Student Number : 0414012 - MSc dissertation - School of Therapeutic Sciences - Faculty of Health Sciences / Aim: The aim of this study was to quantify the level of ability and in particular walking ability of a group of stroke survivors resident in Soweto, between 3-6 months post incident. Design: Descriptive study in which comfortable walking speed over ten metres is correlated with the distance covered in six minutes and two minutes. Subjects: Forty one subjects after stroke divided into two groups. Twenty six with a Barthel Index initial score of ≤60 and fifteen with a score >60. Main Outcome Measures: Walking speed and two and six minute distance were compared between groups. In addition actual distance walked in six minutes was compared with the distance predicted by the ten-metre walking speed test and the distance predicted by normative reference equations. Heart rate was measured during the six minute walking test. Functional ability was compared using the Barthel Index within ten days post stroke and three to six months. Results: Of those who survived 90% of subjects were able to walk independently after stroke. The mean walking speed of 0.55 m/s demonstrated a strong correlation with the distance walked in six minutes (R2=0.816). However it underestimated the distance walked in six minutes by 7.4%. There were no significant differences between groups for the walking tests. The two minute walking test distance accurately predicted the results of the six minute walking test distance (R2=0.97). The average distance walked in six minutes by subjects after stroke was 40% of the distance predicted for healthy adults. For the functional walk test 95.5% of subjects had a heart rate within normal recommended limits. The functional walk test together with a measure of exertion (heart rate) may indicate an individual's ability to sustain submaximal activity. Subjects had minimal rehabilitation training. Lower limb pain did not significantly lower the walking speed (p=0.18) or distance walked in six minutes (p=0.17). Mean Barthel Index score at three to six months was 85.78 indicative of independence with minimal assistance. Although the mortality rate for the Barthel Index group with a score less than 60 is 30.7%, the prognosis of survivors was not uniformly poor. Conclusion: This study demonstrates that though a high percentage of subjects recovered independent walking after stroke in the Soweto community with minimal rehabilitation, their walking speed and distance walked are indicative of limited walking capacity. Walking speed and the two minute walking test could be used to predict functional walk test performance. Pain in the paretic lower limb though commonly reported did not appear to affect walking speed or distance walked. The use of the Barthel Index to predict activities and/or survival merits further investigation.

The benefits of brief-duration, early exercise programs in stroke have been shown, but the effects of longer-duration aerobic training early after stroke have not been examined. The purpose of this study was to determine the effects of an early aerobic exercise program that extended beyond inpatient into outpatient rehabilitation on aerobic capacity, walking parameters (walking distance, speed, and symmetry), health-related quality of life, and balance. Patients in the subacute phase after stroke (n = 15) with mild to moderate impairment received aerobic exercise in addition to conventional rehabilitation. The study participants demonstrated significant improvement in aerobic and walking capacity, peak work rate, quality of life, balance, and gait velocity from baseline to midpoint. However, no difference was found between midpoint and final. This early aerobic exercise program following stroke significantly improved aerobic capacity, walking ability, quality of life and balance during the inpatient period although no further improvement was observed during the outpatient period.

The benefits of brief-duration, early exercise programs in stroke have been shown, but the effects of longer-duration aerobic training early after stroke have not been examined. The purpose of this study was to determine the effects of an early aerobic exercise program that extended beyond inpatient into outpatient rehabilitation on aerobic capacity, walking parameters (walking distance, speed, and symmetry), health-related quality of life, and balance. Patients in the subacute phase after stroke (n = 15) with mild to moderate impairment received aerobic exercise in addition to conventional rehabilitation. The study participants demonstrated significant improvement in aerobic and walking capacity, peak work rate, quality of life, balance, and gait velocity from baseline to midpoint. However, no difference was found between midpoint and final. This early aerobic exercise program following stroke significantly improved aerobic capacity, walking ability, quality of life and balance during the inpatient period although no further improvement was observed during the outpatient period.

