Katharina Stibrant Sunnerhagen

Person-Centered Care — Ready for Prime Time

Long-term diseases are today the leading cause of mortality worldwide and are estimated to be the leading cause of disability by 2020. Person-centered care (PCC) has been shown to advance concordance between care provider and patient on treatment plans, improve health outcomes and increase patient satisfaction. Yet, despite these and other documented benefits, there are a variety of significant challenges to putting PCC into clinical practice. Although care providers today broadly acknowledge PCC to be an important part of care, in our experience we must establish routines that initiate, integrate, and safeguard PCC in daily clinical practice to ensure that PCC is systematically and consistently practiced, i.e. not just when we feel we have time for it. In this paper, we propose a few simple routines to facilitate and safeguard the transition to PCC. We believe that if conscientiously and systematically applied, they will help to make PCC the focus and mainstay of care in long-term illness.

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.

Kinematic Variables Quantifying Upper-Extremity Performance After Stroke During Reaching and Drinking From a Glass

Background. Three-dimensional kinematic analysis provides quantitative and qualitative assessment of upper-limb motion and is used as an outcome measure to evaluate impaired movement after stroke. The number of kinematic variables used, however, is diverse, and models for upper-extremity motion analysis vary. Objective. The authors aim to identify a set of clinically useful and sensitive kinematic variables to quantify upper-extremity motor control during a purposeful daily activity, that is, drinking from a glass. Methods. For this purpose, 19 participants with chronic stroke and 19 healthy controls reached for a glass of water, took a sip, and placed it back on a table in a standardized way. An optoelectronic system captured 3-dimensional kinematics. Kinematical parameters describing movement time, velocity, strategy and smoothness, interjoint coordination, and compensatory movements were analyzed between groups. Results. The majority of kinematic variables showed significant differences between study groups. The number of movement units, total movement time, and peak angular velocity of elbow discriminated best between healthy participants and those with stroke as well as between those with moderate (Fugl-Meyer scores of 39-57) versus mild (Fugl-Meyer scores of 58-64) arm impairment. In addition, the measures of compensatory trunk and arm movements discriminated between those with moderate and mild stroke impairment. Conclusion. Kinematic analysis in this study identified a set of movement variables during a functional task that may serve as an objective assessment of upper-extremity motor performance in persons who can complete a task, such as reaching and drinking, after stroke.

An 8‐year longitudinal study of muscle strength, muscle fiber size, and dynamic electromyogram in individuals with late polio

Twenty‐one subjects with polio 24 to 51 years prior to the first examination were studied on three occasions, each 4 years apart with measurements of muscle strength and endurance for knee extension, macro EMG, and muscle biopsy from vastus lateralis. On average the muscle strength decreased during the 8‐year follow‐up by 9–15%. Endurance decreased during the observation period. The muscle fiber area was markedly increased in most subjects. There was a decrease in the capillarization during the follow‐up. Macro EMG was increased in all subjects (range 3–42 times control) and increased in 20 legs during the 8‐year follow‐up, but showed a decrease in 8 of 9 legs with an approximative breakpoint when macro MUPs were around 20 times the normal size. Thus, evidence of on‐going denervation/reinnervation as well as of failing capacity to maintain large motor units was demonstrated. SFEMG showed a moderate degree of disturbed neuromuscular transmission.

Hydrotherapy--a new approach to improve function in the older patient with chronic heart failure.

Hydrotherapy, i.e. exercise in warm water, as a rehabilitation program has been considered potentially dangerous in patients with chronic heart failure (CHF) due to the increased venous return caused by the hydrostatic pressure. However, hydrotherapy has advantages compared to conventional training. We studied the applicability of an exercise programme in a temperature‐controlled swimming pool, with specific reference to exercise capacity, muscle function, quality of life and safety.

Intravenous immunoglobulin for post-polio syndrome: a randomised controlled trial

BACKGROUND Survivors of poliomyelitis often develop increased or new symptoms decades after the acute infection, known as post-polio syndrome. Production of proinflammatory cytokines within the CNS indicates an underlying inflammatory process, accessible for immunomodulatory treatment. We did a multicentre, randomised, double-blind, placebo-controlled study of intravenous immunoglobulin in post-polio syndrome. METHODS 142 patients at four university clinics were randomly assigned infusion of either 90 g in total of intravenous immunoglobulin (n=73) or placebo (n=69) during 3 consecutive days, repeated after 3 months. Seven patients were withdrawn from the study. Thus, 135 patients were assessed per protocol. Primary endpoints were muscle strength in a selected study muscle and quality of life as measured with the SF-36 questionnaire (SF-36 PCS). Secondary endpoints were 6-minute walk test (6MWT), timed up and go (TUG), muscle strength in muscles not chosen as the study muscle, physical activity scale of the elderly (PASE), visual analogue scale (VAS) for pain, multidimensional fatigue inventory (MFI-20), balance, and sleep quality. Outcome tests were done immediately before the first infusion and 3 months after the second infusion. This study is registered with , number NCT00160082. FINDINGS Compared with baseline, median muscle strength differed by 8.3% between patients receiving intravenous immunoglobulin and placebo, in favour of the treatment group (p=0.029). SF-36 PCS did not differ significantly between the groups after treatment (p=0.321). Differences in the subscale vitality score (p=0.042) and PASE (p=0.018) favoured the active treatment group. MFI-20, TUG, muscle strength in the muscles not chosen as the study muscle, 6MWT, balance, and sleep quality did not differ between groups. For the whole study population there was no significant change in pain, as determined by VAS. Nevertheless, patients who reported pain at the study start improved in the intervention group but not in the placebo group (p=0.037). Intravenous immunoglobulin was well tolerated. INTERPRETATION Intravenous immunoglobulin could be a supportive treatment option for subgroups of patients with post-polio syndrome. Further studies on responding subgroups, long-term effects, and dosing schedules are needed.

