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(1)Enriched, task-specific therapy in the chronic phase after stroke   . ƒ”ƒ‹˜‡.  .  . ‡’ƒ”–‡–‘ˆ ‡ƒŽ–Šƒ†‡Šƒ„‹Ž‹–ƒ–‹‘.

(2) •–‹–—–‡‘ˆ‡—”‘• ‹‡ ‡ƒ†Š›•‹‘Ž‘‰›. ƒŠŽ‰”‡•ƒ ƒ†‡›ǡ‹˜‡”•‹–›‘ˆ ‘–Š‡„—”‰.      . ‘–Š‡„—”‰ʹͲʹͳ.

(3) Printed in Boras, Sweden 2021 Stema Specialtryck AB. NMÄR NEN M Ä R KE KE VANE VA. TT.  Enriched, task-specific therapy in the chronic phase after stroke  © 2021 Sara Vive  sara.vive@neuro.gu.se sara.vive@neurocampus.se  ISBN 978-91-8009-262-3 (PRINT) ISBN 978-91-8009-263-0 (PDF) http://hdl.handle.net/2077/67639. SS. Cover photography: Anna Sjoholm and Pablo Cardenas Rìos . Trycksak Trycksak 3041 0234 3041 0234.

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(6) . “Always more questions than answers, there are”. Yoda.      . .   Till Linus, Ossian och Elis.

(7) Abstract A stroke often radically changes the life situation for the affected indi-. vidual, both physically, as well as psychologically and socially. Recent. findings in neuroscience suggest that the adult brain structure can. change in response to learning but also environmental demands. New research give reason to believe that different kinds of sensory stimu-. lating activities and exercises can enhance the neuroplasticity and re-. organizational processes and improve mobility and cognition. In. animal studies, an Enriched Environment (EE) - including socialization,. exercise, sensory and cognitive stimulation and task-specific exercise. has proved to be an effective intervention for boosting the brain’s ability to reorganize and recover after a stroke. Until recently, an EE has remained mainly a laboratory phenomenon with few examples of. translation to the clinical setting. There are now several studies show-. ing that functional improvements are possible many years after stroke.. Most rehabilitation therapies are primarily offered during the acute. and subacute stages while it is unusual for stroke-affected individuals. to be offered comprehensive rehabilitation during later stages of. stroke.. This thesis includes four papers.. Study I is a longitudinal uncontrolled observational study, with a within-subject, repeated-measures design. The study assessed. whether enriched task-specific therapy (ETT) contributed to any mo-. tor and health-related changes, in individuals with chronic stroke. The intervention was a 3-week long, high intensity, task-specific training. program in an enriched environment in Spain. The ETT program also.

(8) included social and sensory stimulation and speech and language therapy (SLT) to support those with speech, language and communication needs. The 39 participants who completed the ETT program did im-. prove functional motor ability, balance, gait speed and endurance, and. were shown to achieve gains in multiple dimensions of health. The improvements were sustained at the 6-month follow-up.. Study II is a qualitative study using interviews as a tool to create an. understanding of how individuals in a chronic stage of stroke experi-. ence ETT. Focus group interviews were conducted with twenty participants after their completion of the ETT program. Analysis was. performed using qualitative content analysis. Three main categories. were identified describing the informants’ experiences of the ETT pro-. gram. These categories were; 1. The program—different and hard – de-. scribing the participants’ experience of the ETT as strenuous and. different compared to earlier rehabilitation; 2. My body and mind learn. to know better – describing the experience of improvements of the par-. ticipants’ body function and functional ability, as well as behavioural changes experienced throughout the ETT; and 3. The need and trust. from others – highlighting trust in rehabilitation clinicians and the support of family and other participants. From these categories, a main theme could be extracted: It’s hard but possible—but not alone!. Study III is a longitudinal observational study using advanced three-di-. mensional gait analyses to assess gait and movement-patterns. The. aim of the study was to investigate whether the ETT program did pro-. duce any significant changes in spatiotemporal gait parameters or kinematic features of gait. The study had a single-subject-experimental. design (SSED) and four participants from study I (all were men) in. chronic phase after stroke participated. The study showed that two of.

(9) the four participants had significant improvements in gait kinematics, symmetry, and spatiotemporal variables after the intervention. . Study IV is a cross-sectional observational controlled study in which. we studied the relationship between comfortable and maximum gait. speed in individuals with mild to moderately severe disability after. stroke. Furthermore, we studied if this relationship in individuals with chronic stroke differed from that of a control group of community-. dwelling elderly. We found that the maximum gait speed in the indi-. viduals with stroke can be predicted by the comfortable gait speed,. with a coefficient at 1.41. This relationship differed significantly from. that of the control group, for which the corresponding coefficient was 1.20. In the control group, higher age and being a woman had a nega-. tive relationship with maximum gait speed and the corrected relationship was 1.07. In the stroke group, age, gender and time since stroke. did not affect this relationship, while the degree of disability was negatively correlated with maximum gait speed - but not when included in. the multiple analysis.  . In conclusion, this thesis shows that ETT applied to individuals in a. chronic phase after stroke produce beneficial gains in functional motor ability, gait speed, balance and multiple dimensions of health. ETT also seem to have profound emotional impact and might improve kine-. matic gait pattern. In order to understand the underlying mechanisms of recovery and improvement, further research is needed.. . Keywords. stroke; rehabilitation; function; activity; participation; health; enriched environment; intense training; qualitative research; gait analysis; gait speed..

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(11) Sammanfattning pa svenska En stroke kan ofta forandra livet radikalt for den som drabbas, saval. pa ett fysiskt, psykologiskt som pa ett socialt plan. Ny forskning ger an-. ledning att tro att olika typer av sensorisk stimulering, aktivering och. traning kan paskynda hjarnans aterhamtning och lakning av bade motorisk och kognitiv funktion. Djurstudier har visat att en berikad miljö. – som innefattar saval sociala interaktioner, fysisk aktivitet, sensorisk som kognitiv stimulering - och aven uppgiftsspecifik träning visat sig. vara ett satt att nyttja och forstarka hjarnans plasticitet och omorganisation och bidra till aterhamtning efter en stroke. Fram tills nu har be-. greppet berikad miljo varit framst ett forskningsbegrepp med fa forsok. till overforing i klinisk rehabilitering. Det finns dock ett flertal studier. som visar att aterhamtning och forbattring ar mojlig aven flera ar efter en stroke. Trots detta ar manga rehabiliteringsinsatser fokuserade till. det tidiga skedet efter insjuknandet i stroke, och det ar ovanligt att individer med stroke erbjuds sammanhangande intensiva rehabiliteringsinsatser i senare skeden efter sin stroke. Denna avhandling innehaller fyra delarbeten.. Delarbete I ar en okontrollerad longitudinell observationsstudie med upprepade matningar dar varje individ utgor sin egen kontroll. I stu-. dien undersokte vi om ett uppgiftsspecifikt intensivt traningsprogram. i en berikad miljo (ETT) for individer i ett kroniskt skede efter stroke resulterade i forandringar avseende motorik och olika aspekter av. halsa. Interventionen var ett tre veckor langt, hogintensivt, uppgifts-. specifikt program i en berikad miljo i Spanien. ETT-programmet innefattade aven social och sensorisk stimulering samt tal- och.

(12) spraktraning for deltagare med behov av sadana insatser. De 39 deltagarna som genomforde programmet uppvisade forbattring avseende. funktionell motorisk formaga, balans, ganghastighet och uthallighet i. gang. Programmet resulterade aven i upplevd forbattring av olika halsorelaterade domaner. Forbattringarna kvarstod 6 manader senare.. Delarbete II ar en kvalitativ studie med intervjuer som verktyg for att. skapa en forstaelse om hur individer i ett kroniskt skede av stroke. upplever ETT. Fokusgruppsintervjuer utfordes med 20 individer efter. att de deltagit i ETT-programmet. Intervjuerna resulterade i att tre hu-. vudkategorier kunde identifieras, vilka beskrev upplevelsen av pro-. grammet.1. Programmet – annorlunda och tufft – beskrev deltagarnas upplevelse av programmet som anstrangande, kravande och olikt annan rehabilitering de upplevt. 2. Kroppslig och mental inlärning – be-. skrev positiva forandringar pa kroppsfunktioner och aktiviteter, men ocksa insikter och beteendeforandringar som en foljd av ETT-. programmet. 3. Behovet av tillit till och motivation från andra – tryckte pa vikten av tillit till rehabiliteringspersonalen och stodet fran anho-. riga och andra deltagare. Fran dessa tre kategorier kunde ett overgripande tema utronas – Det är svårt men möjligt - men inte ensam!. Delarbete III ar en longitudinell observationsstudie som undersoker. gangmonstret i ett tredimensionellt rorelselaboratorium. Syftet med. delstudien var att undersoka om ETT-interventionen resulterade i sig-. nifikanta forandringar avseende spatiotemporala gangparametrar (parametrar i tid och rum), symmetri eller kinematik (ledvinklar) vid. gang. Studien hade en single-subject-experimental design (SSED) och fyra deltagare fran studie I (samtliga var man) i kronisk fas efter. stroke deltog. Av dessa fyra individer, sags signifikanta och kliniskt re-.

(13) levanta forandringar for tva av deltagarna, gallande gangens kinematik, symmetri och spatiotemporala gangparametrar efter ETTprogrammet. . Delarbete IV ar en observationsstudie dar sambandet mellan maximal och sjalvvald ganghastighet hos individer i ett kroniskt skede efter. stroke och med mild till mattligt svar funktionsnedsattning, undersoktes. Vidare undersoktes hur detta samband skilde sig mellan strokegruppen och friska aldre individer. Strokegruppen bestod av. deltagare fran delstudie I samt individer fran en annan studie-kohort,. sammanlagt 104 individer. Dessa jamfordes mot kontrollgruppen, 154 aldre friska hemmaboende forsokspersoner. Analysen visade att kontrollgruppen gick signifikant snabbare an strokegruppen. Ett linjart samband sags mellan maximal och sjalvvald hastighet i bada grup-. perna. Regressionskoefficienten mellan sjalvvald och maximal hastig-. het hos strokegruppen var 1.41 dvs maxhastigheten kunde forklaras. genom 1.41 ganger den sjalvvalda hastigheten. I kontrollgruppen var. motsvarande ojusterade siffra 1.20. I kontrollgruppen var dock lagre. alder och att vara man korrelerat till hogre maxhastighet och den ju-. sterade koefficienten var 1.07. I strokegruppen sags grad av funktionsbortfall vara negativt korrelerat till maximal ganghastighet, men foll. inte ut signifikant da denna parameter inkluderades i multivariabelanalysen. . Sammanfattningsvis visar denna avhandling att ETT resulterade i for-. battringar av funktionell motorisk formaga, ganghastighet, balans, halsorelaterad livskvalitet och flera andra aspekter av halsa hos individer i ett kroniskt skede efter stroke. ETT verkar ocksa ha inneburit starka. emotionella upplevelser och kan ha haft en paverkan pa gangmonstret hos deltagarna. Mer forskning kravs for att forsta de underliggande mekanismerna for aterhamtning och forbattring..

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(15) List of papers This thesis is based on the following studies, referred to in the text by their roman numerals.

