Saudi Cultural Missions Theses & Dissertations
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Item Restricted Frequency of Post-Stroke Anxiety: A Systematic Review and Meta-Analyses of Observational Studies(King's College London, 2024) Almatrafi, R and Wang Yanzhong; Wang, YanzhongABSTRACT Background: Psychological conditions can exist following a stroke, including anxiety. Anxiety disorders and significant anxiety symptoms are associated with negative consequences and reduced quality of life after stroke. Despite these concerns, the understanding of post- stroke anxiety’s presence remains inadequate and unclear. Therefore, this research aims to conduct an updated systematic review and meta-analysis of observational studies regarding the frequency of post-stroke anxiety. Search Methods: A digital search was performed on Ovid Medline, Embase, PsycINFO, as well as Web of Science for pertinent and eligible studies published from 2013 to July 2024 that assessed anxiety in adult stroke survivors by screening for anxiety symptoms on a rating scale or diagnosing anxiety disorders to generate the outcome of interest, which is anxiety rate. Meta- analyses of eligible observational studies were conducted utilizing random-effects models to provide a general pooled estimate of the anxiety rate as well as anxiety rates based on assessment method, study setting, and time of assessment after stroke. Results: Overall, 17 observational studies with 4,579 unique stroke participants were included in the review, revealing an overall anxiety rate of 23.2% (95% confidence interval: 17.8-29.9, I2: 93%, p-value<0.01). The rate of anxiety based on diagnostic interviews was 20.6% (95% confidence interval: 14.2-29, I2: 80%, p-value<0.01) and 24.2% (95% confidence interval:17.4-32.6, I2: 94%, p-value <0.01) by anxiety rating scales. Additionally, the rate of anxiety in hospital studies was 27.8% (95% confidence interval: 20.6-36.4, I2: 91%, p-value<0.01) and 5.4% (95% confidence interval: 1.2-21.1, I2: 93%, p-value<0.01) in rehabilitation settings. The frequencies of post-stroke anxiety in the acute phase were 35.2% (95% confidence interval: 14.3-63.8, I2: 95%, p-value<0.01), 19.9% (95% confidence interval: 14.3-27, I2: 93%, p-value<0.01) in the medium-term phase. Furthermore, anxiety was present in more chronic phases, showcasing frequencies of 23.8% (95% confidence interval: 16-33.8, I2 :94%, p-value<0.01) in the long-term phase and 30.4% (95% confidence interval: 21.7-40.8, I2: 83%, p-value<0.01) in the very long-term phase. Conclusion: Post-stroke anxiety can show a frequent occurrence across various contexts and phases. The high and significant between-study heterogeneity and the potential methodological concerns within the included studies may have led to limiting the accuracy of the anxiety rates and their generalizability. However, the anxiety rate findings can still pose a concern regarding its burden among a population with a life-limiting condition such as stroke. This is critical given this psychological condition’s role as a predictor of negative outcomes in this population. Thus, anxiety screening using rating scales as well as anxiety diagnostic tools should be considered as a priority measure for patients following stroke onset not only in the initial phase but also consistently across their life span, in addition to considering interventions to alleviate its burden on this population.11 0Item Restricted Developing and evaluating a stroke training programme for physiotherapists to improve the long-term care for patients with stroke in Saudi Arabia through the identification of these patients’ needs and gaps in the current system.(University of Birmingham, 2025) Temehy, Basema; Rosewilliam, Sheeba; Soundy, AndrewAbstract There are about 29 strokes per 100,000 people, annually, in Saudi Arabia (SA). These patients require long-term rehabilitation services to enhance their recovery and independence in the community. Views from both patients and physiotherapists on current practice in SA are essential to ensure that services are feasible and acceptable. Additionally, physiotherapists play an important role in meeting the complex clinical and social needs of stroke survivors. Ongoing training is necessary to meet their educational needs to enable them to provide effective long-term rehabilitation. Thus, the overarching aim of this research was to develop and evaluate a stroke training programme for physiotherapists in SA to enhance long-term care for stroke patients, through the identification of the specific needs of patients with stroke and physiotherapists’ perspectives and training needs. Stage 1: This review aimed to investigate the perceived needs of stroke survivors across various domains of care following their discharge from hospital. A meta-ethnographic review of qualitative studies was conducted. Twenty-seven studies were included. Two main issues were revealed concerning the unmet needs of stroke survivors: (1) a lack of information availability and suitability, and (2) inadequacy of care and services. Stage 2: This stage aimed to explore stroke patients’ needs after their discharge from rehabilitation centres in SA. An interpretive phenomenological analysis (IPA) study was undertaken using semi-structured interviews. Twenty-four patients with stroke were recruited from two hospitals in SA. The key findings suggested that patients experienced limited community rehabilitation services post-discharge unless they were financially able to pay for private therapy. Coping barriers, including medical, psychological, social, and financial factors; and facilitators, including faith, recovery, social support and leisure were identified. Participants suggested strategies to improve rehabilitation services, such as addressing the staff shortage and lack of expertise, access to services, and ongoing care. Stage 3: This stage explored physiotherapists’ perspectives on post-discharge stroke care in SA and gaps in their knowledge regarding the provision of long-term care. An exploratory qualitative study was conducted using semi-structured individual interviews and focus groups. Twenty-six physiotherapists participated in this study. The findings suggested that post-discharge services lacked structure and organisation. Physiotherapists perceived that the long-term approaches involved many barriers for patients and therapists, such as lack of education. The findings also indicated a need for training for physiotherapists involving assessment approaches, using outcome measures, setting goals, and providing effective education to patients to improve the level of care provided to patients with stroke. Stage 4: Based on the previous three studies, a Stroke Training Programme (STP) was developed to meet the knowledge gaps for physiotherapists’ training needs and to enable physiotherapists to deliver long-term care following the discharge of stroke patients. Then, an evaluation of the STP using a sequential explanatory mixed methods design was employed. The quantitative part was a ‘pre-and post’ design to assess the change in physiotherapists’ knowledge, confidence and attitude, while the second part comprised qualitative interviews to assess physiotherapists’ perceptions and the acceptability of the STP. Twenty-six participants completed the STP. The results demonstrated a significant increase in the physiotherapists’ knowledge and confidence. Further, physiotherapists gave positive feedback about the STP. However, major applicability limitations were identified. The care for stroke patients in SA can be improved by standardising care and enhancing the long-term care approaches including ongoing patients’ education, self-management and telerehabilitation. Further, providing training programmes for physiotherapists to enhance their knowledge and skills in stroke rehabilitation. Future research should focus on establishing and implementing structured frameworks to guide the process of stroke rehabilitation and ensure consistency in patient care.41 0Item Restricted Developing an intervention to enhance the engagement and motivation of stroke patients with cognitive impairment in physiotherapy rehabilitation programmes in Saudi Arabia(Universit of Nottingham, 2023) Alshaibani, Fahad; Yates, Katie Robinson; Pip Logan, JenIntroduction Globally, a stroke occurs every two seconds, making it the second leading cause of death after ischemic heart disease. Strokes reduce quality of life and increase disabilities and are often associated with cognitive impairment (CI) with an increased dependency, risk of mortality, development of depression and poor quality of life. Indeed, the incidence of CI after stroke is relatively high, reported to affect 40-70% of stroke survivors, therefore CI after stroke is an important research priority as agreed by stroke patients, caregivers, as well as health professionals. Post-stroke rehabilitation promotes functional recovery and independence of stroke survivors but CI after stroke is negatively associated with poorer functional outcomes. The presence of CI after a stroke can also affect the rehabilitation process as such stroke survivors may be less motivated and interested in rehabilitation programmes and engage in fewer therapy sessions. The concept of engagement and motivation is identified as a cognitive state, therefore, motivation and engagement in the physiotherapy treatment programme tend to be insufficient in stroke survivors with CI. This thesis aimed to develop an intervention to improve engagement and motivation in physiotherapy treatment for stroke survivors with CI in the Kingdom of Saudi Arabia. Methods A mixture of methods approach with three interlinked studies was conducted within the development stage of the Medical Research Council (MRC) framework for the development of complex interventions. A scoping review (study one) was conducted to explore the engagement and motivation strategies used in physical therapy practice for stroke patients with cognitive impairment. Qualitative interviews (study two) with physiotherapists were conducted to identify the individuals and environmental facilitators and barriers to applying engagement and motivation strategies in the Saudi physiotherapy