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L’Artériopathie Oblitérante des Membres Inférieurs (AOMI) est une maladie chronique grave, associée au processus d’athérosclérose, et qui se traduit chez la plupart des patients par une ischémie (apports sanguins insuffisants) à l’exercice.L’ischémie d’exercice peut causer l’apparition de douleurs au niveau des membres inférieurs lors de la marche, limitant de fait la capacité de marche des patients. L’évaluation de la capacité de marche occupe une place importante dans la prise en charge des patients. Grâce au développement de moniteurs d’activité tels que le géo-positionnement par satellites (GPS), cette évaluation peut être conduite en situation écologique de marche via des mesures réalisées en extérieur. Ces mesures GPS ont notamment permis de mettre en évidence une variabilité de la capacité de marche avec une influence probable de la durée de récupération entre deux marches symptômes-limitées. Ceci reste cependant à démontrer expérimentalement. Par ailleurs, méthodologiquement, il est nécessaire de pouvoir standardiser et exprimer de façon plusadéquate les données GPS obtenues afin de juger de la capacité de marche des patients. L’objet du présent travail de thèse était par conséquent double : i) valider une méthodologie pour estimer la dépense énergétique (DE) associée à la marche en extérieur chez le sujet sain et qui serait à terme applicable chez les patients avec AOMI pour pouvoir comparer les résultats de capacité de marche obtenus par mesure GPS ; ii) déterminer dans quelle mesure la durée de récupération suite à une marche symptômes-limitée influence la capacité de marche des patients lors de la marche subséquente. Les résultats des travaux de recherche qui ont été menés dans le cadre de cette thèse montrent que le GPS permet une estimation relativement précise de la DE en extérieur chez le sujet sain en conditions de vitesse et de pente variées. De plus, nos résultats mettent en évidence que la durée de récupération faisant suite à une marche symptômes-limitée influence clairement la capacité de marche des patients. La nature logarithmique de la relation permet d’envisager àmoyen terme l’identification d’une durée minimale de récupération à partir de laquelle les patients pourraient maximiser leur capacité de marche. Des perspectives intéressantes pourraient alors être envisagées dans le réentraînement à l’effort des patients et/ou pour les aider à mieux gérer leurs douleurs au quotidien. / Lower-extremity peripheral artery disease (PAD) is a non-communicable disease that is associated with atherosclerosis and that leads, in most patients, to ischemia (mismatch between blood demand and blood supply) during exercise. Exercise-induced ischemia may lead to the occurrence of pain in the lower extremities during walking, thus limitingwalking capacity. Assessing walking capacity is an important step in the management of PAD patients. Thanks to the development of activity monitors such as global positioning system (GPS), it is possible to assess walking capacity under real-life conditions with measurements performed in outdoor settings. These GPS measurements have highlighted thefact that walking capacity seems variable and is likely to be influenced by the recovery duration between two symptoms-limited walks. However, this remains to be demonstrated in standardized conditions. Moreover, methodological advances are needed to standardize and express more adequately GPS data in order to better interpret walking capacity measurements. Therefore, the aim of the present thesis was two-fold: i) to validate a method for estimating walking energy expenditure (EE) in healthy subjects in outdoor setting, and that could be used in the future in PAD patients in order to compare walking capacity results obtained in outdoor setting; ii) to determine to which extent the duration of the recovery period that follows a first symptom-limited walk influences walking capacity measured during the subsequent walk in PADpatients. Our results show that GPS allows accurate estimations of walking EE in healthy subjects in outdoor setting and with various conditions of speed and grade. Moreover, our results clearly show that recovery duration influences walking capacity in PAD patients. The logarithmic shape of the relationship supports further analyses to determine a minimum recovery duration that could maximize patients walking capacity. This could have interesting implications for the development of new exercise walking programs in PAD and/or to help patients to better manage their pain during daily life.

Objective: The primary objective of this real-world study was to describe the response to fampridine and changes of gait parameters in multiple sclerosis (MS) patients’ walking disability (Expanded Disability Status Scale (EDSS): 4–7) after treatment with fampridine for 2 weeks as recommended by the European Medicines Agency (EMA) and compare it with the overall physician’s judgement. Methods: A total of 211 adult MS patients were analyzed using a multimodal gait assessment including the timed 25-foot walk test (T25FW), 2-minute walking test (2-MWT), 12-item Multiple Sclerosis Walking Scale (MSWS-12), the GAITRite electronic walkway system, and the patients’ clinical global impression (CGI). Multimodal gait assessment was compared with the clinician’s impression of overall improvement after 2 weeks. Results: In total, 189 subjects were included, of which 133 (70.37%) were responders to fampridine (RF), according to physician’s judgement. Looking at independent multimodal gait assessment, RFs showed improvement of 12.60% in the T25FW, 19.25% in the 2-MWT, 21.12% in the MSWS-12, and 6.54% in their Functional Ambulation Profile (FAP) score. The combination of the T25FW and the MSWS-12 would offer the best sensitivity and specificity for determining response to fampridine according to both neurologists’ and patients’ classification. Conclusion: This study provides new information on the use of fampridine in a real-world setting with a large patient sample on the potential benefit of using more definitive responder criteria to fampridine for the clinical setting.

