Kirsti Skavberg Roaldsen

Long-term prevalence of impairments and disabilities after multiple trauma.

The prevalence of impairments and disabilities in activities of daily living (ADL), nonwork activities, and work were registered in a consecutive series (n = 69) of subjects with severe injuries. At follow-up 3 years after trauma, residual impairments prevailed in 80%. Only a few (6%) were ADL-dependent. Seventy-six percent had lost at least one nonwork activity, while vocational disability caused by the trauma occurred in 19%. Cognitive impairment was significantly associated with vocational disability, while physical impairment and pain were significantly associated with nonwork disability. Other parameters that influenced vocational disability negatively were age and blue-collar employment status. Although overall changes in social network quantity and quality were small, significantly more subjects with cognitive impairment or vocational disability experienced a decline in the quality and quantity of their social network after trauma. Furthermore, 25% of the subjects reported an increase in feelings of loneliness after trauma. We recommend the design of individualized, multidisciplinary rehabilitation plans before discharge from departments of surgery.

Cognitive performance in multiple trauma patients 3 years after injury.

OBJECTIVES Patients with sequelae from multiple trauma commonly display cognitive disturbances, specifically in the areas of attention and memory. This study was designed to assess cognitive functioning 3 years after severe multiple trauma and to investigate how cognitive performance is related to head injury severity and psychological distress respectively. METHODS Sixty-eight multiple trauma patients were tested with a screening battery consisting of six neuropsychological tasks 3 years after injury. A measure of psychological distress (20-item General Health Questionnaire, or GHQ-20) was also administered. RESULTS Patients who neither showed signs of reduced consciousness on admission to the hospital nor reported significant psychological distress at follow-up tended to have normal test performance. In five of the six tasks, cognitive impairment was related to the severity of the traumatic brain injury as measured by the Glasgow Coma Scale (GCS). In both attention span tasks, patients designated as cases by the GHQ had significantly lower scores than noncase patients. These bivariate relationships were upheld in multiple regression analyses, in which age, sex, and GCS and GHQ scores were entered as independent variables. When patients with severe head injuries were excluded from the analyses, GCS scores still contributed to the variance in tests of verbal attention span and delayed recall, but performance on attentional tasks was more strongly related to psychological distress than to GCS scores. CONCLUSIONS Cognitive deficits in multiple trauma patients were related both to the severity of the traumatic brain injury and to the degree of psychological distress. The strength of the association between brain injury as indicated by GCS scores and cognitive performance differed between different tasks. Neuropsychological testing may assist in differentiating primary organic from secondary psychogenic impairments.

Fear-avoidance beliefs and pain as predictors for low physical activity in patients with leg ulcer

BACKGROUND AND PURPOSE Previous studies have shown that patients with chronic venous insufficiency are deconditioned and physically inactive. The present study aimed to examine the occurrence of fear-avoidance beliefs in patients with chronic venous insufficiency, and to investigate the role of fear-avoidance beliefs and pain severity in predicting the low level of physical activity in these patients. METHOD Data were collected by a postal questionnaire sent to 146 patients with chronic venous insufficiency and current or previous venous leg ulcer. Complete data were collected from 98 patients aged 60-85 years - 63% women - giving a response rate of 67%. Fear-avoidance beliefs were assessed by the Fear-Avoidance Beliefs Questionnaire, physical activity subscale. Pain and physical activity were assessed by the Six-point Verbal Rating Scale of Pain Assessment and the Physical Activity Questionnaire, respectively. RESULTS Fear-avoidance beliefs were present in 81 (83%) of the patients with chronic venous insufficiency (range 0-24, median 12). Forty patients (41%) had strong fear-avoidance beliefs. One-third of the patients with healed ulcers had strong fear-avoidance beliefs. Patients with low physical activity had significantly stronger fear-avoidance beliefs and more severe pain than patients with high physical activity. Multiple logistic regression showed that the odds ratio (OR) for low physical activity were about three times higher for patients with strong fear-avoidance beliefs (OR 3.1, 95% confidence interval 1.1-8.3; p = 0.027) than for patients with weak fear-avoidance beliefs. CONCLUSIONS Fear-avoidance beliefs were present in most patients with chronic venous insufficiency and were associated with low physical activity. Clinical implications ought to include a better recognition of fear-avoidance beliefs, early information about the negative consequences of such beliefs, and the importance of physical activity to counteract poor mobility.