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(22) Ǥ. ‹˜‡ǡˆ ‡‹Œ‡”•–ƒ ǡ—Š ǡ—‡–‘”’Ǧ¡ŽŽǤ”‹ Š‡†ǡ ƒ•Ǧ’‡ ‹ˆ‹ Š‡”ƒ’›‹–Š‡Š”‘‹ Šƒ•‡ˆ–‡”–”‘‡ǣšǦ ’Ž‘”ƒ–‘”›–—†›Ǥ ‡—”‘ŽŠ›•Š‡”ǤʹͲʹͲ’”ǢͶͶȋʹȌǣͳͶͷǦͳͷͷǤ †‘‹ǣͳͲǤͳͲͻ͹ȀǤͲͲͲͲͲͲͲͲͲͲͲͲͲ͵ͲͻǤ

(23) ǣ͵ʹͳͳͺ͸ͳ͸Ǣ 

(24) ǣ͹Ͳ͹͹ͻ͹Ͳ. ‹˜‡ǡ—‡–‘”’Ǧ¡ŽŽǡƒ”Ž••‘ Ǥš’‡”‹‡ ‡‘ˆ‡”‹ Š‡†”‡Ǧ Šƒ„‹Ž‹–ƒ–‹‘‹–Š‡ Š”‘‹ ’Šƒ•‡‘ˆ•–”‘‡Ǥ‹•ƒ„‹Ž‡Šƒ„‹ŽǤʹͲʹͲ —ͳǣͳǦͺǤ†‘‹ǣͳͲǤͳͲͺͲȀͲͻ͸͵ͺʹͺͺǤʹͲʹͲǤͳ͹͸ͺͷͻͺǤ’—„ƒŠ‡ƒ†‘ˆ ’”‹–Ǥ

(25) ǣ͵ʹͶ͹ͺͷ͹͵Ǥ. ‹˜‡ǡò‰‡”ǡ”ƒ„‡”‰ǡ—‡–‘”’Ǧ¡ŽŽǤ ƒ‹–‹‡ƒ–‹ • ƒ†’ƒ–‹‘–‡’‘”ƒŽƒ”‹ƒ„Ž‡•ƒˆ–‡””‹ Š‡†ǡƒ•Ǧ’‡ ‹ˆ‹  Š‡”ƒ’›‹–Š‡Š”‘‹ Šƒ•‡ƒˆ–‡”–”‘‡Ǥ‹‰Ž‡Ǧ—„Œ‡ –šǦ ’‡”‹‡–ƒŽ‡•‹‰–—†›Ǥ” Š‹˜‡•‘ˆŽ‹‹ ƒŽƒ†‡†‹ ƒŽƒ•‡ ‡’‘”–•ͷȋʹͲʹͳȌǣ͵ʹͷǦ͵͵ͺǤ. ‹˜‡ǡŽƒǡ—‡–‘”’Ǧ¡ŽŽǤ‘ˆ‘”–ƒ„Ž‡ƒ†ƒš‹—‰ƒ‹– •’‡‡†‹‹†‹˜‹†—ƒŽ•™‹–Š Š”‘‹ •–”‘‡ƒ† ‘—‹–›Ǧ†™‡ŽŽǦ ‹‰ ‘–”‘Ž•ǤʹͲʹͳ—„‹––‡†Ǥ  .

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(27) ‘–‡–. 20. Abbreviation. 21. Definitions. 23. 1. Introduction. ʹ͵. . ʹ͵. . ͳǤͳ–”‘‡. . ͳǤͳǤͳ–”‘‡†‡ˆ‹‹–‹‘ƒ†‡’‹†‡‹‘Ž‘‰›. . ͳǤͳǤ͵‘•‡“—‡ ‡•‘ˆ•–”‘‡. . ͳǤͳǤͷ‘”ƒŽ‰ƒ‹–. ʹͶ. . ͳǤͳǤʹŽƒ•–‹ ‹–›ƒˆ–‡”•–”‘‡. ʹͷ. . . ʹͶ. ʹ͹. ʹͺ. ʹͻ.  . . . ͳǤͳǤͶ–”‘‡‹–Š‡

(28)   ‘–‡š–. . ͳǤͳǤ͸ ƒ‹–ƒˆ–‡”•–”‘‡. ͳǤʹ–”‘‡‡Šƒ„‹Ž‹–ƒ–‹‘. ͵Ͳ. . . ͳǤʹǤͳ–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘‹–‡”˜‡–‹‘•. ͵ʹ. . . ͳǤ͵Ǥͳ‡˜‡Ž‘’‡–‘ˆ–Š‡”‹ Š‡†˜‹”‘‡–’ƒ”ƒ†‹‰. ͵ʹ. ͵Ͷ. ͵ͻ. . .  . . . . . . . ͳǤ͵Ǥʹ”‹ Š‡†˜‹”‘‡–‹•–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘. ͳǤ͵Ǥ͵–—†‹‡•—•‹‰–‡”‹‘Ž‘‰‹‡•‹ Ž—†‹‰‡Ž‡‡–•‘ˆƒ. . ͶͲ. 42. 2. Aims. 44. 3. Materials and Methods. ͶͶ. . ͳǤ͵”‹ Š‡†˜‹”‘‡–. ͳǤ͵ǤͶ—ƒ”‹œƒ–‹‘‘ˆ‹ Ž‹‹ ƒŽ•–”‘‡•‡––‹‰. ͵Ǥͳƒ–‡”‹ƒŽ. ͶͶ. . . ͵ǤͳǤͳ–—†›•‡––‹‰ƒ††‡•‹‰. Ͷ͸. . . ͵ǤͳǤ͵—„Œ‡ –•. Ͷͺ. . ͵Ǥʹ

(29) –‡”˜‡–‹‘. Ͷͷ. Ͷ͹. . . . . ͵ǤͳǤʹ—„Œ‡ –”‡ ”—‹–‡–. ͵ǤͳǤͶŽ‹‰‹„‹Ž‹–›.

(30) Ͷͺ. . . ͵ǤʹǤͳ. ͷͲ. . . ͵ǤʹǤʹƒ•‡Ž‹‡’Šƒ•‡. ͷͷ. . . ͵Ǥ͵Ǥͳ‡‘‰”ƒ’Š‹ †ƒ–ƒ. ͷʹ. ͷͷ. ͷͺ. ͸Ͳ. . . . . ͵Ǥ͵‡ƒ•—”‡•. . . . ͵Ǥ͵Ǥ͵ƒ–‹‡–‡’‘”–‡†—– ‘‡‡ƒ•—”‡•. ͵Ǥ͵ǤͶ‹‡ƒ–‹ •ƒ†•’ƒ–‹‘–‡’‘”ƒŽ‰ƒ‹–’ƒ”ƒ‡–‡”•. ͸ͳ ͸͵. . 66. 4. Ethical Considerations. 67. 5. Results. ͸͹. ͸ͺ. ͸ͺ. ͸ͻ. ͹ͷ. . . . . . . ͵Ǥ͵Ǥʹ„•‡”˜‡”ƒ••‡••‡†‡ƒ•—”‡•. . ͵Ǥ͵Ǥͷ—ƒŽ‹–ƒ–‹˜‡‡–Š‘†• ͵Ǥ͵Ǥ͸–ƒ–‹•–‹ •. ͷǤͳ‡‘‰”ƒ’Š‹ • . . ͷǤͳǤͳ –‹˜‹–‹‡•†—”‹‰„ƒ•‡Ž‹‡’Šƒ•‡. ͷǤͳǤʹ†˜‡”•‡‡˜‡–•ƒ†‹••‹‰†ƒ–ƒ. ͷǤʹ‘–‘”ˆ‹†‹‰•. ͷǤ͵•ˆ‹†‹‰•. ͹ͷ. . . ͷǤ͵Ǥͳƒ•‡Ž‹‡’Šƒ•‡ˆ‹†‹‰•. ͹ͷ. . . ͷǤ͵Ǥ͵Š”‡‡‘–Š•ˆ‘ŽŽ‘™—’. ͹ͷ. ͹͸. . . . ͷǤ͵Ǥʹ‘•–Ǧ. . ͷǤ͵ǤͶ‹š‘–Š•ˆ‘ŽŽ‘™—’. . ͷǤ͵Ǥͳƒ‹ ƒ–‡‰‘”‹‡•. ͹ͻ. . ͷǤ͵—ƒŽ‹–ƒ–‹˜‡ˆ‹†‹‰•. ͹ͻ. . . ͹ͻ. ͺʹ. . . . . ͷǤ͵Ǥʹ—„ ƒ–‡‰‘”‹‡•. ͷǤ͵Ǥ͵˜‡”ƒŽŽ–Š‡‡. ͺʹ. ͷǤͶ ƒ‹–•’‡‡† ‘””‡Žƒ–‹‘ƒŽˆ‹†‹‰•. 84. 6. Discussion. 94. 7. Conclusion. 96. 8. Future perspective.

(31) 98. Acknowledgements. 101 References 113 Appendix.

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(33) Abbreviation 10MWT 30MWT 6MWT BBS BBT CIMT DLS EE EQ5D ETT FES FIS HRQOL ICF ITT LISAT LOCF MADRS MCID MDC M-MAS UAS MoCA MRS QOL SLP SLT TSDB UC. 10-meter walk test 30-meter walk test 6-minute walk test Berg Balance Scale Š‡‘šƲŽ‘ •‡•– ‘•–”ƒ‹–Ǧ

(34) †— ‡†‘˜‡‡–Š‡”ƒ’› ‘—„Ž‡ǦŽ‹„•—’’‘”– Enriched Environment —”‘’‡ƒ—ƒŽ‹–›‘ˆ‹ˆ‡ˆ‹˜‡Ǧ†‹‡•‹‘ “—‡•–‹‘ƒ‹”‡ Enriched Task-Specific Therapy Falls Efficacy Scale Fatigue Impact Scale Health Related Quality of Life The

(35) –‡”ƒ–‹‘ƒŽŽƒ••‹ˆ‹ ƒ–‹‘‘ˆ — –‹‘Ǧ ‹‰ǡ‹•ƒ„‹Ž‹–›ƒ† ‡ƒŽ–Š Intention To Treat ‹ˆ‡ƒ–‹•ˆƒ –‹‘Š‡ Ž‹•– Last Observation Carried Forward Montgomery Asberg Depression Rating Scale Minimal Clinically Important Difference Minimal Detectable Change Modified Motor Assessment Scale according to Uppsala Akademiska Sjukhuset ‘–”‡ƒŽ‘‰‹–‹˜‡••‡••‡– Modified Rankin Scale Quality of Life Speech-Language pathologist Speech-Language Therapy Two Standard Deviation Band Method Usual Care.

(36)  Definitions Activity. The execution of a task or action by an individual (WHO, 2001). Body Functions. . The physiological functions of body systems (WHO, 2001) . Body structures. . Anatomical parts of the body. such as organs, limbs and their components (WHO, 2001)  Impairment. . Problems in body function or. structure as a significant deviation or loss (WHO, 2001) Functioning. . Umbrella term of Body Func-. tions and Structures and Activities and Participation, positive aspects (WHO, 2001).

(37) Participation. Involvement in a life situation (WHO, 2001). Capacity. . Ability to execute a task or an action in a standardised environmental (WHO, 2001) . Performance. . What a person does in his or her current environment (WHO,.  . 2001).

(38) 1. Introduction ͳǤͳ–”‘‡. 1.1.1 Stroke definition and epidemiology. According to the World Health Organization (WHO) stroke is defined as an “acute neurological dysfunction of vascular origin with sudden or at least. rapid occurrence of symptoms or signs corresponding to involvement of focal areas of the brain lasting >24 hours unless interrupted by surgery or. death.”[1] The prevalence of stroke in Sweden is 300 cases per 100 000 in-. habitants, where 200 are individuals who have their first time stroke. Every. year in Sweden, 25 000 - 30 000 individuals suffer from acute stroke, and. about 25 % of those unfortunately die from the stroke within a month.. About 74% are over 70 years when the stroke occurs, and about 4% are un-. der 50 years of age. [2] Although the stroke mortality rate over the past two. decades has declined, the amount of people affected by, or with long-lasting. disabilities from stroke has increased around the world, in both men and. women of all ages. [1] Stroke is the second most common cause of death and a leading cause of adult disability worldwide. [3] Stroke often lead to lasting consequences, which usually are multifaceted and can result in problems across multiple domains of functioning, activities and participation. [4] . 1. INTRODUCTION. 23.

(39) . 1.1.2. Plasticity after stroke Most of those who survive the acute phase improve spontaneously the first. months after stroke onset. [4] The mechanisms causing these functional improvements are not completely known. [5] One possible explanation is that the stroke-affected individuals develop compensatory strategies in an at-. tempt to regain lost functions. One other possible explanation is the reor-. ganization that takes place in the cerebral tissues around the lesion within. the damaged hemisphere, as well as in the undamaged hemisphere. [6] The brain´s ability to reorganize and modify itself after an injury is known as. neuroplasticity, which is considered to be the main reason why individuals with brain damage can improve function after a stroke. [7] Neuroplasticity is seen during the developmental stages of the brain and during learning.. Research over the last 50 years has led to an increased knowledge about the brain’s ability to change. Previously, the regrowth of connections after damage in the adult human brain was viewed upon as impossible. This. knowledge contributes to a paradigm shift with positive implications for the rehabilitation of individuals with stroke. [8] The latest research findings on stroke have shown that the brain has a significant and life-long potential of plasticity. [9-12]. 1.1.3. Consequences of stroke Regardless of the etiology of a cerebrovascular disease, the symptoms of. stroke vary depending on the area of the brain exposed to oxygen deficiency and the extent of the damage. The signs and symptoms of a stroke as well as the degree of difficulty therefore vary from person to person. One of the most frequently observed symptoms is a mild (hemiparesis) to severe. weakness (hemiplegia) of one side of the body opposite the side of the brain 24. 1 . IN T R O D U C T I O N .