rehabilitation context. These findings were combined with the use of a theoretical domain framework to develop a behaviour change intervention. The intervention was presented in programme theory using a logic model to demonstrate the visual pipeline consequence, highlighting the evidence-based findings, facilitators and barriers, selected behaviour change techniques, mechanism of action and intervention outcomes. After designing the logic model and explaining the intervention components, stakeholders were engaged using the nominal group technique (study three) to discuss the applicability of the behaviour change intervention in the local rehabilitation context and refine the logic model. Results The scoping review included 17 studies and indicated a lack of robust evidence on strategies used in physical therapy practice and how these strategies were applied and improved the level of engagement and motivation of stroke patients with CI during treatment. The engagement and motivation strategies identified were therapeutic interactions and communication, an enriched environment, the use of technology, and applying strategy training. The qualitative interviews conducted with twelve physiotherapists identified five facilitators, “Promising impacts”, “Professional responsibilities and treatment priority”, “Positive connections with patients and their families”, “Training and educational support”, and “Physiotherapists self-attitude” and four barriers, “Information and case identification”, “Organisational culture”, “Patient belief and circumstances”, and “Physiotherapists` awareness and self-confidence”. The stakeholder engagement activity was conducted with fifteen stakeholders including physiotherapists, heads of departments, quality managers and clinical researchers. The participants agreed that educational workshops and restructuring the physiotherapy department environment were extremely important (67%) or important (33%) behaviour change techniques to enhance professionals' skills and improve stroke rehabilitation services. Regarding changing protocols, more than a quarter of the participants (27%) were not sure that changing protocols would be an effective strategy to enhance physiotherapists' skills and stroke patient outcomes. They attributed this to physiotherapists' negative attitude regards using the rehabilitation protocols, the long process to change protocols, frequent changes in the rehabilitation protocols and organisational pressure to develop protocols for accreditation purposes. These responses were used to amend the logic model and intervention. Conclusion This thesis highlighted the complexity of patient engagement and motivation, as well as the role of individual and environmental factors in supporting stroke patients with CI engagement and motivation in rehabilitation programmes. The study explored the facilitators and barriers to applying engagement and motivation strategies in the Saudi rehabilitation context and acknowledged the individual and organisational barriers. Consequently, a theoretically driven behaviour change intervention was developed to improve the engagement and motivation of stroke patients with CI in physiotherapy rehabilitation programmes. The thesis concluded with recommendations and suggestions regarding improving the rehabilitation services for stroke patients with CI, considering engagement and motivation and further researching different strategies to support them. It also provided recommendations for policymakers in the Saudi rehabilitation context to improve the services provided for stroke patients with CI and the importance of multidisciplinary collaboration to support patients' outcomes and treatment services. Following the intervention development, research is needed to deliver and evaluate the behaviour change intervention for improving the engagement and motivation of stroke patients with CI.10 0Item Restricted Left Atrial Dysfunction in Stroke Patients with Sinus Rhythm: A Case-Control Study(Imperial College London, 2024-08) ALmuwallad, Zainab; Shun-Shin, MatthewBackground: Globally, the second leading cause of death and disability is stroke. Many cardiovascular functions may be impaired in patients that have suffered from stroke. A recent study demonstrated that left atrial (LA) function was impaired in stroke patients with atrial fibrillation (AF) (Brann, Day & Bunch, 2012). However, there is limited evidence that supports an association between LA dysfunction in patients with stroke and sinus rhythm abnormalities. As a result, this study assessed the LA function in the sinus rhythm of stroke patients using the speckle tracking echocardiography (STE) and the standard transthoracic echocardiography (TTE) in the United Kingdom. Methodology: The study design was a case-control study, retrospective in nature, with sixty adult patients who had scans performed in the echocardiography laboratory at three different sites. The cases consisted of thirty patients with confirmed stroke in sinus rhythm and the other thirty patients were specified for other causes. The participants were age-, gender-, and