Birgitta Lindmark

Self-efficacy in relation to impairments and activities of daily living disability in elderly patients with stroke: a prospective investigation

OBJECTIVES The objectives of this prospective study, undertaken in elderly patients with stroke undergoing rehabilitation, were to determine to what extent fall-related self-efficacy changes over time, its relationships to objectively assessed functions and activities, and the predictive capacity of self-efficacy at discharge for activities of daily living 10 months after stroke. METHODS The study comprised 37 patients, aged 66-89 years. Main outcome measurement instruments were the Falls Efficacy Scale (Swedish version), Berg Balance Scale and Functional Independence Measure. RESULTS Significant improvements occurred in all these measures from admission to discharge, but patients with low self-efficacy at discharge showed less pronounced improvements than those with high self-efficacy. Falls Efficacy Scale (Swedish version) was closely associated with all other measures and was a more powerful predictor of activities of daily living than the observer-based measures of balance. CONCLUSION To minimize dependence in activities of daily living, rehabilitation interventions should incorporate self-efficacy enhancement.

Fear of falling in patients with stroke: a reliability study

Objective: To examine the scaling properties and test–retest reliability of an expanded version of the Falls Efficacy Scale (FES) and to compare group differences in the scores. The expanded version focuses on more basic, primary activities of daily living (ADL), which makes the scale more suitable for subjects with moderate to low functional ability, e.g. patients with stroke. Design: A test–retest reliability study with one group convenience sample. Setting: Two day-care units: a rehabilitation unit and a geriatric rehabilitation unit. Subjects: A volunteer sample of 30 patients (mean age 65 years, SD 11 years) who had sustained stroke between 5 and 84 months prior to the investigation. Main outcome measure: A 13-activity questionnaire (the Swedish modification of the Falls Efficacy Scale (FES(S)) comprising the 10 activities of the original FES and three additional activities was used. Falls efficacy was rated on a 10-point visual analogue scale for each activity on two occasions, 5–22 (mean 10, Md 7) days apart. Results: The overall test–retest reliability of the FES(S) was high (intraclass correlation coefficient (ICC) = 0.97). The ICC for the personal ADL (items 1–6) scores was 0.93 and for the instrumental ADL (items 8–13) 0.97. ICC for the individual items ranged from 0.76 to 0.97. Conclusions: On the basis of these preliminary findings, the FES(S) appears to have acceptable test–retest reliability. The test may be a reasonable addition for assessing stroke patients with balance disturbances and risk for falls.

Better postural balance in elderly women receiving estrogens

OBJECTIVE The amount of bone mass and the tendency to fall are main risk factors for hip fractures and both deteriorate with advancing age. The dynamics between estrogen exposure and fracture protection seem too rapid to be explained by an effect on bone mass only. Postural balance function may be another potential mechanism for the fracture-protecting effect of estrogens. STUDY DESIGN We examined 16 long-term users of 17 beta-estradiol implants (20 mg) (mean age 67.9 years and mean duration of treatment 17.3 years [3.3 to 34 years]) and 16 age-matched (+/-2 years) nonusers (mean age 68.3 years). Postural balance (sway velocity) was measured by static posturography before and after blindfolding and application of vibration stimulus (20 to 100 Hz) to the calf muscles to disturb the proprioception and to induce imbalance. RESULTS Sway velocities were significantly lower in estrogen users than in nonusers (p = 0.0067) and similar to those in young premenopausal women. The differences were accentuated after provocation by blindfolding and by increasing frequencies of vibration stimulus to the calf muscle. Serum levels of estradiol and estradiol/sex hormone-binding globulin were negatively and follicle-stimulating hormone levels positively associated with sway velocity (p = 0.0194, p = 0.0036, and p = 0.0052, respectively) and independent of age (p = 0.02 to 0.005), supporting causality between estrogen exposure and postural balance. CONCLUSIONS These data indicate that postural balance function is better preserved in long-term estrogen users than in nonusers. Effects on postural balance function may be one mechanism explaining the rapid increase in distal forearm fractures early after menopause and the rapid dynamics between estrogen exposure and hip fracture protection and may potentially reduce the fracture risk in elderly women starting estrogen replacement therapy in spite of marginal increases in bone mass.