(40) affected by the stroke. In addition to the motor difficulties that often follow a stroke, other common symptoms are lack of sensory functions, language. and speaking problems, perceptive problems, visual loss, attention deficits,. other cognitive problems and motor planning disorders. [4] Initially, 80% of. the survivors suffer a hemiparesis of the body, with consequences regarding the individual´s activities of daily living (ADL), such as eating, drinking, talk-. ing, walking and grasping, which in turn affect the individuals’ ability to participate in social, family and personal activities. [1,3,4,13] Previous research. describe that most recovery from stroke occurs within the first six months,. and most commonly, the individual then reaches a plateau. [14,15] Approximately 1/3 of the survivors suffer from substantial impairments still pre-. sent 6–12 months after stroke onset. [16] As much as 40 to 60% of stroke-. affected individuals reach an acceptable degree of functional independence, however, at a highly variable speed during the period 3 months to 10 years after the stroke onset. [17,18] . 1.1.4 Stroke in the ICF context The consequences of a stroke can be described and defined using a specific classification system, The International Classification of Functioning, Disa-. bility and Health (ICF, figure 1). [19,20] In ICF, status of health, illness or injury can be placed in a dynamic system together with dimensions such as. body functions and structures, activity and participation. The system may. be affected by contextual factors, e.g. environmental and personal ones (Figure 1). In the case of the activity and participation list of domains, two important qualifiers are described: capacity and performance. The. performance qualifier describes what an individual does in his or her cur-. rent environment. The capacity qualifier describes an individual’s ability to. execute a task. [19] The evaluation in the present studies aims at describing. 1. INTRODUCTION. 25.

(41) several levels of functional ability and impairment in relation to health according to the ICF. ICF is commonly used in rehabilitation and research. worldwide. However, several issues has been raised concerning the system, for example the need to include subjective dimensions in the framework,. such as quality of life (QOL). [19,21] The definition of QOL and Health-re-. lated Quality of Life (HRQoL) are often overlapping, but in this thesis, the definition of HRQoL used is set to self-perceived health-status [22] . Figure 1ǤŠ‡‘†‡Ž‘ˆ

(42) –‡”ƒ–‹‘ƒŽŽƒ••‹ˆ‹ ƒ–‹‘‘ˆ — –‹‘‹‰ǡ‹•ƒ„‹Ž‹–›ƒ† ‡ƒŽ–Š ȋ

(43)  ȌǤ .

(44) ’”‘˜‡‡–•‹–Š‡

(45)   ‘’‘‡–•„‘†›•–”— –—”‡•ǡ„‘†›ˆ— –‹‘•ǡƒ Ǧ. –‹˜‹–›ƒ†’ƒ”–‹ ‹’ƒ–‹‘ƒˆ–‡”ƒ•–”‘‡‹‰Š–„‡†—‡–‘’Žƒ•–‹ ‹–›’”‘ ‡••‡•ǡ. ”‡•–‘”ƒ–‹˜‡’”‘ ‡••‡•ƒ† ‘’‡•ƒ–‘”›‡ Šƒ‹••Ǥȏʹ͵ǡʹͶȐ”—‡”‡ ‘˜Ǧ. ‡”›†‡ˆ‹‡•–Š‡”‡•–‘”‹‰‘ˆ–Š‡ƒ„‹Ž‹–›–‘’‡”ˆ‘”ƒ‘˜‡‡–‹–Š‡•ƒ‡. ‹‡ƒ–‹ ƒ‡”ƒ•‹–™ƒ•’‡”ˆ‘”‡†„‡ˆ‘”‡–Š‡‹Œ—”›ǡƒ† ‘’‡•ƒ–‹‘. 26. 1 . IN T R O D U C T I O N . .

(46) ‹•†‡• ”‹„‡†ƒ•’‡”ˆ‘”‹‰ƒ‘Ž†‘˜‡‡–‹ƒ‡™ƒ‡”ǡ—•‹‰ƒŽ–‡”Ǧ. ƒ–‹˜‡‘˜‡‡–’ƒ––‡”ǡ”‡•—Ž–‹‰‹ƒ Šƒ‰‡‹—• Ž‡ƒ –‹˜ƒ–‹‘ǡ†‹ˆˆ‡”Ǧ. ‡––‹‹‰ƒ†‹‡ƒ–‹ ’ƒ––‡”•Ǥȏʹ͵ǦʹͷȐ‡ ‹•‹‘•ƒ„‘—–™Š‡–Š‡”. „‡Šƒ˜‹‘—”ƒŽ‹’”‘˜‡‡–”‡ˆŽ‡ –•–”—‡”‡ ‘˜‡”›‘”—•‡‘ˆ ‘’‡•ƒ–‘”›. •–”ƒ–‡‰‹‡•‹•†‹ˆˆ‹ —Ž––‘ƒ‡ȏʹʹǡͳʹͺȐƒ† Ž‹‹ ƒŽ”‡Šƒ„‹Ž‹–ƒ–‹‘•–—†‹‡•ƒ”‡. ‘ˆ–‡—•— ‡••ˆ—Ž‹†‹•–‹‰—‹•Š‹‰‹ˆ–Š‡‹””‡•—Ž–•”‡ˆŽ‡ ––”—‡”‡ ‘˜‡”›‘” ‘’‡•ƒ–‹‘Ǥȏʹ͵ǦʹͷȐ. 1.1.5 Normal gait The biomechanics of normal gait are rather reproducible. [26] The prerequisites of gait according to Perry are: stability in stance, foot clearance during swing, appropriate prepositioning during swing, adequate step length and. energy conservation. [27] A gait cycle consists of steps and strides, each foot has a stance phase and swing phase, where the stance phase takes about. 60% of the cycle and the swing phase about 40%. These two phases can further be described in 8 temporal phases: Initial contact, loading response,. midstance, terminal stance, pre swing, initial swing, mid swing and terminal/late swing. [28] The normal gait and its common described temporal. phases described in figure 2. . 1. INTRODUCTION. 27.

(47) Figure 2.‘”ƒŽ‰ƒ‹–ƒ†‹–•’Šƒ•‡•ƒ†‡˜‡–•ǤŠ‡’‹ –—”‡‹• ”‘’’‡†ƒ†”‡’”‹–‡†™‹–Š ’‡”‹••‹‘ǤȏʹͻȐ. 1.1.6 Gait after stroke . Hemiparesis after stroke is one of the most commonly observed symptoms after stroke. As a consequence of hemiparesis, walking dysfunction is the. most frequently described limitation of activities after stroke and may affect independence, quality of life (QoL), and participation. [30] Hemiparesis and. walking dysfunction are shown to hamper postural control, predispose indi-. viduals to sedentary behaviours [31], and also increase the risk of falling. [11] The literature describes that improvements in gait are seen over the. first 3 to 6 months after the stroke and then plateaus. [32] During the first week after a stroke, only one third are able to walk without support. [33]. Three weeks after the stroke, 50–80% can walk unaided. [34] Even if 85% of. individuals with stroke regain independent walking ability and are able to. walk independently without assistance from another person [35], there are only about 7% who are able to walk the speeds and distances required to walk independent in the community. [36,37] Not being able to walk inde-. pendent is shown to be a predictor for discharge to nursing homes in stroke 28. 1 . IN T R O D U C T I O N .

(48) individuals. [38] Gait speed is shown to be an important predictor for the. levels of physical activity and sedentary behaviour [31] and many individuals with stroke are not able to reach the recommended amount of physical. activity after stroke specified as: cardiovascular activity 20-60 minutes 3-5. times a week.[39] The measure of gait speed in comfortable or maximum. paces are commonly used in rehabilitation evaluations [40] but the relationship between maximum and comfortable gait speed for individuals with. long-term residual disability in the chronic phase is not fully known. . ͳǤʹ–”‘‡‡Šƒ„‹Ž‹–ƒ–‹‘. WHO has defined rehabilitation as "a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments", and is. “instrumental in enabling people with limitations in functioning to remain in or return to their home or community, live independently, and participate in education, the labour market and civic life”. [41]. Physiotherapy is defined as “health profession with the expertise in movement and exercise prescription throughout the lifespan across the health. spectrum.”[42] Physiotherapy has the aim of promote health, minimise suffering and keep or regain optimal movement ability and movement perfor-. mance. [43] ”Physiotherapy involves specific interventions to individuals. and populations where movement and function are, or may be, threatened. by illness, ageing, injury, pain, disability, disease, disorder or environmental factors. Such interventions are designed and prescribed to develop, restore and maintain optimal health.” [42]. . 1. INTRODUCTION. 29.

(49) The phases after a stroke are often defined and divided into acute (from. stroke onset to 7 days after the stroke), subacute (7 days to 6 months) and. chronic phase (later that 6 months after stroke). [24] The care after an acute. stroke is recommended to be offered in a stroke unit. [44] The Swedish National Board of Health and Welfare describes that rehabilitation interven-. tions should start early and be offered as long as the individual have a need of it. [44] Unfortunately, the stroke care and rehabilitation offered to individuals with stroke are unequal around the country. [44]. 1.2.1 Stroke rehabilitation interventions . A considerably large amount of research has been done on different rehabilitation approaches designed to reduce functional impairments after stroke. The current perspective on motor learning is focused on task-specific and goal-directed training, such as training of activities and functions that are. meaningful for the individual and where the goal is set to improve these activities. [45] The present paradigm within motor relearning utilizes feed-. back, repetition, intensity and specificity with the aim to provide long-term. recovery. [4,30,46]. ‘–‘”–”ƒ‹‹‰ƒ†”‡Ž‡ƒ”‹‰‹•ƒ‹’‘”–ƒ–’ƒ”–‘ˆ•–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘Ǥ. ȏͶ͹Ȑ‡˜‡”ƒŽ’”‘‹•‹‰ƒ’’”‘ƒ Š‡•ƒ”‡„ƒ•‡†‘–Š‡‘”‹‡•‘ˆ‘–‘”Ž‡ƒ”‹‰. •— Šƒ•–”ƒ‹‹‰‘ˆƒ‘Ǧ ‘’‡•ƒ–‘”›ƒ–—”‡ǡ•‘Ǧ ƒŽŽ‡† ‘•–”ƒ‹–Ǧ‹†— ‡†. ‘˜‡‡––Š‡”ƒ’›ȋ

(50) Ȍǡˆ‘ —•‹‰‘ƒ˜‘‹†‹‰ ‘’‡•ƒ–‹‘‘ˆ–Š‡‘Ǧ. ƒˆˆ‡ –‡† •‹†‡ ‘ˆ –Š‡ „‘†› ƒ† ‡ˆ‘” ‹‰ –Š‡ —•‡ ‘ˆ –Š‡ ƒˆˆ‡ –‡† •‹†‡Ǥ ȏͶͺȐ. ‡‹‰Š–Ǧ•—’’‘”–‡†–”‡ƒ†‹ŽŽ–”ƒ‹‹‰ȏͶͻȐǡ”‘„‘–‹ –”ƒ‹‹‰ȏͷͲȐǡ ƒ”†‹‘˜ƒ• —Ǧ. Žƒ”–”ƒ‹‹‰ȏͷͳȐǡ„‹Žƒ–‡”ƒŽƒ”–”ƒ‹‹‰ȏͷʹȐǡƒ†‰‘ƒŽǦ†‹”‡ –‡†’Š›•‹ ƒŽ‡š‡”Ǧ. ‹•‡ȏͷ͵Ȑƒ”‡‘–Š‡”‡šƒ’Ž‡•‘ˆ ‹–‡”˜‡–‹‘• ™‹–Š ’‘••‹„‹Ž‹–‹‡•–‘ ‹’”‘˜‡. ”‡ ‘˜‡”›†—”‹‰•—„ƒ —–‡‘” Š”‘‹ •–ƒ‰‡•ƒˆ–‡”•–”‘‡Ǥƒ•Ǧ‘”‹‡–‡†ǡ‰‘ƒŽǦ. †‹”‡ –‡†–”ƒ‹‹‰–Šƒ–‹ Ž—†‡•ˆ‡‡†„ƒ ǡ”‡’‡–‹–‹‘ǡ‹–‡•‹–›ƒ†•’‡ ‹ˆ‹ ‹–› 30. 1 . IN T R O D U C T I O N .

