Karin Hellström

Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground:

Objective: To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke. Design: Randomized controlled experimental study. Setting: Multicentre design; three departments of rehabilitation medicine. Subjects: Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group. Interventions: The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups. Main outcome measures: Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Bergs Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up. Results: There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Bergs Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up. Conclusions: Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground.

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.

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.

Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease

Objective: To examine the risk and frequency of falls, prevalence of fear of falling and activity avoidance, the magnitude of fall-related self-efficacy, and anxiety and depression in patients with chronic obstructive pulmonary disease. Design and settings: A cross-sectional study in patients with a diagnosis of chronic obstructive pulmonary disease who visited a lung clinic at a university hospital in Sweden. Subjects: Successive inclusion from autumn 2005 to spring 2006 of 80 patients with a mean age of 65 years. Intervention: Nil. Main measures: A questionnaire about fall history and consequences of fall, The Falls Efficacy Scale, Swedish version, and the Hospital Anxiety and Depression Scale were used. Results: Twenty patients (25%) reported at least one fall in the last year and 29% displayed fear of falling. Odds ratio for falling was 4—5 times higher in patients with severe chronic obstructive pulmonary disease. Older patients, women and patients with previous falls had a higher rate of fear of falling, and those with fear of falling had lower fall-related self-efficacy, increased level of anxiety and depression, more activity avoidance and use of assistive device. Conclusion: The increased risk of falls in patients with chronic obstructive pulmonary disease warrants attention in order to reduce serious and adverse health consequences of falls.

Balance function and fall-related efficacy in patients with newly operated hip fracture:

Objective: To investigate the relation between fall-related efficacy in daily-life activities and functional as well as instrumental tests of balance in patients with hip fracture. Design: Analysis of different aspects of balance using the Falls Efficacy Scale, Swedish version FES(S), questions on fear of falling, Functional Reach (FR) and tests on a balance platform (Chattanooga). Subjects: Fifty-five elderly inpatients (mean age 82.3) with newly operated hip fracture who were assessed during the last week in hospital before discharge. Results: The results showed a significant relationship between the subjective ability measured with the FES(S) and the objectively measured balance in the Functional Reach test and also between fall-related efficacy measured with FES(S) and fear of falling. Very few significant correlations were found between the results from balance tests on the force platform and those obtained with FES(S) and FR. Conclusions: Both the Falls Efficacy Scale, Swedish version, and the Functional Reach have been shown to be useful in analysing balance function in elderly patients newly operated on for hip fracture. The Falls Efficacy Scale also indicates which of the daily activities the patient perceives as troublesome and thus require further training.

Effects of individually tailored physical and daily activities in nursing home residents on activities of daily living, physical performance and physical activity level: a randomized controlled trial.

Background: Nursing home residents are extremely inactive and deterioration in health and an increasing dependence in activities of daily living (ADL) are common. Physical activity and exercise play a major role in the preservation of physical function and quality of life late in life. However, evidence for the benefit of rehabilitation in nursing home residents is conflicting and inconclusive. Objective: To evaluate the effect of an individually tailored intervention program of 3 months, for nursing home residents, on ADL, balance, physical activity level, mobility and muscle strength. Methods: In this single-blind randomized clinical trial with parallel groups, nursing home residents >64 years of age from three Nordic countries were included. The intervention group (IG) was assigned to individually tailored physical and daily activities, while the control group (CG) received ordinary care. Primary outcomes were ADL and balance, and secondary outcomes physical activity level, mobility and muscle strength. Results: At baseline, 322 nursing home residents were included, of whom 266 were assessed after 3 months of intervention. Following the intervention, a significant difference was found between participants in the IG and CG on measures of balance, physical activity and transfers. The IG significantly improved walking/wheelchair speed and functional leg muscle strength. The CG had significantly deteriorated in ADL, balance and transfers. Persons who had taken part in the intervention for more than 150 min/week significantly improved their balance and physical activity level. Participation in more than 10 weeks of intervention significantly improved physical activity and walking/wheelchair speed, while a deterioration was seen in those who had participated less. Conclusion: Individually tailored intervention in nursing home residents focusing on physical and daily activities is effective in improving transfers, balance and physical activity level compared to usual care. The effect of the intervention is dependent on the total activity time.