Exercise and health-related quality of life during the first year following acute stroke. A randomized controlled trial

Purpose: To evaluate the impact of two different physiotherapy exercise regimes in patients after acute stroke on health-related quality of life (HRQoL) and to investigate how the degree of motor and balance function, gait capacity, activities of daily living and instrumental activities of daily living influenced HRQoL. Methods: A longitudinal randomized controlled stratified trial of two interventions: the intensive exercise groups with scheduled intensive training during four periods of the first year after stroke and the regular exercise group with self-initiated training. Results: There was a tendency of better HRQoL in the regular exercise group on NHP total score (p= 0.05). Patients with low scores in activities of daily living, balance and motor function and inability to perform 6-minute walk test on admission, scored lower on self-perceived health than patients with high scores and ability to perform the walking test. At 1 year post-stroke, total scores on NHP were moderately associated with motor function (r= −0.63), balance (r= −0.56), gait (r= −0.57), activities of daily living (r= −0.57) and instrumental activities of daily living (r= −0.49–0.58). The physical mobility sub-scale of NHP had the strongest association ranging from r= −0.47–0.82. Conclusion: The regular exercise group with self-initiated training seemed to enhance HRQoL more than the intensive exercise group with scheduled intensive training. The degree of motor function, balance, walking capacity and independence in activities of daily living is of importance for perceived HRQoL.

CHEST PHYSIOTHERAPY AFTER CORONARY ARTERY BYPASS GRAFT SURGERY— A COMPARISON OF THREE DIFFERENT DEEP BREATHING TECHNIQUES

The effectiveness of three deep breathing techniques was evaluated in 98 male patients after coronary artery bypass graft surgery in a randomized trial. The techniques examined were deep breathing with a blow bottle-device, an inspiratory resistance-positive expiratory pressure mask (IR-PEP) and performed with no mechanical device. Pulmonary function and roentgenological changes were evaluated. Four days post-operatively there were significantly decreased vital capacity, inspiratory capacity, forced expiratory volume in 1 second, functional residual capacity, total lung capacity and single-breath carbon monoxide diffusing capacity in all three groups (p < 0.0001). No major differences between the treatment groups were found, but the impairment in pulmonary function tended to be less marked using the blow bottle technique. The Blow bottle group had significantly less reduction in total lung capacity (p = 0.01) compared to the Deep breathing group, while the IR-PEP group did not significantly differ from the other two groups.

The Falls-Efficacy Scale, Swedish version : does it reflect clinically meaningful changes after stroke?

Purpose : The overall aim of this prospective investigation was to evaluate the ability of the Falls Efficacy Scale (Swedish version) (FES(S)) to reflect clinically meaningful changes over time. Method : Changes on the FES(S) scale were compared with changes in two different standardized measures of observer-assessed balance, the Berg Balance Scale (BBS), the Fugl-Meyer balance subscale (FMB), and of motor function and ambulation in 62 stroke patients. Assessments took place on admission for rehabilitation, at discharge and 10 months after the stroke. Indices of effect size were used to evaluate responsiveness of the instruments. Three time periods were studied: admission to discharge (early response), discharge to 10 month follow-up (late response) and admission to follow-up (overall response). Results : The main findings are that the FES(S) is as responsive as BBS and FMB in detecting changes during the early and overall response periods. Changes in FES(S) scores between admission and discharge correlated significantly with changes in observer-assessed balance, motor function and ambulation scores. Conclusions : The present results suggest that measurement of perceived confidence in task performance using the FES(S) scale is responsive to improvement in patients with hemiparesis at an early stage after stroke.

Test-retest intra-rater reliability of grip force in patients with stroke.