(51) Šƒ•’”‘˜‡–‘„‡’”‘‹•‹‰”‡Šƒ„‹Ž‹–ƒ–‹‘‹–‡”˜‡–‹‘•‹‹’”‘˜‹‰‘˜‡Ǧ. ‡–ˆ— –‹‘ǡƒ„‹Ž‹–›ƒ†’‡”ˆ‘”ƒ ‡ǤȏͷͶǡͷͷȐ ‘”‹†‹˜‹†—ƒŽ•™‹–Š Š”‘‹  •–”‘‡ǡ•‘‡‹–‡”˜‡–‹‘•Šƒ˜‡’”‘˜‡„‡‡ˆ‹ ‹ƒŽ‹–‡”•‘ˆ™ƒŽ‹‰˜‡Ž‘ Ǧ. ‹–›ǡ†‹•–ƒ ‡™ƒŽ‡†ǡƒ†Ž‡˜‡Ž‘ˆ‹†‡’‡†‡ ‡ȏͶͷǡͷ͸ǡͷ͹Ȑǡ„—–‹’”‘˜‡‡–• ƒ”‡‘–ƒŽ™ƒ›••—•–ƒ‹‡†‹–Š‡Ž‘‰–‡”Ǥȏͷ͸ǡͷͺȐ††‹–‹‘ƒŽŽ›ǡ‡™•–—†‹‡• ‰‹˜‡ ”‡ƒ•‘ –‘ „‡Ž‹‡˜‡ –Šƒ– †‹ˆˆ‡”‡– ‹†• ‘ˆ •‡•‘”› •–‹—Žƒ–‹‰ ƒ –‹˜‹–‹‡• ƒ†‡š‡” ‹•‡• ƒ•’‡‡†—’–Š‡Š‡ƒŽ‹‰’”‘ ‡••ƒ†ˆ— –‹‘ƒŽ”‡ ‘˜‡”›‹–Š‡ „”ƒ‹ ‘ ‡”‹‰„‘–Š‘„‹Ž‹–›ƒ† ‘‰‹–‹‘ǤȏͷͻȐ. •— Šƒ•ͶͲ–‘͸ͲΨ‘ˆ•–”‘‡Ǧƒˆˆ‡ –‡†‹†‹˜‹†—ƒŽ•”‡ƒ ŠƒŽ‡˜‡Ž‘ˆ‹†‡Ǧ. ’‡†‡ ‡”‡‰ƒ”†‹‰–”ƒ•ˆ‡”•ƒ†ƒ –‹˜‹–‹‡•‹†ƒ‹Ž›Ž‹˜‹‰ƒ–ƒŠ‹‰ŠŽ›˜ƒ”‹ƒǦ „Ž‡•’‡‡††—”‹‰ƒ’‡”‹‘†ˆ”‘͵‘–Š•—–‹ŽͳͲ›‡ƒ”•ƒˆ–‡”–Š‡•–”‘‡. ‘•‡–Ǥȏͳ͹Ȑ ƒ”†™‘”‹•”‡“—‹”‡†–‘‡‡’ƒƒ Š‹‡˜‡†Ž‡˜‡Ž‘ˆ‹†‡’‡†Ǧ. ‡ ‡ǡƒ†‹†‹˜‹†—ƒŽ•‘ˆ–‡Ž‘•‡”‡Ž‡ƒ”‡†ˆ— –‹‘•ƒ‰ƒ‹‘˜‡”–‹‡Ǥȏ͸ͲȐ. ‘•–”‡Šƒ„‹Ž‹–ƒ–‹‘‡ƒ•—”‡•ƒ”‡ƒ‹Ž›ƒ’’Ž‹‡††—”‹‰–Š‡ƒ —–‡ƒ†•—„Ǧ. ƒ —–‡•–ƒ‰‡•™Š‹Ž‡‹–‹•——•—ƒŽˆ‘”•–”‘‡ƒˆˆ‡ –‡†‹†‹˜‹†—ƒŽ•–‘„‡‘ˆˆ‡”‡† ‘’”‡Š‡•‹˜‡”‡Šƒ„‹Ž‹–ƒ–‹‘†—”‹‰Žƒ–‡”•–ƒ‰‡•ƒˆ–‡”•–”‘‡ȏ͵ͲȐǡ‡˜‡. –Š‘—‰Š–Š‡”‡ƒ”‡•‡˜‡”ƒŽ•–—†‹‡••Š‘™‹‰–Šƒ–ˆ— –‹‘ƒŽ‹’”‘˜‡‡–•ƒ”‡ ’‘••‹„Ž‡‹Žƒ–‡”’Šƒ•‡•ƒˆ–‡”•–”‘‡ǤȏͶǡ͸ͳȐ˜‡–Š‘—‰Š–Š‡”‡ƒ”‡ƒ–‹‘ƒŽ. ‰—‹†‡Ž‹‡•ˆ‘”•–”‘‡ ƒ”‡‹™‡†‡ȏͶͶȐǡ‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡‡š’‡”‹Ǧ ‡ ‡—ˆ—Žˆ‹ŽŽ‡†‡‡†•‹”‡Šƒ„‹Ž‹–ƒ–‹‘•‡”˜‹ ‡•”‡ ‡‹˜‡†Ǥȏ͸ʹȐ. .

(52) ••—‡•”‡Žƒ–‡†–‘”‡Šƒ„‹Ž‹–ƒ–‹‘Šƒ˜‡„‡‡‹˜‡•–‹‰ƒ–‡†‹‘–Œ—•–“—ƒ–‹–ƒǦ –‹˜‡„—–ƒŽ•‘“—ƒŽ‹–ƒ–‹˜‡•–—†‹‡•Ǥ’”‡˜‹‘—••–—†›‘‡š’‡”‹‡ ‡‘ˆ’Š›•‹‘Ǧ. –Š‡”ƒ’›ƒˆ–‡”•–”‘‡•Š‘™‡†–Šƒ––Š‡‹†‹˜‹†—ƒŽ•ƒ’’”‡ ‹ƒ–‡†’Š›•‹‘–Š‡”ƒ’› •‹ ‡‹–™ƒ•˜‹‡™‡†‘ƒ•Ž‡ƒ†‹‰–‘ˆ— –‹‘ƒŽ‹’”‘˜‡‡–Ǥȏ͸͵ȐŠ‡›ƒŽ•‘. ˆ‘—†–Šƒ––Š‡”ƒ’‹•–•™‡”‡ ‘•‹†‡”‡†ƒ•ƒ•‘—” ‡‘ˆƒ†˜‹ ‡ƒ†‹ˆ‘”ƒ–‹‘ ƒ†ƒ•‘—” ‡‘ˆˆƒ‹–Šƒ†Š‘’‡Ǥȏ͸͵Ȑ. ‘™‡˜‡”ǡ‹†‹˜‹†—ƒŽ•Ž‹˜‹‰™‹–Š•–”‘‡ƒ”‡‹‰”‘™‹‰—„‡”•Ž‡ˆ–™‹–Š. 1. INTRODUCTION. 31.

(53) Ž‘‰ǦŽƒ•–‹‰‹’ƒ‹”‡–•ȏͶȐǡƒ†ƒ›Žƒ •–‹—Žƒ–‹‘ǡ‡š‡” ‹•‡ƒ†•‘Ǧ. ‹ƒŽ‹œƒ–‹‘ǤȏͳͳȐŠ‡•–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘ˆ‹‡Ž†‡‡†•–‘ˆ‘ —•„‘–Š‘‹’Ž‡Ǧ ‡–‹‰‡™•–”ƒ–‡‰‹‡•–‘‹’”‘˜‡Ž‘‰Ǧ–‡”‘—– ‘‡ȏ͸ͶȐǡƒ†–ƒ‹Ž‘”‹‰. –”‡ƒ–‡–‹–‡”˜‡–‹‘•–‘–Š‡‡‡†•‘ˆ–Š‡‹†‹˜‹†—ƒŽǤȏ͸ͷȐ–”‘‡•—”˜‹˜‘”•. ƒ”‡‘ˆ–‡‹ƒ –‹˜‡ƒ†ƒŽ‘‡ǡ‡˜‡‹ƒ ‘’”‡Š‡•‹˜‡ƒ —–‡•–”‘‡—‹–ȏ͸͸Ȑǡ ƒŽ–Š‘—‰Š”‡ ‡–”‡•—Ž–••Š‘™–Šƒ–‹–‹•’‘••‹„Ž‡ˆ‘”‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡–‘ •’‡†‘”‡–‹‡ƒ –‹˜‡ƒ†‘—–‘ˆ„‡†ƒ†–‘‡‰ƒ‰‡‹Š‹‰Š‡”‘–‘”ƒ –‹˜‹Ǧ –‹‡•Ǥȏ͸͹ȐŠ‡”‡‹•ƒ‡‡†–‘‹ ”‡ƒ•‡‘’’‘”–—‹–‹‡•ˆ‘”–”ƒ‹‹‰ƒ†•‘ ‹ƒŽ‹œǦ ‹‰ƒ†’”‘‘–‡ƒ –‹˜‹–›‹ƒ†‘—–•‹†‡‘ˆ–Š‡”ƒ’›–‹‡Ǥ”‡ƒ–‹‰ƒ ‡”‹ Š‡†‡˜‹”‘‡–ƒ›„‡ƒ™ƒ›–‘ƒ’’”‘ƒ Š–Š‡•‡‡‡†•Ǥȏ͸ͺȐ.  ͳǤ͵”‹ Š‡†˜‹”‘‡–. 1.3.1 Development of the Enriched Environment paradigm Enriched environment (EE) was first described by Donald O Hebb. He found, as early as 1947, that rats that were able to roam freely performed better in problem solving, than rats kept in cages. [69] Several studies have shown. that stroke-lesioned rats being exposed to a so-called EE show signs of tis-. sue regeneration/plasticity, e.g. thickened cortex, stronger synapses, in-. creased neural sprouting, and increased neurogenesis in the hippocampus. [70-72] In rat studies, an EE condition often consists of housing animals in. groups of up to 10 animals per cage. The cages are large, equipped with toys. like boards, chains, swings, wooden blocks and objects of different sizes and materials. The objects in the cages are moved around and exchanged for new ones several times a week to accomplish a variation in the environ-. ment. Research has shown that rats exposed to this EE, with possibilities for. 32. 1 . IN T R O D U C T I O N .

(54) physical activity and social interactions, are recovering significantly faster than rats in standard cages, despite the fact that the total tissue loss be-. tween the rats did not differ. [73-76] Figure 3 presents a typical EE condition and a standard housing condition. . 1. INTRODUCTION. 33.

(55) Figure 3. (A). Appearance of nerve cells in the mouse brain after being in an enriched environ-. ment, including increased space and equipped with a variety of objects that encourage exercise,. balancing or climbing, and challenge cognitive functions. The animals are introduced to the. stimulating environment in groups to facilitate social interaction. (B). A standard housing condition that generally entails a cage with bedding and access to water and food.. 1.3.2 Enriched Environment in stroke rehabilitation

(56) ”‘†‡–•ǡƒǦ‹ Ž—†‹‰•‘ ‹ƒŽ‹œƒ–‹‘ǡ‡š‡” ‹•‡ǡ•‡•‘”›ƒ† ‘‰‹–‹˜‡. •–‹—Žƒ–‹‘‹•’”‘˜‡†–‘Šƒ˜‡ƒ’‘™‡”ˆ—Žƒ†’‘•‹–‹˜‡‹’ƒ –‘–Š‡„”ƒ‹•. ’Žƒ•–‹ ‹–›ƒ†–‘‡Šƒ ‡”‡ ‘˜‡”›ƒˆ–‡”ƒ•–”‘‡Ǥȏͳͳǡ͹Ͷǡ͹͹Ȑ ‘™‡˜‡”ǡ˜‡”› ˆ‡™•–—†‹‡•Šƒ˜‡–”‹‡†–‘–”ƒ•Žƒ–‡–Š‡’ƒ”ƒ†‹‰–‘ƒ Ž‹‹ ƒŽŠ—ƒ 34. 1 . IN T R O D U C T I O N .

