercise depression and cognitive scale and a usability survey. Results: Recruitment was difficult; the proposed number (8-10) of stroke survivors was successfully fulfilled over a 6 month time period. Of the eight consented subjects, seven completed the study with one lost to follow-up. Pre- and -post depression and cognitive scales were compared and analyzed. Half of the participants showed a small increase in cognitive function and showed a significant positive change after completion of the online exercises. Usability of the Cognuse® program was overall perceived in a neutral capacity by the participants and although the subjects liked the idea of the program, it was not as user friendly as expected. Conclusion: Recruitment of community dwelling stroke survivors is feasible for a study using an online computer exercise program to determine emotional health. However, the usability of the selected program was determined to be neutral; participants liked the idea of the program but found there were many limitations. Upon completion of the three week online exercises, subjects showed an increase in cognitive function and slight decrease in depressive symptoms, illustrating a possible link between cognitive function and depression.

No description available.

Magister Scientiae (Occupational Therapy) - MSc(OT) / Individuals diagnosed with stroke particularly in rural communities have a poor return to work rate. Vocational rehabilitation has been used as an intervention strategy with various types of clients with disability or injury in order to improve their work skills. The aim of the proposed study is to describe the experiences and perceptions of individuals diagnosed with stroke about the usefulness of the Model of Occupational Self Efficacy in assisting them in returning to their worker role particularly in a rural setting. Eight participants were purposively selected from the data base of a local hospital and semi structured interviews were conducted with the participants until saturation occurred. Furthermore, two focus groups were conducted with eight participants. A key informant was also interviewed to assist the researcher with a different perspective and to avoid bias. The data was analysed by means of thematic analysis into codes, categories and themes. Trustworthiness was ensured by means of credibility, applicability, transferability and conformability. Informed consent and confidentiality was ensured. Permission was obtained from the UWC research committee and from the Department of Health. Four themes were merged from the findings: Theme one: Obstacles which affects the return to work of CVA Participants in a rural community. Theme two: Establishing a strong belief in functional ability through occupation. Theme three: Adaptation strategies that enhances the work participation of stroke survivors in a rural community. Finally Theme four: The MOOSE enables transition to the worker role in a rural context. The findings revealed that the participants experienced a loss of their former self thus affecting their worker identity as they were no longer able to experience the gratification of fulfilling their worker role. This was due to the participants not being aware of the return to work options that they had. After the stroke the participants battled with not only overcoming their condition but also the stigma which the community and their employers had of stroke. Overcoming the stroke event and returning to work required that potential barriers and facilitators be identified by the participants and the researcher. The study also identified adaptation strategies that the participants utilised in order to overcome the barriers and assist the participants to have a smoother transition into the workplace. In conclusion the findings of the study revealed that the participants suffer a loss of their former abilities and undergo a loss of their self-esteem. As a result of the loss, participants struggled to return to work not only due to their loss of abilities but also their lack of knowledge regarding return to work and stroke. The findings indicated that there should be more education regarding the stroke that needs to be conducted in communities via media such as local newspapers, local radio stations, clinics and hospitals. The findings of the study may assist Occupational Therapy practitioners to improve services in a rural community for stroke survivors and improve the facilitation of the return to work process after stroke. The MOOSE facilitates motivation for participants to regain their self-esteem and thus move forward to resume a worker role. / 2020-08-31

Faculty of Health Sciences School of Public Health 9501477y maharaja@therapy.wits.ac.za / 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.

A RESEARCH REPORT SUBMITTED TO THE FACULTY OF HEALTH SCIENCES, SCHOOL OF THERAPEUTIC SCIENCES, UNIVERSITY OF THE WITWATERSRAND, JOHANNESBURG, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN OCCUPATIONAL THERAPY JOHANNESBURG, APRIL 2015 / Studies to determine which underlying motor deficits have the greatest impact on improvement in functioning within activities of daily living in stroke patients are nonexistent with regard to the South African context. Effective stroke rehabilitation is essential due to rapid discharge rates and therefore it is important to focus on the motor deficit that will contribute most significantly to function. Patients from the ages of 35 to 85, who had suffered a stroke and were admitted to a private, neurological, rehabilitation facility in Johannesburg gave consent to participate in three outcome measures determining adequacy of balance (Berg Balance Scale), upper limb movement (Frenchay Arm Test) and gait (Timed Up-and-go Test) as well as one outcome measure determining level of functioning within activities of daily living (Functional Independence Measure). Results from the pre- and post-tests indicated that all participants improved during the time of rehabilitation. The findings of the outcome measures for each of the three different motor components were correlated with functioning in ADLs for each patient. The results showed that balance had the strongest correlation with functioning in ADLs, followed by upper limb movement, and then gait. The use of the FIM as a functional measure appeared to have some limitations and is not standardised to be used within the South African context.