Sex and gender considerations are influential on psychosocial and physiological determinants of cardiovascular health in individuals with and without stroke. The first study of this thesis explored gender-based differences in exercise self-efficacy, outcome expectations for exercise and motivation for exercise post-stroke. Gender identity was assessed using the Bem Sex-Role Inventory-12 and a gender role index was created using established gender-related roles. The Self-Efficacy for Physical Activity Scale was used to assess self-efficacy for exercise, the Short Outcome Expectations for Exercise Scale assessed outcome expectations for exercise and a Relative Autonomy Index was calculated to assess motivation for exercise. We found that masculine gender identity was associated with highest ratings of exercise self-efficacy, whereas feminine gender identity was related to the lowest exercise self-efficacy [F(3, 9)=5.36, p<0.05]. Gender identity was not associated with outcome expectations [F(3,8)=0.86, p=0.50) nor motivation for exercise [F(3,4)=0.67, p=0.61)]. Additionally, there were no associations between gender roles and self-efficacy (n=13, r=0.10, p=0.73), outcome expectations (n=13, r=-0.13, p=0.68), or motivation for exercise (n=8, r=0.09, p=0.83). The second study of this thesis examined the associations between global cognitive function (Montreal Cognitive Assessment, MoCA), arterial stiffness (carotid-femoral pulse wave velocity) and sex, and between global cognitive function, walking capacity (6-Minute Walk Test, 6MWT) and sex in older male and female adults with and without stroke. There was no association between global cognition and arterial stiffness, and sex did not moderate this association. However, cognitive function was positively associated with 6MWT, and with the addition of sex, Sex*6MWT, age and history of stroke, explained 21% of the variance of the MoCA score. Our findings provide insight into the importance of sex-and gender-based considerations in clinical research and may inform future larger-scaled studies aiming to increase the generalizability of their findings to males and females and individuals of all gender identities. / Thesis / Master of Science Rehabilitation Science (MSc) / The roles that an individual undertakes, and how they see themselves and are seen by others may be related to exercise participation. In addition, a person’s biological makeup may impact their health and ability to think. In the first study of this thesis, we found that individuals with stroke seeing themselves as women had lower beliefs about their abilities to exercise, but their beliefs about the benefits of exercise or their motivation for exercise were similar to individuals who identify as men. There were no differences in beliefs about exercise abilities, outcomes, or motivation between individuals with stroke who took on masculine vs. feminine roles. In the second study, we found that walking distance, but not arterial health, was related to the ability to think in males and females. Overall, this work provides information of the importance of biological, social roles and behaviours on health.