(57) •–”‘‡•‡––‹‰Ǥȋ ‹‰—”‡ͶǤȌ‡ƒ•‘•ˆ‘”–Š‡Žƒ ‘ˆ Ž‹‹ ƒŽ•–—†‹‡•‹ Ž—†‡. †‹ˆˆ‹ —Ž–‹‡•‹†‡ˆ‹‹‰ƒ†•–ƒ†ƒ”†‹œ‹‰ƒ ”‘••†‹ˆˆ‡”‡– Ž‹‹ ƒŽ•‹–‡•ǡ Žƒ ‘ˆ‘™Ž‡†‰‡ ‘ ‡”‹‰™Šƒ–ƒ•’‡ –‘ˆ‡”‹ Š‡––Šƒ–”‡’”‡•‡–•. –Š‡‘•–‹’‘”–ƒ–‡Ž‡‡–ˆ‘”‡Šƒ ‹‰„”ƒ‹’Žƒ•–‹ ‹–›ǡƒ†–Š‡Žƒ ‘ˆ ‘™Ž‡†‰‡ƒ„‘—––Š‡ƒctual required “dose” of enrichment. . . Figure 4.”ƒ•Žƒ–‹‘‘ˆ„ƒ•‹ ”‡•‡ƒ” Š–‘ Ž‹‹ ƒŽ”‡•‡ƒ” ŠǤ. . ‡˜‡”–Š‡Ž‡••ǡƒˆ‡™•–—†‹‡•‘Šƒ˜‡„‡‡’‡”ˆ‘”‡†‹ Ž‹‹ ƒŽ•–”‘‡. •‡––‹‰•Ǥȏ͹ͺǦͺͳȐ

(58) –Š‡•‡•–—†‹‡•ǡ–Š‡‡˜‹”‘‡–ƒŽ‡”‹ Š‡–Šƒ•„‡‡. ƒ’’Ž‹‡†‹ ‘—ƒŽ‘”‹†‹˜‹†—ƒŽƒ”‡ƒ•ǤŠ‡‘’’‘”–—‹–‹‡•ˆ‘”‡”‹ Š‡–. Šƒ•„‡‡•—‰‰‡•–‡†–‘‹ Ž—†‡–Š‡’”‘˜‹•‹‘‘ˆ—•‹ ǡ”‡ƒ†‹‰‘”Ž‹•–‡‹‰–‘. „‘‘•ǡ’‡”ˆ‘”‹‰’—œœŽ‡•ǡ’Žƒ›‹‰‰ƒ‡•ƒ†Ȁ‘”‘–Š‡”Š‘„„›•—’’Ž‹‡•ǡƒ† ƒŽ•‘‘ˆˆ‡”‹‰–ƒ„Ž‡–•ƒ† ‘’—–‡”•Ǥ–Š‡”’‘••‹„‹Ž‹–‹‡• ‘—Ž†„‡–Š‡ƒ˜ƒ‹ŽƒǦ „‹Ž‹–›‘ˆ”‡ ”‡ƒ–‹‘ƒŽƒ –‹˜‹–‹‡•ǡƒ†‘ˆˆ‡”‹‰ ‘—ƒŽƒ”‡ƒ•ˆ‘”‡ƒŽ•ǡ•‘Ǧ ‹ƒŽƒ†‘–Š‡”‰”‘—’ƒ –‹˜‹–‹‡•Ǥ. 1. INTRODUCTION. 35.

(59) ƒ••‡‡–ƒŽǤȏͺʹȐǡˆ‹”•–’”‡•‡–‡†ƒ•–—†›’”‘–‘ ‘Žƒ††‡•‹‰‘ˆƒ•–—†›‘. ‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡’ƒ”–‹ ‹’ƒ–‹‰‹”‡Šƒ„‹Ž‹–ƒ–‹‘‹ƒ‹š‡†”‡Šƒ„‹Ž‹–ƒǦ –‹‘—‹–ǤȏͺʹȐ

(60) –Šƒ–•–—†›ǡ–Š‡™ƒ•†‡ˆ‹‡†ƒ•ƒ•–‹—Žƒ–‹‰‡˜‹”‘Ǧ. ‡–ǡ™‹–Š ‘—ƒŽƒ”‡ƒ•ˆ‘”‡ƒ–‹‰ƒ†•‘ ‹ƒŽ‹œ‹‰ƒ††ƒ‹Ž›‰”‘—’. ƒ –‹˜‹–‹‡•Ǥˆ‡™›‡ƒ”•Žƒ–‡”ǡ–Š‡›’—„Ž‹•Š‡†ˆ‹†‹‰•ˆ”‘ƒ’‘•–Ǧƒ —–‡‹š‡†. •–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘—‹–•Š‘™‹‰–Šƒ–‹†‹˜‹†—ƒŽ•‹ƒ™ƒ”†™‡”‡‘”‡ Ž‹‡Ž›–‘‡‰ƒ‰‡‹ ‘‰‹–‹˜‡ǡ’Š›•‹ ƒŽƒ†•‘ ‹ƒŽƒ –‹˜‹–‹‡•ƒ†™‡”‡Ž‡••. Ž‹‡Ž›–‘„‡‹ƒ –‹˜‡ǡƒŽ‘‡‘”ƒ•Ž‡‡’ ‘’ƒ”‡†–‘•—„Œ‡ –•™Š‘”‡ ‡‹˜‡† —•—ƒŽ ƒ”‡Ǥȏ͹ͻȐ“—ƒŽ‹–ƒ–‹˜‡•–—†›‘–Š‡ ƒ”‡•–ƒˆˆ‘ˆ–Š‡•‡‹†‹˜‹†—ƒŽ•. •Š‘™‡†–Šƒ––Š‡•–ƒˆˆ‡š’‡”‹‡ ‡†–Šƒ––Š‡—•‡‘ˆ‹–Š‡‹””‡Šƒ„‹Ž‹–ƒ–‹‘. —‹–’”‘‘–‡†ƒ –‹˜‹–›ƒ†’ƒ”–‹ ‹’ƒ–‹‘‹–Š‡‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡ǤŠ‡ ”‡•—Ž–•Š‹‰ŠŽ‹‰Š–‡†–Š‡•‹‰‹ˆ‹ ƒ ‡‘ˆ•‘ ‹ƒŽ•—’’‘”––‘’ƒ”–‹ ‹’ƒ–‡‹–Š‡. ™ƒ”†‡˜‹”‘‡–ƒ†–Š‡’‘•‹–‹˜‡ ‘•‡“—‡ ‡•for the individuals’ mood. Ž‡˜‡Ž•Ǥȏͺ͵ȐŠ‡•ƒ‡‰”‘—’ǡ™‹–ŠŠ‹–‡ƒ•ˆ‹”•–ƒ—–Š‘”ǡ’—„Ž‹•Š‡†ƒ‘–Š‡”. “—ƒŽ‹–ƒ–‹˜‡•–—†›†‡• ”‹„‹‰•–”‘‡•—”˜‹˜‘”•Ʋ‡š’‡”‹‡ ‡‘ˆ’ƒ”–‹ ‹’ƒ–‹‘‹ ƒǤŠ‡”‡•—Ž–•”‡’‘”–‡†˜ƒ”‹‘—•„‡‡ˆ‹–•‹ Ž—†‹‰‹ ”‡ƒ•‡†‘–‘”ǡ ‘‰Ǧ. ‹–‹˜‡ƒ†•‡•‘”›•–‹—Žƒ–‹‘ƒ†•‘ ‹ƒŽ‹–‡”ƒ –‹‘ǡŽ‡••†‡‰”‡‡‘ˆ„‘”‡Ǧ †‘ƒ†‹ ”‡ƒ•‡†ˆ‡‡Ž‹‰•‘ˆ’‡”•‘ƒŽ ‘–”‘ŽǤŠ‡’ƒ”–‹ ‹’ƒ–•ƒŽ•‘. ‹†‡–‹ˆ‹‡†•‡˜‡”ƒŽ‘„•–ƒ Ž‡•–Šƒ–‡ˆˆ‡ –‡†–Š‡‹’Ž‡‡–ƒ–‹‘‘ˆ–Š‡ǤȏͺͶȐ. ‘•„‡”‰‡‡–ƒŽǤȋˆ”‘–Š‡•ƒ‡”‡•‡ƒ” Š‰”‘—’ƒ• ƒ•‡‡–ƒŽǤȌ Šƒ‰‡†–Š‡ ’”‘–‘ ‘Žˆ”‘ ƒ•‡Ʋ••–—†›ȏ͹ͻȐǡƒ†‹˜‡•–‹‰ƒ–‡†™Š‡–Š‡”ƒ‡„‡†Ǧ. †‡†‹ƒƒ —–‡•–”‘‡—‹– ‘—Ž†‹ ”‡ƒ•‡ƒ –‹˜‹–›Ž‡˜‡Ž•ƒ†”‡†— ‡ƒ†˜‡”•‡. ‡˜‡–•‹‹†‹˜‹†—ƒŽ•™‹–Šƒ —–‡•–”‘‡ǤȏͺͲȐŠ‡‹†‹˜‹†—ƒŽ•‹–Š‡‰”‘—’ •’‡–‘”‡–‹‡‘ˆ–Š‡†ƒ›‡‰ƒ‰‡†‹̵ƒ›̵ƒ –‹˜‹–›‹ ‘’ƒ”‹•‘–‘–Š‡. —•—ƒŽ ƒ”‡‰”‘—’ǤŠ‡›™‡”‡‘”‡ƒ –‹˜‡‹’Š›•‹ ƒŽǡ•‘ ‹ƒŽƒ† ‘‰‹–‹˜‡. †‘ƒ‹•ƒ†–Š‡•‡„‡Šƒ˜‹‘—”ƒŽ Šƒ‰‡•™‡”‡Žƒ•–‹‰•‹š‘–Š•ƒˆ–‡”–Š‡. ‹–‡”˜‡–‹‘Ǥ—„Œ‡ –•‹–Š‡‰”‘—’Šƒ†ƒ•‹‰‹ˆ‹ ƒ–Ž›•Š‘”–‡”Ž‡‰–Š‘ˆ. •–ƒ›ǤȏͺͲȐŠ‡•ƒ‡ƒ—–Š‘”ǡ‘•„‡”‰‡‡–ƒŽǤ†‹†ƒŽ•‘‹˜‡•–‹‰ƒ–‡–Š‡‡ˆˆ‡ –‘ˆ ƒ’’Ž‹‡†‹ƒƒ —–‡•–”‘‡—‹–‘Š‘™ƒ†™Š‡•—„Œ‡ –•—†‡”–ƒ‡ƒ Ǧ –‹˜‹–‹‡•ƒ†–Š‡—„‡”‘ˆ•–ƒˆˆƒ••‹•–ƒ ‡‡‡†‡†ǡ‹ ‘’ƒ”‹•‘™‹–Šƒ. 36. 1 . IN T R O D U C T I O N .

(61) ‘–”‘Ž‡˜‹”‘‡–™‹–Š‘‡”‹ Š‡–ǤȏͺͳȐ ‹‰Š‡”ƒ –‹˜‹–›Ž‡˜‡Ž•‹–Š‡. ‰”‘—’‘ —””‡††—”‹‰’‡”‹‘†•‘ˆ• Š‡†—Ž‡† ‘—ƒŽƒ –‹˜‹–›ǡ™Š‡. ‘’ƒ”‡†–‘–Š‡ ‘–”‘Ž‰”‘—’ǡ„—–‘†‹ˆˆ‡”‡ ‡•™‡”‡‘„•‡”˜‡†‘—–•‹†‡‘ˆ • Š‡†—Ž‡†ƒ –‹˜‹–‹‡•ǤŠ‡‡”‹ Š‡†‰”‘—’•’‡–‘”‡–‹‡‘—’’‡”Ž‹„ƒ Ǧ –‹˜‹–‹‡•ǡ ‘—ƒŽ•‘ ‹ƒŽ‹œ‹‰ǡƒ†Ž‹•–‡‹‰ƒ†–ƒ„Ž‡–ƒ –‹˜‹–‹‡•ǤŠ‡. ƒ‘—–‘ˆ–‘–ƒŽ•–ƒˆˆƒ••‹•–ƒ ‡†—”‹‰ƒ –‹˜‹–‹‡••Š‘™‡†‘†‹ˆˆ‡”‡ ‡„‡Ǧ –™‡‡‰”‘—’•ǤȏͺͳȐŠ‡•ƒ‡‰”‘—’ƒŽ•‘‹˜‡•–‹‰ƒ–‡†“—ƒŽ‹–ƒ–‹˜‡–Š‡ ƒ”‡Ǧ ‰‹˜‡”•’‡” ‡’–‹‘•ƒ†•Š‘™‡†–Šƒ––‡ƒ™‘”ƒ† ƒ”‡ˆ—Ž Šƒ‰‡‘ˆ. ƒƒ‰‡‡–™ƒ•‹’‘”–ƒ–ˆƒ –‘”•ˆ‘”‹’Ž‡‡–‹‰–Š‡‹–Š‡—‹–Ǥ. ȏͺͷȐ