race-matched without known stroke and in sinus rhythm. To assess the LA function, logistic regression and Student’s t- tests were utilised to examine the relationship between left atrial strain (LAS) and the presence of stroke. Results: Left atrial reservoir strain (LASr), conduit (LAScd), and the averaged LAS were statistically different among the stroke-affected and non-affected groups (P < 0.05, 95% confidence interval [CI], odds ratios [OR] of 0.67, 0.88, and 0.93, respectively). Moreover, these parameters were dramatically reduced in patients with stroke as compared to the controls. Conclusion: LAS could be a valuable STE tool in stroke stratification, as these findings highlight the importance of cardiac monitoring in patients at risk for stroke.9 0Item Restricted Reward-based improvements of motor performance in health and disease(University of Birmingham, 2024-07-19) Alghamdi, Ahmad Ali; Galea, JoesphReward has been found to boost motor performance and improve learning in both healthy individuals and in clinical populations. The aim of this thesis was to gain a better understanding of how reward affects different specific aspects of motor performance and learning across various age and health status groups. This work provides an important step towards optimising the use of reward within clinical populations such as stroke patients. The introductory chapter (Chapter 1) provides a comprehensive review of relevant literature, setting the stage for the investigations that follow. As motor performance and reward responsiveness tend to decline with age, Chapter 2 investigated the age- related differences in reward-based improvement in motor performance. We observed that both young and older adults showed improved performance with rewards, but the young group exhibited significantly higher reward-based enhancement in motor performance. In chapter 3, we extended these results by examining how reward impacts motor performance in stroke patients. In this study, we also investigated the impact of rehabilitation on reward sensitivity. Our findings suggest that stroke patients' motor performance significantly improved with the presence of reward. We also found that patients' performance improved after rehabilitation, but there were no changes in reward sensitivity. Chapter 4 investigated the role of the primary motor cortex within the reward-based enhancement of motor performance using repetitive transcranial magnetic stimulation. No effects on performance were observed. In Chapter 5 of this thesis, we explored how reward affects sequential movements and how manipulating task difficulty can impact reward-based improvement in sequential movement fusion. Our findings suggest that sequential movement fusion is more effective when the task is easy, and this effect is further enhanced by the presence of a reward. The thesis concludes with Chapter 6, which synthesizes the findings, discusses their implications, and proposes directions for future research. This study not only advances our understanding of reward-based motor learning but also provides a foundation for optimizing reward utilization in clinical settings, offering hope for improved rehabilitation strategies.20 0Item Restricted Behavioural testing in the neonatal rodent invaluable tools for understanding models of brain injury(RMIT University, 2024) Baabbad, Murad; Bobbi, FleissBackground: Perinatal ischemic stroke causes long-term neurological problems that consist of behavioural deficits, cognitive as well as motor deficits that lead to increased social and health care costs. The incidence of symptomatic perinatal ischemic stroke in infants is at least 1 in every 4,000 births. Photothrombotic cerebral ischemic stroke influences purposeful performance controlled by the impacted areas of the brain. Ischemic or haemorrhagic stroke causes post-stroke movement disorders, as well as vascular parkinsonism and hemichorea- hemiballismus disorders. To understand the effects of neonatal and prenatal stroke on infants, this project examined the behavioural analysis of neonatal rats subjected to a photothrombotic stroke and controls (sham-operated) using the carotid artery ligation and exposure to hypoxia and middle cerebral arty occlusion models. The aim of this study was to conducted wire hang tests to examine the behaviour in stroke effected animals to determine whether these functions are impaired by stroke or not. Our hypothesis based on the literate was that stroke would cause the deficits in the behavioural testing. Results- The study found that neonatal stroke induced by ischemic injury impaired behavioural changes of the rats that lead to a significant reduction of hanging (grip) capabilities. However, the stroke did not impair the rat pup’s ability to use their paws to hang on the wire. We also found that the location of the stroke was important in causing the wire hang deficit, as animals with mis-placed stroke lesions had no deficit. Conclusion - subjecting rats to a photothrombotic stroke impaired hanging behaviour and capabilities, indicating that it is an appropriate model (in this regard) for studying