Made available in DSpace on 2014-12-17T15:16:06Z (GMT). No. of bitstreams: 1 SheylaTSL.pdf: 1123530 bytes, checksum: 9d193a5e8ae6cbd93482dabd85a41d69 (MD5) Previous issue date: 2009-07-30 / Introduction: The ability to walk is impaired in obese by anthropometric factors (BMI and height), musculoskeletal pain and level of inactivity. Little is known about the influence of body adiposity and the acute response of the cardiovascular system during whole the 6-minute walk test (6mWT). Objective: To evaluate the effect of anthropometric measures (BMI and WHR waist-to-hip ratio), the effort heart and inactivity in ability to walk the morbidly obese. Materials and Methods: a total 36 morbidly obese (36.23 + 11.82 years old, BMI 49.16 kg/m2) were recruited from outpatient department of treatment of obesity and bariatric surgery in University Hospital Onofre Lopes and anthropometric measurements of obesity (BMI and WHR), pulmonary function, pattern habitual physical activity (Baecke Questionnaire) and walking capacity (6mWT). The patient was checking to measure: heart rate (HR), breathing frequency (BF), peripheral oxygen saturation, level of perceived exertion, systemic arterial pressure and duplo-produto (DP), moreover the average speed development and total distance walking. The data were analysed between gender and pattern of body adiposity, measuring the behavior minute by minute of walking. The Pearson and Spearmam correlation coefficients were calculated, and stepwise multiple Regression examined the predictors of walking capacity. All analyses were performed en software Statistic 6.0. Results: 20 obese patients had abdominal adiposity (WHR = 1.01), waist circumference was 135.8 cm in women (25) and 139.8 cm in men (10). Walked to the end of 6mWT 412.43 m, with no differences between gender and adiposity. The total distance walked by obesity alone was explained by BMI (45%), HR in the sixth minute (43%), the Baecke (24%) and fatigue (-23%). 88.6% of obese (31) performed the test above 60% of maximal HR, while the peak HR achieved at 5-minute of 6mWT. Systemic arterial pressure and DP rised after walking, but with no differences between gender and adiposity. Conclusion: The walk of obese didn?t suffers influence of gender or the pattern of body adiposity. The final distance walked is attributed to excess body weight, stress heart, the feeling of effort required by physical activity and level of sedentary to obese. With a minute of walking, the obeses achieved a range of intensity cardiovascular trainning / Introdu??o: A capacidade de caminhar dos obesos ? prejudicada pelo ?ndice de Massa Corporal (IMC), dores osteomioarticulares e n?vel de sedentarismo. Pouco se sabe sobre a influ?ncia do perfil da adiposidade corporal, do g?nero e da resposta aguda do sistema cardiovascular sobre a capacidade de caminhada do obeso. Objetivo: Avaliar o efeito de medidas antropom?tricas (IMC e WHR, waist-to-hip ratio), esfor?o card?aco e sedentarismo sobre a capacidade de caminhada de portadores de obesidade m?rbida. Materiais e M?todos: Entre setembro de 2007 e setembro de 2008, 36 obesos m?rbidos (idade 36,23 + 11,82; IMC 49,16 kg/m2) foram recrutados no ambulat?rio de tratamento da obesidade e cirurgia bari?trica do Hospital Universit?rio Onofre Lopes e avaliados quanto marcadores antropom?tricos de obesidade, fun??o pulmonar, n?vel de atividade f?sica habitual (Question?rio de Baecke) e capacidade de caminhar (TC6M). O paciente era monitorado para verificar: freq??ncia card?aca (FC) e respirat?ria (FR), satura??o perif?rica de oxig?nio, n?vel de esfor?o percebido, press?o arterial sist?mica (PA) e duplo-produto (DP). Durante a caminhada, ainda mensurava-se a velocidade m?dia desenvolvida e dist?ncia total percorrida pelos portadores de obesidade m?rbida. Os dados foram analisados entre os g?neros e o tipo de distribui??o de gordura corporal, avaliando o comportamento das vari?veis a cada minuto caminhado. As correla??es de Pearson e Spearmam foram analisadas. A Regress?o M?ltipla buscou preditores da capacidade de caminhada. Foi utilizado o software Statistic 6.0 para an?lise estat?stica. Resultados: 20 obesos tinham adiposidade abdominal (WHR = 1,01), circunfer?ncia da cintura de 135,8 cm nas mulheres (25) e de 139,8 cm nos homens (10). Durante TC6M, foi caminhada uma dist?ncia de 412,43 m, sem diferen?as entre g?nero ou adiposidade. Essa dist?ncia total percorrida foi explicada isoladamente pelo IMC (45%), FC no sexto minuto (43%), Baecke (24%) e fadiga (-23%). 88,6% dos obesos (31) realizaram o teste acima de 60% da FCM?xima, sendo o pico de FC atingido aos 5 minutos de caminhada. PA e DP aumentaram significativamente com a caminhada, mas sem diferen?as entre g?nero ou adiposidade. Conclus?o: A acaminhada dos obesos m?rbidos n?o sofre influ?ncia do g?nero ou do perfil de adiposidade corporal. A dist?ncia final percorrida ? atribu?da ao excesso de peso corporal, estress card?aco, sensa??o de esfor?o imposta pela caminhada e ao n?vel de sedentarismo pr?vio do obeso. Dentro de 1 minuto de caminhada, os obesos atingem uma zona de treinamento cardiovascular