(62) ƒ•–—†›„›Šƒ‡–ƒŽǤȏ͹ͺȐǡ‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡ƒ†‹†‹˜‹†—ƒŽ•. ™‹–Š‘–Š‡”‡—”‘Ž‘‰‹ ƒŽ†‹•‘”†‡”•‡”‘ŽŽ‡†‹ƒ™‡”‡•–—†‹‡†ƒ•–Š‡› ”‡ ‡‹˜‡†ƒ‹–‡”˜‡–‹‘ƒ–ƒ”‡Šƒ„‹Ž‹–ƒ–‹‘Š‘•’‹–ƒŽǤŠ‡‹–‡”˜‡Ǧ. –‹‘• ‘•‹•–ed of an “Activity Arcade” and included an additional 2ǦŠƒ –‹˜Ǧ. ‹–›•‡••‹‘’”‘˜‹†‡†‘™‡‡†ƒ›•ƒŽ‘‰™‹–Š–Š‡‹”†ƒ‹Ž›™ƒ”†ƒ –‹˜‹–‹‡•ǡ. „ƒ•‡†‘’ƒ”–‹ ‹’ƒ– Ž‹‹ ƒŽ‡‡†Ǥƒ”‹‘—•‡”‹ Š‡–ƒ –‹˜‹–‹‡•™‡”‡ƒ˜ƒ‹ŽǦ. ƒ„Ž‡ˆ‘”–Š‡’ƒ”–‹ ‹’ƒ–•–‘ Š‘‘•‡„‡–™‡‡Ǥ‘’ƒ”‡†™‹–Š ‘–”‘Ž•ǡ–Š‡ ‰”‘—’•Š‘™‡†•‹‰‹ˆ‹ ƒ–‹’”‘˜‡‡–ƒ–†‹• Šƒ”‰‡‹̶†‡’”‡••‹‘̶ǡƒ†. ̶•–”‡••̶Ǣ‘ƒ†–Š‡‘–‘”ȋ–‘–ƒŽȌ•—„• ƒŽ‡ƒ•™‡ŽŽƒ•–Š‡•‡ŽˆǦ ƒ”‡ƒ†. ‘„‹Ž‹–›•—„• ƒŽ‡•‘ˆ — –‹‘ƒŽ

(63) †‡’‡†‡ ‡‡ƒ•—”‡ȋ

(64) ȌǤ––Š‡͵Ǧ ‘–Šˆ‘ŽŽ‘™Ǧ—’ǡ•‹‰‹ˆ‹ ƒ–‰ƒ‹•‹–Š‡ƒŒ‘”‹–›‘ˆ–Š‡•‡ ‘†ƒ”›‘—–Ǧ. ‘‡•™‡”‡ƒ‹–ƒ‹‡†ˆ‘”–Š‡’ƒ”–‹ ‹’ƒ–•Ǥ‘‰‹–‹˜‡ˆ— –‹‘ƒ†ƒ Ǧ. –‹˜‹–‹‡•‹’”‘˜‡†‘•–ˆ”‡“—‡–Ž›‹’ƒ”–‹ ‹’ƒ–•™‹–Š•–”‘‡ǡƒ• ‘’ƒ”‡† –‘–Š‡‰”‘—’™‹–Š‘–Š‡”‡—”‘Ž‘‰‹ ƒŽ†‹ƒ‰‘•‡•Ǥȏ͹ͺȐŠƒ‡–ƒŽǤ†‹†ƒŽ•‘. ’—„Ž‹•Šƒƒ”–‹ Ž‡•Š‘™‹‰–Šƒ––Š‡’”‘‰”ƒ™ƒ•ˆ‡ƒ•‹„Ž‡ƒ†‡ˆˆ‡ –‹˜‡‹ ‹’”‘˜‹‰—’’‡”Ž‹„ˆ— –‹‘ƒ†‹ ”‡ƒ•‹‰–Š‡ƒ –‹˜‹–›‘ˆ‹†‹˜‹†—ƒŽ• †—”‹‰–Š‡‹”‹’ƒ–‹‡–•—„ƒ —–‡ ƒ”‡Ǥȏͺ͸Ȑ  . . 1. INTRODUCTION. . 37.

(65) ƒ„Ž‡ͳ’”‡•‡–••’‡ ‹ˆ‹ ƒ–‹‘•‘ˆ–Š‡‹–‡”˜‡–‹‘•‹ Ž—†‡†‹–Š‡’”‡˜‹Ǧ. ‘—•–”ƒ•Žƒ–‹‘ƒŽ•–—†‹‡†ȋ†‘•‡‘ˆ–Š‡”ƒ’›ǡ ‡”‹ Š‹‰ ‘’‘‡–• ‹ Ž—†‡† ȏ•‘ ‹ƒŽǡ ’Š›•‹ ƒŽǡ ‘‰‹–‹˜‡ ƒ† •‡•‘”›Ȑǡ •–—†› †‡•‹‰ ƒ† –Š‡ ’Šƒ•‡ ’‘•–Ǧ •–”‘‡ȌǤ . Table 1. ’‡ ‹ˆ‹ ƒ–‹‘ ‘ˆ –Š‡  ‹–‡”˜‡–‹‘• ‹ Ž—†‡† ‹ –Š‡ ’”‡˜‹‘—• –”ƒ•Žƒ–‹‘ƒŽ •–—†‹‡•. ȋᛇ•Ǣα‘ȌǤ Author. Dose. Social. Physical. Cognitive. Sensory. Type. Phase. Janssen et al.. ͳ͵†ƒ›•ǡ. . . . . ‘–”‘ŽŽ‡†. ‘•–Ǧƒ —–‡. White at. ’‹‰. al.. Ͷƒ’Ǧ. ƒ’’‹‰ǡ. †ƒ›•. —ƒŽ‹–ƒ–‹˜‡. ’ƒ”–‹ ‹’ƒ–•ǡ “—ƒŽ‹–ƒ–‹˜‡. research. ƒ”‡‰‹˜‡”•. group) Rosbergen et al.. •–”‘‡—‹–. ‡ƒ•‹„‹Ž‹–›ǡ. (same. . „‡ˆ‘”‡Ǧƒˆ–‡”ǡ. ͳͲǦͳʹ. †ƒ›•ǡ͵. . Ȁ. . . ƒ’’‹‰.  ‘–”‘ŽŽ‡† „‡ˆ‘”‡Ȁƒˆ–‡”ǡ ‡Šƒ˜‹‘—”ƒŽ. †ƒ›•.  —–‡. •–”‘‡—‹–. ƒ’’‹‰ǡ. —ƒŽ‹–ƒ–‹˜‡ ƒ”‡‰‹˜‡”•. Khan et al.. ʹŠȀ†ƒ›. . ™‡‡Ǧ. †—”‹‰ †ƒ›•. ‡ƒͳͶ †ƒ›•. 38. . Ȁ. . . . ‡ƒ•‹„‹Ž‹–› . —„ƒ —–‡ Ȁ Š”‘‹  •–”‘‡. Ϊ‘–Š‡”. ‡—”‘Ž‘‰‹  †‹ƒ‰‘•‡•. 1 . IN T R O D U C T I O N .

(66) 1.3.3 Studies using terminologies including elements of an EE ˆ‡™•–—†‹‡•—•‹‰–‡”‹‘Ž‘‰‹‡••›‘›‘—•™‹–ŠŠƒ˜‡„‡‡’—„Ǧ. Ž‹•Š‡†ǤŠ‡•‡•–—†‹‡•†‡• ”‹„‡–Š‡‹–‡”˜‡–‹‘ƒ•’”‘˜‹†‹‰•‘‡‹†‘ˆ. ‡”‹ Š‡–Ǥ

(67) –Š‡•‡ƒ”–‹ Ž‡•ǡ–Š‡ƒ—–Š‘”•†‹• —••–Š‡”‡•—Ž–•‹–Š‡ ‘–‡š–. ‘ˆ–Š‡ ‘ ‡’–‘ˆǡ„—––Š‡‹”‹–‡”˜‡–‹‘•™‡”‡‘–†‡• ”‹„‡†ƒ•ƒ’‡”. •‡Ǥ. ‡•–—†›‹˜‡•–‹‰ƒ–‡†–Š‡‡ˆˆ‡ –‹˜‡‡••‘ˆƒ‡š‡” ‹•‡”‡Šƒ„‹Ž‹–ƒ–‹‘—•‹ . ’”‘‰”ƒ. ȏͺ͹ȐŠ‡ˆ‹†‹‰•‹’Ž‹‡†–Šƒ––Š‡—•‹ Ǧ„ƒ•‡†‡š‡” ‹•‡’”‘‰”ƒ. Šƒ†‡ˆˆ‡ –•‘–Š‡‘‘†‹–Š‡‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡Ǥ‘”‡‘˜‡”ǡ–Š‡‹†‹Ǧ. ˜‹†—ƒŽ•Šƒ†ƒŠ‹‰Š‡””‡ ‘˜‡”›”ƒ–‡™Š‡–Š‡‡š‡” ‹•‡”‡Šƒ„‹Ž‹–ƒ–‹‘’”‘‰”ƒ ƒŽ•‘‹ Ž—†‡†ƒ‡”‹ Š‡†•‘—†‡˜‹”‘‡–™‹–Š‡š’‡”‹‡–‹ƒŽ—•‹ Ǥȏͺ͹Ȑ. ’”‡˜‹‘—•‹˜‡•–‹‰ƒ–‡†–Š‡‡ˆˆ‡ –‹˜‡‡••‘ —Ž–‹‘†ƒŽ‹–‡”˜‡–‹‘•ǡ ‘”‡•’‡ ‹ˆ‹ ƒŽŽ›Š‘”•‡Ǧ”‹†‹‰ƒ†”Š›–Šƒ†—•‹ Ǧ„ƒ•‡†–Š‡”ƒ’›ǤȏͷͻȐ. Š‡ˆ‹†‹‰•ǡ‹ Ž—†‹‰‹†‹˜‹†—ƒŽ•™‹–Š Š”‘‹ •–”‘‡ǡ•Š‘™‡†–Šƒ–„‘–Š. –Š‡”ƒ’‹‡•Ž‡†–‘‰ƒ‹•‹•‡ŽˆǦ”ƒ–‡†”‡ ‘˜‡”›ǡ„ƒŽƒ ‡ǡ‰ƒ‹–ǡ‰”‹’•–”‡‰–Šǡƒ† ™‘”‹‰‡‘”›ǤȏͷͻȐ“—ƒŽ‹–ƒ–‹˜‡•–—†›‘–Š‡’ƒ”–‹ ‹’ƒ–•‹–Š‡ƒˆ‘”‡Ǧ. ‡–‹‘‡†•–—†›™Š‘”‡ ‡‹˜‡†–Š‡—•‹ Ǧƒ†”Š›–ŠǦ„ƒ•‡†–Š‡”ƒ’›. •Š‘™‡†–Šƒ–the individuals’ described’‘•‹–‹˜‡‡š’‡”‹‡ ‡•‹–‡”•‘ˆ‘Ǧ –‘”ǡ ‘‰‹–‹˜‡ǡƒ†‡‘–‹‘ƒŽ„‡‡ˆ‹–•ƒˆ–‡”’ƒ”–ƒ‹‰‹–Š‡—Ž–‹‘†ƒŽ”‡Ǧ. Šƒ„‹Ž‹–ƒ–‹‘’”‘‰”ƒǤ

(68) ’‘”–ƒ–ˆƒ –‘”•™‡”‡–Š‡—•‹ ǡ–Š‡•‘ ‹ƒŽ. ‹–‡”ƒ –‹‘ǡ–Š‡ ŠƒŽŽ‡‰‹‰‡š‡” ‹•‡•ǡƒ†–Š‡•‹ŽŽ‡†‹•–”— –‘”ǤȏͺͺȐ“—ƒŽǦ. ‹–ƒ–‹˜‡•–—†›‘–Š‡’ƒ”–‹ ‹’ƒ–•™Š‘”‡ ‡‹˜‡†–Š‡Š‘”•‡Ǧ”‹†‹‰‹–‡”˜‡–‹‘ •Š‘™‡†–Šƒ––Š‡’ƒ”–‹ ‹’ƒ–•”‡’‘”–‡†Šƒ˜‹‰Ž‡ƒ”‡†‡™•‹ŽŽ•ǡ‹ ”‡ƒ•‡† –Š‡‹”•‡ŽˆǦ‡ˆˆ‹ ƒ ›ƒ†•‡ŽˆǦ‡•–‡‡ƒ†Šƒ†‹’”‘˜‡‡–•‹„ƒŽƒ ‡ƒ†. ‰ƒ‹–ǤŠ‡Š‘”•‡’Žƒ›‡†ƒ ”— ‹ƒŽ”‘Ž‡ƒ†ƒŽ•‘–Š‡‘–Š‡”‰”‘—’‡„‡”•ǡ–Š‡. ‹•–”— –‘”•ǡƒ†–Š‡ ŠƒŽŽ‡‰‹‰–ƒ••ǤȏͺͻȐ. ‘–Š‡”†‹†‹˜‡•–‹‰ƒ–‡™Š‡–Š‡”—•‹ Ž‹•–‡‹‰ ‘—Ž†‹’”‘˜‡”‡ ‘˜Ǧ ‡”›‘ˆ ‘‰‹–‹˜‡ˆ— –‹‘•ƒˆ–‡”•–”‘‡ǤȏͻͲȐ‡•—Ž–•ˆ”‘–Š‹••Š‘™‡† 1. INTRODUCTION. 39.