OBJECTIVE Coefficients of repeatability and reproducibility can be guides in differentiating between real changes and measurement error. The aim was to evaluate test-retest intra-rater reliability of a clinical procedure measuring grip force with Grippit in stroke patients, to assess relationship between grip force of the hands and between sustained and peak grip force. PATIENTS AND METHODS Eighteen patients were tested using the Grippit at two occasions one hour apart. Each occasion comprised three consecutive trials per hand. RESULTS The paretic hand needs to score a 50 N change within and between occasions to exceed the measurement error in 95% of the observations, irrespective of calculation method. Expressed by CV(within) the measurement error was 10%. There was no learning or fatigue effect during measuring. There was a wide variation between subjects but the mean ratio between sides was 0.66. The mean ratio between sustained and peak grip force was 0.80-0.84. CONCLUSION The measurement errors were acceptable and the instrument can be recommended for the use in stroke patients at a department of rehabilitation medicine.

The immediate effects of deep breathing exercises on atelectasis and oxygenation after cardiac surgery

Objective—To investigate the effects of deep breathing performed on the second postoperative day after coronary artery bypass graft surgery. Design—The immediate effects of 30 deep breaths performed without a mechanical device (n = 21), with a blow bottle device (n = 20) and with an inspiratory resistance‐positive expiratory pressure mask (n = 20) were studied. Spiral computed tomography and arterial blood gas analyses were performed immediately before and after the intervention. Results—Deep breathing caused a significant decrease in atelectatic area from 12.3 ± 7.3% to 10.2 ± 6.7% (p < 0.0001) of total lung area 1 cm above the diaphragm and from 3.9 ± 3.5% to 3.3 ± 3.1% (p < 0.05) 5 cm above the diaphragm. No difference between the breathing techniques was found. The aerated lung area increased by 5% (p < 0.001). The PaO 2 increased by 0.2 kPa (p < 0.05), while PaCO 2 was unchanged in the three groups. Conclusion—A significant decrease of atelectatic area, increase in aerated lung area and a small increase in PaO 2 were found after performance of 30 deep breaths. No difference between the three breathing techniques was found.

An evaluation of two different exercise regimes during the first year following stroke : A randomised controlled trial.

The purpose of this randomised controlled trial was to evaluate the effects of two different exercise approaches during the first 12 months post stroke on Instrumental Activities of Daily Living (IADL), motor function, gait performance, balance, grip strength, and muscle tone. This study is a double-blind longitudinal randomised trial of first-time-ever stroke patients. Seventy-five patients were included: 35 in an intervention group and 40 in a self-initiated exercise group. After discharge from acute rehabilitation, patients assigned in the intervention group had physiotherapy for a minimum amount of 80 hours during the first year. Patients in the self-initiated exercise group were not recommended any specific therapy besides treatment when needed. Main outcome measures were Instrumental Activities of Daily Living according to Fillenbaum, Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go Test, grip strength, Modified Ashworth Scale, and pulse monitoring. The patients were tested on admission, at discharge, and after 3, 6, and 12 months post stroke by an experienced investigator, blinded to group assignment. Twelve months post stroke showed higher levels of independence in all items of the Instrumental Activities of Daily Living Test and improvements in the results of Motor Assessment Scale, 6-Minute Walk Test, Berg Balance Scale, Timed Up-and-Go, and grip strength in both groups. Only a few significant differences were seen between groups, and they were in favour of the self-initiated exercise group (e.g., ability to use the telephone independently). Attending examination sessions following each intervention phase appeared to be strong motivators for training, irrespective of group allocation.

A five-year follow-up of stroke survivors: motor function and activities of daily living

At the University Hospital, Uppsala, a study was conducted to assess and follow the changes in motor activities, primary activities of daily living (ADL) and instrumental ADL over a five-year period. The functional level of 280 acute stroke patients was assessed over five years. One year after the stroke 193 patients (68%) were alive, and after five years 113 patients (40%). Of the latter, 101 patients were assessed. During the first year after the stroke, a significant improvement was shown in all the assessed variables. However, most of the variables had deteriorated significantly between one and five years post-stroke. The activities that were best preserved were primary ADL and locomotion. The ability to perform active movements, maintain balance, walk and perform some household tasks and some psychosocial activities had declined. Five years post-stroke approximately one-quarter had substantial motor loss and one-third were moderately impaired. Three-quarters managed their primary ADL without or almost without help. Differences were found between men and women in instrumental ADL behaviour, the women showing more deterioration post-stroke. In spite of this most of the patients felt satisfied with their health and life situation.