Virtual Rehabilitation in an Activity Centre for Community-Dwelling Persons with Stroke

Background: The main purpose of this study was to place a virtual reality (VR) system, designed to assess and to promote motor performance in the affected upper extremity in subjects after stroke, in a nonhospital environment. We also wanted to investigate if playing computer games resulted in improved motor function in persons with prior stroke. Methods: The intervention involved 11 patients after stroke who received extra rehabilitation by training on a computer 3 times a week during a 4-week period. The control group involved 11 patients after stroke who continued their previous rehabilitation (no extra computer training) during this period. The mean age of all was 68 years (range = 47–85) and the average time after stroke 66 months (range = 15–140). The VR training consisted of challenging games, which provided a range of difficulty levels that allow practice to be fun and motivating. An additional group of 11 right-handed aged matched individuals without history of neurological or psychiatric illnesses served as reference subjects. Results: All the participants reported that they were novel computer game players. After an initial introduction they learned to use the VR system quickly. The treatment group demonstrated improvements in motor outcome for the trained upper extremity, but this was not detected in real-life activities. Conclusions: The results of this research suggest the usefulness of computer games in training motor performance. VR can be used beneficially not only by younger participants but also by older persons to enhance their motor performance after stroke.

MUSCLE PERFORMANCE IN AN URBAN POPULATION SAMPLE OF 40- TO 79-YEAR-OLD MEN AND WOMEN

An urban population sample of 40 to 79-year-old men and women was investigated to evaluate the influence of age and activity level on muscle strength and endurance and to establish a reference material. During the investigation 144 persons were tested bilaterally, except for ankle strength, when only the right side was examined. Isometric muscle strength was determined in the knee extensors and flexors. Isokinetic (at 60 degrees/s and at 180 degrees/s) muscle strength was determined concentrically and eccentrically in the knee extensors and flexors. The dynamic and static endurance of the extensors was measured. Isometric strength was determined in the ankle plantar and dorsiflexor muscles. Isokinetic ankle plantar flexion strength was determined concentrically at 60 degrees/s with and without prior eccentric muscle contraction. Hand-grip strength was evaluated with a dynamometer. Walking velocity and the number of heel-rises were recorded. Physical activity level was assessed by questionnaire. Muscle biopsies were taken from the vastus lateralis muscle for histochemical and enzymatic analyses. Walking and the different muscle tests declined with age, and with a slight gender difference. Muscle biopsies showed a trend toward smaller muscle fibers with age. The results of our study can be used as reference material for clinical studies in different age groups.

ENERGY EXPENDITURE IN STROKE SUBJECTS WALKING WITH A CARBON COMPOSITE ANKLE FOOT ORTHOSIS

OBJECTIVE To measure walking speed and energy cost in patients with prior stroke with and without a carbon composite ankle foot orthosis. DESIGN Within-group comparisons of 2 walking conditions. PARTICIPANTS Convenience sample of 10 hemiparetic patients with a stroke at least 6 months earlier (average age 52 years) habituated to a carbon composite ankle foot orthosis. METHODS Subjects walked on a treadmill at self-selected speed both with and without ankle foot orthosis for 5 minutes on each occasion. Energy expenditure was measured by breath-by-breath analysis and electrocardiography. Main outcome measures were walking speed, oxygen consumption, heart rate and energy cost per metre. RESULTS Walking speed: without ankle foot orthosis 0.27 (SEM +/- 0.03) m/s, with 0.34 (+/- 0.06) m/s, difference 20%. Oxygen consumption: without ankle foot orthosis 8.6 (+/- 0.4) ml/kg/min, with 8.8 (+/- 0.5) ml/kg/min. Energy cost: without ankle foot orthosis 0.58 (+/- 0.07) ml/kg/m, with 0.51 (+/- 0.06) ml/kg/m, difference 12%. CONCLUSION Use of a carbon composite ankle foot orthosis in patients with stroke may increase speed and decrease energy cost during walking.

Assessment and Training in a 3-Dimensional Virtual Environment With Haptics: A Report on 5 Cases of Motor Rehabilitation in the Chronic Stage After Stroke

Objective. This exploratory study assessed the possible effectiveness of hemiparetic upper extremity training in subjects with chronic stroke with computer instrumentation (haptic force feedback) and 3-dimensional visualization applied to computer games, as well as to evaluate concurrent computer-assisted assessment of the kinematics of movements and test whether any improvement detected in the computer environment was reflected in activities of daily living (ADLs). Methods. A single-subject repeated-measures experimental design (AB) was used. After baseline testing, 5 patients were assigned to the therapy 3 times a week for 45 min for 5 weeks. Velocity, time needed to reach, and hand path ratio (reflecting superfluous movements) were the outcome measures, along with the Assessment of Motor and Process Skills and the Box and Block test. The follow-up phase (C) occurred 12 weeks later. Results. Improvements were noted in velocity, time, and hand path ratio. One patient showed improvement in occupational performance in ADLs. Conclusions.The application of this strategy of using virtual reality (VR) technologies may be useful in assessing and training stroke patients. The results of this study must be reproduced in further studies. The VR systems can be placed in homes or other nonclinical settings.