(69) –Šƒ––Š‡—•‹ ‰”‘—’‹ ”‡ƒ•‡†–Š‡‹”˜‡”„ƒŽ‡‘”›ǡ–Š‡‹”ƒ––‡–‹‘‹Ǧ. ’”‘˜‡†•‹‰‹ˆ‹ ƒ–Ž›ǡƒ†–Š‡›‡š’‡”‹‡ ‡†Ž‡••†‡’”‡••‹‘ǡ–Šƒ–Š‡ ‘–”‘Ž. ‰”‘—’ǤȏͻͲȐ‘–Š‡””‡ ‡–‘‹†‹˜‹†—ƒŽ•™‹–Šƒ’Šƒ•‹ƒƒˆ–‡”•–”‘‡. •Š‘™‡†–Šƒ–†ƒ‹Ž›–”ƒ†‹–‹‘ƒŽ‡š’‡”‹‡–‹ƒŽ—•‹ Ž‹•–‡‹‰‹ ”‡ƒ•‡†–Š‡”‡Ǧ. ‘˜‡”›”ƒ–‡ ‘’ƒ”‡†–‘•–ƒ†ƒ”† ƒ”‡ǤȏͻͳȐ. ’‹Ž‘–•–—†›‘ƒ˜‹”–—ƒŽ”‡ƒŽ‹–›”‡Šƒ„‹Ž‹–ƒ–‹‘•›•–‡ƒ’’Ž‹‡†–‘Š‡Ž’‹Ǧ. ’”‘˜‹‰”‡ƒ Š‹‰‘˜‡‡–•‘ˆ’‡‘’Ž‡™‹–ŠŠ‡‹’ƒ”‡•‹•ƒˆ–‡”•–”‘‡™ƒ•. ’‡”ˆ‘”‡†„›—ˆˆ‡–ƒŽǤȏͻʹȐŠ‡ˆ‡‡†„ƒ ™ƒ•’”‘˜‹†‡†„›˜‹•‹‘ƒ†—Ǧ. •‹ ƒ•ƒ•–‹—Žƒ–‹‰ǡ’”‘‘–‹‰—Ž–‹‘†ƒŽ•‡•‘”›Ǧ‘–‘”‹–‡‰”ƒ–‹‘Ǥ.

(70) ’”‘˜‡‡–•™ƒ••‡‡‹ Ž—†‹‰–Š‡•’‡‡†ƒ†•‘‘–Š‡••‹”‡ƒ Š‡•ǡ. „‡––‡” ‘‘”†‹ƒ–‹‘ƒ†”‡†— ‡† ‘’‡•ƒ–‘”›ƒ –‹˜ƒ–‹‘‹–Š‡–‘”•‘ƒ†. •Š‘—Ž†‡”Ǥȏͻ͵Ȑ. Š‡‡ˆˆ‡ –‘ˆ†‹ˆˆ‡”‡–™ƒŽ‹‰‡˜‹”‘‡–•‹†—ƒŽǦ–ƒ•™ƒŽ‹‰ƒˆ–‡”. •–”‘‡Šƒ•„‡‡•–—†‹‡†„›‹‡”ƒ•‡–ƒŽǤȏͻͶȐŠ‡› ‘ Ž—†‡†–Šƒ––Š‡. ™ƒŽ‹‰‡˜‹”‘‡–™ƒ•‹ˆŽ—‡ ‹‰–Š‡ ‘‰‹–‹˜‡Ǧ‘–‘”‹–‡”ˆ‡”‡ ‡ƒ† ’”‹‘”‹–‹œƒ–‹‘‘ˆ–ƒ••†—”‹‰†—ƒŽǦ–ƒ•™ƒŽ‹‰‹–Š‡‹†‹˜‹†—ƒŽ•ǤȏͻͶȐ. –Š‡”ƒ—–Š‘”•Šƒ˜‡†‡• ”‹„‡†Š‘™–Š‡‡˜‹”‘‡–ƒˆˆ‡ –•‘–‘”‘—–Ǧ. ‘‡•Ǥƒ‰‡–ƒŽǤ•Š‘™‡†–Šƒ–ƒ‘–‹‘Ǧ„ƒ•‡†˜‹”–—ƒŽ”‡ƒŽ‹–›–”ƒ‹‹‰‹–‡”Ǧ. ˜‡–‹‘‹•ƒˆ‡ƒ•‹„Ž‡•—’’Ž‡‡–ƒ”›‹–‡”˜‡–‹‘‹”‡Šƒ„‹Ž‹–ƒ–‹‘–Šƒ–‹‰Š–. ˆƒ ‹Ž‹–ƒ–‡–Š‡‹’”‘˜‡‡–‘ˆ‘–‘”•‹ŽŽ•‹‹†‹˜‹†—ƒŽ•™‹–Š•—„ƒ —–‡ •–”‘‡ǤȏͻͷȐ. 1.3.4 Summarization of EE in clinical stroke setting. Š‡ƒ‹ˆ‹†‹‰•”‡‰ƒ”†‹‰ Ž‹‹ ƒŽƒ’’Ž‹ ƒ–‹‘•‘ˆ‹ƒ Ž‹‹ ƒŽ•–”‘‡. ”‡Šƒ„‹Ž‹–ƒ–‹‘‹†‹ ƒ–‡–Šƒ–ƒ‹•ˆ‡ƒ•‹„Ž‡–‘‡„‡†‹ƒƒ —–‡•–”‘‡•‡–Ǧ –‹‰•ȏͺʹȐǡƒ†–Šƒ––Š‡‹†‹˜‹†—ƒŽ•™‹–Š•–”‘‡‹ƒƒ —–‡ƒ†•—„ƒ —–‡ ™ƒ”†ƒ”‡‘”‡‡‰ƒ‰‡†‹ƒ –‹˜‹–‹‡•ƒ• ‘’ƒ”‡†–‘ ‘–”‘Ž•ȏ͹ͻǦͺͳȐǡƒ† 40. 1 . IN T R O D U C T I O N .

(71) Šƒ˜‡•Š‘”–‡”Ž‡‰–Š‘ˆ•–ƒ›‹–Š‡ƒ —–‡Š‘•’‹–ƒŽ™ƒ”†ǤȏͺͲȐ —”–Š‡”ǡƒ’Ǧ ’Ž‹‡†–‘‹Ǧ’ƒ–‹‡–•–”‘‡•‡––‹‰• ƒŽ‡ƒ†–‘•‹‰‹ˆ‹ ƒ–‹’”‘˜‡‡–‹. ‘‰‹–‹˜‡ˆ— –‹‘ƒ†‘–‘”ƒ –‹˜‹–‹‡•Ǥȏ͹ͺȐŠ‡ƒ‹“—ƒŽ‹–ƒ–‹˜‡ˆ‹†‹‰•. ”‡‰ƒ”†‹‰‹ƒ Ž‹‹ ƒŽ•–”‘‡•‡––‹‰•—‰‰‡•––Šƒ––Š‡”‡Šƒ„‹Ž‹–ƒ–‹‘ ƒ”‡Ǧ. ‰‹˜‡”•’‡” ‡‹˜‡–Šƒ–‡Šƒ ‡†’ƒ–‹‡–ƒ –‹˜‹–›ǡ–Š‡ƒ—–Š‘”•‡’Šƒ•‹•‡–Š‡. ‹’‘”–ƒ ‡‘ˆ•‘ ‹ƒŽ•—’’‘”–ƒ†’ƒ”–‹ ‹’ƒ–‹‘‹–Š‡™ƒ”†‡˜‹”‘‡–‹ ‘”†‡”–‘ƒˆˆ‡ ––Š‡‘‘†‘ˆ–Š‡‹†‹˜‹†—ƒŽ•Ǥȏͺ͵Ȑ —”–Š‡”ǡ•–”‘‡•—”˜‹˜‘”•. ™Š‘’ƒ”–‹ ‹’ƒ–‡†‹ƒ”‡’‘”–‘ˆ‹ ”‡ƒ•‡†•–‹—Žƒ–‹‘‘ƒ›Ž‡˜‡Ž•Ǥ. ȏͺͶȐ. ‘™‡˜‡”ǡ–Š‡–”ƒ•Žƒ–‹‘‘ˆ–Š‡ ‘ ‡’––‘ƒ Ž‹‹ ƒŽ•‡––‹‰†‹ˆˆ‡”•ƒŽ‘–. „‡–™‡‡•–—†‹‡•ǤŠ‡•–—†‹‡•‘‹†‹˜‹†—ƒŽ•™‹–Šƒ —–‡ƒ†•—„ƒ —–‡•–”‘‡ did investigate EE as an “add on” to usual careǤȏ͹ͻǡͺͳȐFor example, an “EEǦ. area” was offered with games, puzzles, musicƒ†’‘••‹„‹Ž‹–‹‡•‘ˆ•‘ ‹ƒŽ‹•ƒǦ. –‹‘ƒ†–Š‡†‘•ƒ‰‡‘ˆ™ƒ•‘–ˆ—ŽŽ›†‡• ”‹„‡†ǤŠ‡Ž‡˜‡Ž‘ˆ‡˜‹†‡ ‡‹. ‘•–‘ˆ–Š‡’—„Ž‹•Š‡†•–—†‹‡•‘‹•™‡ƒǡ‘Ž›‘‡™ƒ•ˆ‘—†Ǥȏ͹ͺȐ. Š”‡‡‘”‡•†‹†‡˜ƒŽ—ƒ–‡‹–‡”˜‡–‹‘•„ƒ•‡†‘‡”‹ Š‹‰ ‘’‘Ǧ. ‡–•ȋŠ‘”•‡Ǧ”‹†‹‰ǡ”Š›–ŠȀ—•‹ Ǧ–Š‡”ƒ’›ȏͷͻȐƒ†—•‹ ǦŽ‹•–‡‹‰. ȏͻͲǡͻͳȐȌǤŠ‡•–—†‹‡•‘‡”‹ Š‹‰ ‘’‘‡–• ‘—Ž†Šƒ˜‡ƒ•’‡ –•‘ˆǡ‡Ǧ ”‹ Š‡–•–Š”‘—‰Š–‡ Š‹ ƒŽ†‡˜‹ ‡••— Šƒ•˜‹”–—ƒŽ”‡ƒŽ‹–›ȏͻͷǡͻ͸Ȑǡƒ‹ƒŽ ‡”‹ Š‡–•ˆ‘”‡šƒ’Ž‡™‹–ŠŠ‘”•‡Ǧ”‹†‹‰–Š‡”ƒ’›ȏͷͻȐǡ—•‹ ǦŽ‹•–‡‹‰ ȏͻͲȐǡ—•‹ ‡š‡” ‹•‡’”‘‰”ƒ•ȏͺ͹Ȑ‘””Š›–ŠǦƒ†—•‹ Ǧ„ƒ•‡†–Š‡”ƒ’›Ǥ. ȏͷͻȐ. Š‡†‘•‡ƒ†–Š‡ ‘–‡–‘ˆƒƒ’’Ž‹‡†‹•–”‘‡”‡Šƒ„‹Ž‹–ƒ–‹‘ƒ•™‡ŽŽƒ• ‹–•‡ˆˆ‡ –‹˜‡‡•• ‘’ƒ”‡†–‘—•—ƒŽ ƒ”‡ƒ”‡ƒ•’‡ –•–Šƒ–ƒ”‡›‡–—‘™Ǥ. —”–Š‡”ǡ‹–”‡ƒ‹•–‘„‡ Žƒ”‹ˆ‹‡†™Š‹ Š ‘’‘‡–‘ˆǦ‹ Ž—†‹‰ƒ—Ǧ. „‡”‘ˆ„‡Šƒ˜‹‘—”ƒŽ ‘’‘‡–•–‘”‡”‹ Š‡†”‡Šƒ„‹Ž‹–ƒ–‹‘ǡ‹ ‘„‹ƒ–‹‘ ™‹–Š ‘’‘‡–•‘ˆ‡š‡” ‹•‡ǡ–Šƒ–„‡•–’”‘‘–‡”‡ ‘˜‡”›ƒˆ–‡”•–”‘‡Ǥȏ͹͹Ȑ. 1. INTRODUCTION. 41.