neuroprotective agents in the future.9 0Item Restricted Exploring and Using Storytelling for People with Stroke: Implications for Occupational Therapy Practice and Research(Saudi Digital Library, 2023-12-15) Alwafi, Rana; Soundy, AndyStroke is the largest cause of severe adult disabilities in the United Kingdom (UK). Psychosocial well-being is often threatened after stroke and survivors may experience a wider range of psychosocial difficulties such as depression, anxiety, general psychological distress and social isolation. Effective psychosocial rehabilitation is associated with decreased depression and anxiety, improved quality of life and community participation following stroke. A novel intervention that has attracted attention is storytelling, a relatively new behavioural intervention that can help stroke patients meet their psychological needs. Reviews of storytelling interventions in chronic illness groups have revealed consistent evidence demonstrating a variety of benefits, including lower levels of depression, increased socialisation and higher levels of perceived quality of life. However, the usefulness of storytelling as a therapeutic intervention in stroke has received less attention, even though it can be an approachable and cost-effective intervention to promote psychosocial well-being following stroke. Moreover, it can be utilised as an educational tool to improve psychological and communication skills of healthcare professionals (HCPs) who work with stroke patients. Previous research has shown that student HCPs lacked confidence in their core communication skills and that there is scant evidence of psychological and communication skills training in UK institutions for trainee HCPs. Receiving health care from professionals who have received psychological training has been proved to improve patients’ well-being. This thesis presents four studies to establish the usefulness of storytelling as a therapeutic intervention to promote psychosocial well-being in stroke survivors and as an educational tool to enhance the psychological and communication skills of HCP students who work with stroke patients . Study 1 was an integrated review aimed to establish existing evidence of the effects iii of storytelling and ‘peer sharing interventions’ on coping with the psychosocial difficulties following stroke and to explore the mechanisms underlying specific outcomes. The review found that storytelling interventions can alleviate loneliness, promote hope and positivity, and facilitate coping through information sharing. The key mechanisms influencing these results seem to be social comparisons and social control. Study 2 was a qualitative study aimed to examine illness narrative master plots as expressed by people who had had a stroke. The results provided a novel perspective on illness narrative by identifying a new master plot expressed by people with stroke, entitled ‘overcoming the monster’. The plot relates to stroke as the different experiences related to, and following the onset of stroke can represent a monster which needs to be overcome. Examples of a ‘monster’ for people following a stroke include interpersonal challenges, mental health challenges, isolation and changes to their social identities. Study 3 aimed to explore the responses of physiotherapy students to three versions of this master plot. It found that ‘overcoming the monster’ elicited more empathic responses from students than has been identified in other master plots. Study 4 aimed to test the impact and understand the experience of physiotherapy students who participated in a novel placement that integrated the model of emotions, adaptation and hope tool and a narrative-based approach with simulated training (role play) and in-person training with stroke survivors. The results were improved communication skills, increased self-efficacy, reduced stigma and enhanced empathy among physiotherapy students .Overall, narrative-based/storytelling interventions appeared to be potentially useful therapeutically in promoting the psychosocial well-being of stroke survivors, as well as a valuable educational tool for improving the psychological and communication skills of HCP students.11 0Item Restricted Role of Tissue Doppler Ultrasonography for Emergency Assessment of Stroke(Saudi Digital Library, 2023-12-01) Almudayni, Alanoud; Chung, Emma; Lecchini-Visintini, AndreaBackground: The primary aims of my PhD project were to explore the feasibility of acquiring high quality brain tissue pulsation (BTP) measurements from stroke patients. The impact of artefacts on BTP estimates, and potential differences in BTP amplitude between patients and healthy controls are explored. My secondary aim was to better understand the impact of middle cerebral artery blood flow velocity (MCAv) changes on BTP amplitude. Methods: A systematic review was conducted to explore existing methods of investigating BTPs using MR techniques. A reduction in MCAv, induced in healthy volunteers through ingestion of caffeine, was used to explore the impact of lowering MCAv on BTP amplitude (measured using a transcranial tissue Doppler [TCTD] system) under controlled conditions. TCTD and physiological measurement data were obtained from stroke patients to investigate the quality of recordings, impact of artefacts on BTP estimates, and impact of stroke on BTP amplitude. Results: The systematic review confirmed that brain motion varies regionally within the brain, and that BTPs may be altered in the presence of pathology (e.g. Chiari I malformation). The physiological measurement study showed that BTP amplitude increases in response to caffeine. Analysis of healthy volunteer and patient data showed that artefacts tended to increase estimates of BTP amplitude. Analysis of the first 20 gates (which show limited penetration) from 18 ischaemic stroke patients and control subjects suggested a median (IQR) BTP amplitude in ischaemic stroke patients measured through the forehead of 8 μm (5.7, 13.6) compared to 16.2 μm (10.6, 24) in 24 age-matched control subjects. Waveform shapes appeared qualitatively similar to control subjects. Conclusions: BTP amplitude appears to be lower in stroke patients compared to healthy controls but increases in response to caffeine, which lowers MCAv. Further work is required to better understand the relationship between BTPs and cerebrovascular physiology.20 0Item Restricted The Effect of Repetitive Peripheral Magnetic Stimulation on Cortical Excitability and Motor Performance(Saudi Digital Library, 2024-10-17) Aljuhni, Rehab; Madhavan, SangeethaThe aim of this dissertation was to investigate the effects of repetitive peripheral magnetic stimulation (rPMS) as a sensory-based priming technique on lower limb corticomotor excitability (CME) and motor skill performance in both stroke-affected and healthy individuals. Our primary goal was to ascertain the duration-dependent effects of rPMS on lower limb CME in healthy participants and lower limb motor skill performance in individuals with stroke. rPMS was administered to the belly of the TA muscle at 10% above motor threshold (MT). Each participant received approximately 2400 pulses delivered at a frequency of 20 Hz for 3 seconds, followed by a 19-second rest period. We employed transcranial magnetic stimulation to evaluate alterations in CME following a single application of rPMS. Our findings revealed a significant increase in the motor evoked potential (MEP) amplitude of the stimulated TA; however, no changes were observed in MEP latency or MEP duration. Moreover, we employed a custom-built ankle device to assess lower limb motor skill performance, comparing the effects of rPMS with Sham stimulation. The Sham stimulation was applied to the dorsal part of the foot at minimal intensity. Our results suggest that rPMS did not induce any significant changes in motor skill performance for individuals with stroke compared to sham stimulation. In conclusion, rPMS shows promise in enhancing MEP amplitude in the motor cortex, but it demonstrates limited effectiveness in improving complex tasks such as motor skill performance. Future research should focus on establishing a standardized protocol for rPMS applications.26 0Item Restricted A Comparison of Proximal and Distal Upper Limb Impairment Patterns after Stroke(Saudi Digital Library, 2023-08-28) AL MIARAJ, AHMAD; Ward, NickStroke is a widespread and devastating disorder leading to significant morbidity and mortality worldwide. Upper limb impairment is a typical consequence of stroke, affecting both the proximal and distal areas of the arm. However, there is a lack of consensus on these deficits' severity and recovery patterns. This study will fill a research gap by examining intensive upper limb rehabilitation outcomes in chronic stroke patients. Also, the study aimed to find the distribution of distal and proximal impairments among chronic stroke patients who underwent an intensive rehabilitation program. Moreover, the study investigated the relationship between the distal-proximal ratio and the severity of the condition in individuals with chronic stroke. This study used a cross-sectional approach and analysed data from chronic stroke survivors who were assessed and received therapy at University College London's Queen Square Upper Limb neurorehabilitation program. The findings imply that the intensive intervention caused a significant change in upper limb function as measured by functional outcome measures in both the short and long term. Also, the findings revealed that the distribution of impairments was primarily distal, with a greater percentage of impairments identified in the wrist and hand regions than in the shoulder and elbow. Further, the study found a positive association between the distal-proximal ratio and functional outcome measure scores, revealing that larger distal-proximal ratios were associated with better functional outcomes. The improvement observed in this study is consistent with previous research that utilized similar treatment approaches for chronic stroke patients. Additional research is needed to investigate effective intervention protocols, long-term effects, and factors impacting rehabilitation efficacy in people with chronic stroke.33 0