Relationship of confidence in task performance with balance and motor function after stroke

The principal aim of this investigation was to relate perceived confidence in task performance without falling and observer-assessed balance, both to each other and to motor function at three different times after a fi rst stroke. Sixty-two patients 24-65 years of age participated in this study. Perceived confidence in task performance was self-reported using a Swedish modification of the Falls-Efficacy Scale (FES(S)). For observer assessments the Berg Balance Scale and the balance and motor function sections of the Fugl-Meyer Stroke Assessment Instrument were used. Assessments were performed on admission, at discharge, and at a 10-month follow-up. FES(S) was significantly associated with observer-assessed balance (rho = 0.46-0.68) and motor function (rho = 0.45-0.56) onadmission and on discharge (rho = 0.38-0.51). At follow-up these correlations were generally weaker, ranging from 0.20-0.49. We conclude that self-reported confidence in task performance is a valuable measure in clinical practice, adding information to that gained from objective assessments.

Fall risk six weeks from onset of stroke and the ability of the Prediction of Falls in Rehabilitation Settings Tool and motor function to predict falls

Objective: To investigate whether the Prediction of Falls in Rehabilitation Settings Tool (Predict FIRST) and motor function could be used to identify people at risk of falling during the first six weeks after stroke, and to compare the risk of falling according to Predict FIRST with real falls frequency. Design: A longitudinal, prospective study. Patients: Sixty-eight people newly diagnosed with stroke admitted to an acute stroke unit. Methods: The participants underwent an assessment of motor ability (Modified Motor Assessment Scale according to Uppsala University Hospital version 99 (M-MAS UAS-99)) and falls risk (Predict FIRST) on the first to fourth day at the acute stroke unit. Falls occurring in the acute stroke unit were recorded and falls occurring after discharge were reported by telephone follow-up. The prediction of falls was analysed with binary logistic regression. Results: Fourteen of the patients (21%) fell at least once during the first six weeks after stroke. The strongest significant predictor for falls was a high score on Predict FIRST (odds ratio 5.21, confidence interval (CI) 1.10–24.78) followed by M-MAS UAS-99 parts C–E (odds ratio 0.65, CI 0.44–0.95). Predict FIRST underestimated the risk of falling as the median fall risk was 9% according to Predict FIRST. Conclusion: Although Predict FIRST has the ability to predict falls in people with recent onset of stroke, there is some underestimation of fall risk.

Physical activity in subjects with multiple sclerosis with focus on gender differences: a survey.

BackgroundThere is increasing research that examines gender-issues in multiple sclerosis (MS), but little focus has been placed on gender-issues regarding physical activity. The aim of the present study was to describe levels of physical activity, self-efficacy for physical activity, fall-related self-efficacy, social support for physical activity, fatigue levels and the impact of MS on daily life, in addition to investigating gender differences.MethodsThe sample for this cross-sectional cohort study consisted of 287 (84 men; 29.3%) adults with MS recruited from the Swedish Multiple Sclerosis Registry. A questionnaire was sent to the subjects consisting of the self-administrated measurements: Physical Activity Disability Survey – Revised, Exercise Self-Efficacy Scale, Falls- Efficacy Scale (Swedish version), Social Influences on Physical Activity, Fatigue Severity Scale and Multiple Sclerosis Impact Scale. Response rate was 58.2%.ResultsMen were less physically active, had lower self-efficacy for physical activity and lower fall-related self-efficacy than women. This was explained by men being more physically affected by the disease. Men also received less social support for physical activity from family members. The level of fatigue and psychological consequences of the disease were similar between the genders in the total sample, but subgroups of women with moderate MS and relapsing remitting MS experienced more fatigue than men.ConclusionsMen were less physically active, probably a result of being more physically affected by the disease. Men being more physically affected explained most of the gender differences found in this study. However, the number of men in the subgroup analyses was small and more research is needed. A gender perspective should be considered in strategies for promoting physical activity in subjects with MS, e.g. men may need more support to be physically active.