(72) 2. Aims Overall aim. The overall aim of this thesis was to study whether ETT contributed to any changes with respect to function, activity, participation and different as-. pects of health in individuals with chronic stroke. . Specific aims I. The aim of study I was to assess whether the ETT contributed to any. changes in functional motor performance as well as balance, gait, hand. strength, and dexterity in individuals with residual hemiparesis in the chronic phase after stroke. Further, to assess whether ETT led to any. changes of confidence in task performance, fatigue, depression, life satisfaction and HRQoL.. II. The aim of study II was to explore the experiences of individuals who. participated in an ETT program in the chronic phase after stroke.. III. The aim with study III was to assess whether any changes in spatiotem-. poral gait parameters, gait kinematics or symmetry could be shown in individuals who participated in an ETT program in the chronic phase after stroke.. IV. The aim of study IV was to study the relationship between comfortable and maximum gait speed in individuals with chronic stroke with mild to. 42. 2. AIMS.

(73) moderately severe disability. Further, to examine if the relationship be-. tween comfortable and maximum gait speed in individuals with chronic. stroke differ from that of a community dwelling elderly control group, and. also to study which parameters that did affect this relationship in respective group. . 2. AIMS. 43.

(74) 3. Materials and Methods  ͵Ǥͳƒ–‡”‹ƒŽ. 3.1.1 Study setting and design . This thesis contains four papers that altogether include three study cohorts.  Table 2 presents the study design and the number of participants in each study.  . Study I is a longitudinal uncontrolled observational study, in which the par-. ticipants received a 3-week long intervention (ETT), preceded by a 3-week. long baseline phase. Follow-up assessments were performed at 3 and 6. months.. Study II is a qualitative study where focus group interviews was performed directly after the intervention (ETT).. Study III is a longitudinal observational study using a single-subject ABA. experimental design [97], with follow-up at 6 months. The initial phase (A1). was a baseline period before the intervention, lasting for 3 weeks. During. A1, three to five analyses were done at least one day apart. [98] The B-phase was the 3-week intervention period (ETT). Immediately after the intervention, the A-phase was repeated (A2 phase). A single follow-up was done 6. months after the intervention. . Study IV is a cross-sectional observational controlled study, where baseline. data from three study cohorts (Study I, [59] and [99]) was merged.. . 44. 3 . M A T E R I A LS A N D M E T H O D S .

(75) Table 2. Number of individuals who were part of the different study cohorts, description of. study designs, and at which timepoints the outcome measure data were collected. Study nr. Nr included (also in study I). Study design. Measurement timepoints. Study I. Ͷͳ. ‘‰‹–—†‹ƒŽ— ‘–”‘ŽŽ‡† ‘„•‡”˜ƒ–‹‘ƒŽ•–—†›. Study II. ʹ͵ȋͳ͵Ȍ. Study III. Ͷȋ͵Ȍ. —ƒŽ‹–ƒ–‹˜‡ˆ‘ —•‰”‘—’‹–‡”Ǧ ˜‹‡™•–—†›. ‡ˆ‘”‡Ȁƒˆ–‡” ‘–”‘Ž’Šƒ•‡ǡ ƒˆ–‡”ǡ͵ƒ†͸‘–Š• ƒˆ–‡”. Study IV. ʹͷͺȋͳ͹Ȍ. ‘‰‹–—†‹ƒŽ‘„•‡”˜ƒ–‹‘ƒŽ •–—†›™‹–ŠƒǦǦ †‡•‹‰. ”‘••Ǧ•‡ –‹‘ƒŽ‘„•‡”˜ƒ–‹‘ƒŽ ‘–”‘ŽŽ‡†•–—†›. ‹”‡ –Ž›ƒˆ–‡”. ͵Ǧͷƒ••‡••‡–•†—”‹‰ͳǡ ƒ†͵Ǧͷƒ••‡••‡–•†—”Ǧ ‹‰ʹǡ‘‡ƒ••‡••‡–ƒ–͸ ‘–Š•  ‡ƒ••‡••‡–„‡ˆ‘”‡ƒ› ‹–‡”˜‡–‹‘Ǥ. 3.1.2 Subject recruitment Subjects in study I, II and III were recruited from the waiting list from Neuro. Optima Forsk Rehab AB´s rehabilitation programs. The company requested permission for the project leader to contact individuals who had applied to. the rehabilitation program. The project leader provided the individuals with information of the study along with a screening of potential study partici-. pants, after which oral and written consent were collected. In addition to. participants who underwent the ETT program, additional subjects in study IV were retrieved from two other research projects [59,99] in Gothenburg.. 3 . M A T E R I A LS A N D M E T H O D S. 45.

(76) 3.1.3 Subjects . The study subjects are described in table 3. In study IV, including 258 indi-. viduals, 17 subjects were part of the cohort in study I (those over 60 years),. 87 from another intervention study on chronic stroke [59], and 154 community-dwelling older controls from another study on individuals over 65. years. [99]   . Table 3. Demographic variables and baseline characteristics in the four studies. Mean. (SD)/median [min;max] is given for continuous variables and n (%) for categorical variables.. Šƒ”ƒ –‡”‹•–‹ •. –—†›

(77) . –—†›

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(79) . –—†›

(80)

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(82) . ‘‡ȋΨȌ. ͺȋʹͲȌ. ͺȋͶͲȌ. ͲȋͲȌ. ƒ”–‹ ‹’ƒ–• ‡ȋΨȌ. ‡ƒƒ‰‡ǡ›‡ƒ”•ȋȌ ‡†‹ƒȏ‹ǢƒšȐ ‘–Š••‹ ‡•–”‘‡ ‘•‡–ǡ‡ƒȋȌ ‡†‹ƒȏ‹ǢƒšȐ. ‘†‹ˆ‹‡†ƒ‹ ƒŽ‡a. ‡ƒ‰”ƒ†‡ǡ‡ƒȋȌ ‡†‹ƒȏ‹ǢƒšȐ. ”ƒ†‡ʹȋΨȌ. ”ƒ†‡͵ΨȌ. Ͷͳ. ͵͵ȋͺͲȌ. ͷͻǤ͸ȋͳ͵ǤͻȌ ͸ͶȏʹʹǢͺͶȐ ͵ͷǤͷȋʹͻǤͷȌ ʹ͸ȏ͸Ǣͳ͵ͲȐ . ͵ǤͶȋͲǤ͹Ȍ ͵ǤͲȏʹǢͶȐ ͷȋͳʹȌ. ͳ͸ȋ͵ͻȌ. ʹͲ. ͳʹȋ͸ͲȌ. ͸ͳȋͳ͵ǤͳȌ ͸ͶȏʹͷǢͺͶȐ. ͵ͲǤͶȋ͵ͶǤͳȌ ͳ͹ǤͲȏ͸Ǣͳͷ͸Ȑ . ͵ǤͶȋͲǤ͹Ȍ ͵ǤͷȏʹǢͶȐ ͵ȋͳͷȌ ͹ȋ͵ͷȌ. Ͷ. ͸ͳǤͺ ͸ʹǤͷȏͷ͹Ǣ͸ͷȐ ͵͸Ǥ͵ȋ͵ͲǤͻȌ ͵ͲǤͲȏͳͳǢͺͺȐ ʹǤͺȋͲǤͶȌ ͵ǤͲȏʹǢ͵Ȑ ͳȋʹͷȌ ͵ȋ͹ͷȌ. –—†›

(83)  ‘–”‘Ž•. ͸ͷȋ͸ʹǤͷȌ. ͹͵ȋͶ͹ǤͶȌ. ͳͲͶ. ͶȋͳͲͲȌ. . –—†›

(84)  •–”‘‡. ͵ͻȋ͵͹ǤͷȌ. ͸͸ǤͷȋͶǤʹȌ ͸͸ȏ͸ͲǢͺͲȐ. ͵ͷǤʹȋʹͲǤͲȌ ͵ͲǤͶȏ͸ǢͳʹʹȐ. ͳͷͶ. ͺͳȋͷʹǤ͸Ȍ. ͹ʹǤͳȋͶǤ͹Ȍ ͹ʹȏ͸ͷǢͺͳȐ Ǧ. . . ͶͺȋͶ͸Ȍ. Ǧ. ʹǤ͸ȋͲǤ͸Ȍ ͵ǤͲȏʹǢͶȐ ͷͲȋͶͺȌ. Ǧ Ǧ. ”ƒ†‡ͶȋΨȌ ʹͲȋͶͻȌ ͳͲȋͷͲȌ ͲȋͲȌ ͸ȋ͸Ȍ Ǧ a An ordinal disability rating scale scored 0–6. 2 - Slight disability; Able to look after own affairs without assistance, but unable to carry out all previous activities. 3 -Moderate disability; Requires some help, but able to walk unassisted. 4 - Moderately severe disability; Unable to attend to own bodily needs without assistance and unable to walk unassisted.. 46. 3 . M A T E R I A LS A N D M E T H O D S .

(85) 3.1.4 Eligibility The eligibility criteria in study I, II and III were: At least 6 months and a maximum 10 years since the onset of stroke; Disability grade 2–4 on the. modified Rankin Scale[100]; Baseline motor deficit defined as less than a full score on the primary outcome measure (M-MAS UAS) [101]; No other in-. jury, illness, or addiction, making the individual unsuitable for participation, including exercise-induced epilepsy, assessed by the referring or prescribing physician; Cognitive and speech ability that enables instruction, inter-. vention, and evaluation; Ability and willingness to travel to the place of. evaluation; Able to perform sit-to-stand and stand-to-sit transfers inde-. pendently or with assistance, without assistive technology such as mechanical lifts; Not having participated in a similar high-dose rehabilitation. program (other than post-stroke acute and subacute rehabilitation) within. the previous 6 months; Not scheduled for other treatment focused on inten-. sive, high-dose training during the study period.. In study II, additionally criteria was: Cognitive and speech ability that ena-. bled being included in a group interview.. In study III, the additionally criteria were: Affected/asymmetric gait pat-. tern; Ability to walk independently 10 m indoors without assistive devices;. and Live near Gothenburg, to enable repeated assessments in the gait labor-. atory.. In study IV, the eligibility criteria for the cohorts with chronic stroke were. the same as in study I with the addition that the subjects had to be ≥60. years. For the community-dwelling control group, the criteria were: No severe musculoskeletal injuries or problems affecting physical performance;. No detectable neurological, cardiopulmonary or cognitive problems; or arthroplastic surgery in the lower extremity, and ≥65 years.. . 3 . M A T E R I A LS A N D M E T H O D S. 47.

(86) 3.2 Intervention  . 3.2.1 ETT . ETT refers to Enriched, task-specific therapy, where “enriched” refers to environmental enrichment—an intervention to increase motor, sensory, cognitive, and social activity by providing a stimulating environment. “Task-. specific” refers to repetitive functional training in everyday tasks, meaning-. ful for the individual. The ETT program was conceptualized by the medical board of former Neuro Optima Forsk Rehab AB.. Directly after the baseline phase, the 3-week long ETT program took place. at two rehabilitation facilities in Spain, near Marbella and Malaga. The ETT was performed in groups of four to nine, but the content was individually tailored, and supervised by physiotherapists (PTs) (and speech-language. pathologists [SLPs] when needed). Depending on the group size, and the. participants’ disability level, as many as three PTs were sometimes required. to supervise and assist the training. The ETT was characterized by large dosage of therapy. Rehabilitation activities was scheduled 5.5 hours on. weekdays, 3.5 hours on Saturdays, and Sundays off, for three weeks. The. therapy was divided into three sessions of 1.5–2 hours each weekday, mixed with social activities, such as scheduled coffee breaks and lunch. Partici-. pants with speech impairments received individualized treatment with a. SLP for a maximum of 2 hours per day, included in the 5.5 (weekdays) or 3.5 hours (Saturdays). The content of the program is described in Table 4. The. various components acting in the clinical translation of the EE model in this study are presented in Figure 5 and examples of the physical environment in the ETT in figure 6. . . 48.  3 . M A T E R I A LS A N D M E T H O D S .

(87) Table 4.Š‡ ‘–‡–‘ˆ–Š‡‡”‹ Š‡†–ƒ•Ǧ•’‡ ‹ˆ‹ –Š‡”ƒ’›ȋȌ’”‘‰”ƒǤ Therapy domain — –‹‘ƒŽ–”ƒ‹‹‰ˆ‘” –”ƒ•ˆ‡”•ƒ†—’’‡”ȀŽ‘™‡” Ž‹„ (1–3 daily sessions depending on the individual need).

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