Physical activity in patients with venous leg ulcer – between engagement and avoidance. A patient perspective

Objective: To identify and describe the qualitative variations in how physical activity is perceived and understood by individuals with current or previous venous leg ulcer. Design: A qualitative study using semi-structured interviews. Method: Twenty-two individuals aged 60–85 years were interviewed. The interviews were recorded, transcribed verbatim and analysed by three researchers using a phenomenographic research approach. A set of categories of descriptions and their internal relationships were constructed based on the essential features of the variation in patients’ perceptions of physical activity. Results: Four categories of descriptions were identified: (i) ‘self-management’, (ii) ‘instructions and support’, (iii) ‘fear of injury’ and (iv) ‘a wish to stay normal’. The categories could be interpreted by a two-dimensional construct: (1) perception of venous leg ulcer as a chronic or acute condition and (2) engagement or avoidance behaviour toward physical activity. Chronicity and behaviour combined together formed a 2 × 2 square housing the four qualitatively different categories. Irrespective of category, the participants reported that information given by caregivers regarding leg ulcer and physical activity was insufficient or contradictory. Written information or exercise programmes were not obtained regularly and not at all in primary care. Conclusion: A dichotomous view emerged from participants’ experiences of physical activity based on (1) perception of venous leg ulcer as a chronic or acute condition and (2) engagement or avoidance behaviour toward physical activity.

Self-reported function and disability in late life - cross-cultural adaptation and validation of the Swedish version of the late-life function and disability instrument.

Abstract Purpose: To translate and perform a cross-cultural adaptation of the Late-Life Function and Disability Instrument (LLFDI) to Swedish, to investigate absolute and relative reliability, concurrent validity, and floor and ceiling effects within a Swedish-speaking sample of community-dwelling older adults with self-reported balance deficits and fear of falling. Method: Translation, reliability and validation study of the LLFDI. Sixty-two community-dwelling, healthy older adults (54 women and 8 men) aged 68–88 years with balance deficits and fear of falling performed the LLFDI twice with an interval of 2 weeks. Results: Test–retest agreement, intra-class correlation coefficient was very good, 0.87–0.91 in the LLFDI function component and 0.82–0.91 in the LLFDI disability component. The standard error of measure was small, 5–9%, and the smallest real difference was 14–24%. Internal consistency (Cronbach’s alpha) was high (0.90–0.96). Correlation with the SF-36 PCS and PF-10 was moderate in both LLFDI function, r = 0.39–0.68 and r = 0.35–0.52, and LLFDI disability, r = 0.40–0.63 and 0.34–0.57, respectively. There was no floor or ceiling effects. Conclusion: The Swedish version of the LLFDI is a highly reliable and valid instrument for assessing function and disability in community-dwelling older women with self-reported balance deficits and fear of falling. Implications for Rehabilitation The Swedish LLFDI is a highly reliable and valid instrument for assessing function and disability in older women with self-reported balance deficits and fear of falling. The instrument may be used both in clinical settings and in research. The instrument is sensitive to change and a reasonably small improvement is enough to detect changes in a group or a single individual.

Task-specific balance training improves self-assessed function in community-dwelling older adults with balance deficits and fear of falling: a randomized controlled trial

Objective: To evaluate the effects of a 12-week balance training programme on self-assessed function and disability in healthy community-dwelling older adults with self-perceived balance deficits and fear of falling. Design: A prospective, randomized controlled trial. Setting: Stockholm County, Sweden. Participants: A total of 59 community-dwelling older adults (42 women and 17 men) aged 67–93 were randomized to either an intervention group (n = 38) or to serve as controls (n = 21) after baseline testing. Intervention: The intervention was a 12-week, three times per week, progressive, specific and individually adjusted group balance-training programme. Main measures: Self-perceived function and disability measured with Late Life Function and Disability Instrument. Results: The intervention group reported improvement in overall function (p = 0.016), as well as in basic (p = 0.044) and advanced lower extremity function (p = 0.025) compared with the control group. The study showed no improvement in overall disability or upper extremity function. Conclusion: This group balance training programme improves self-assessed function in community-dwelling older adults with balance deficits and fear of falling.

“Pushing the Limits”: Rethinking Motor and Cognitive Resources After a Highly Challenging Balance Training Program for Parkinson Disease

Background There is growing evidence for the positive effects of exercise training programs on balance control in Parkinson disease (PD). To be effective, balance training needs to be specific, progressive, and highly challenging. Little evidence exists, however, for how people with PD‐related balance impairments perceive highly challenging and progressive balance training programs with dual‐task components. Objective The purpose of this study was to explore and describe perceptions of a highly challenging balance training program among people with mild to moderate PD. Design This study was qualitative in nature. In‐depth interviews were conducted with 13 individuals with mild to moderate PD who had participated in a highly challenging balance training program. Interview transcripts were analyzed using qualitative content analysis, with an inductive approach. Results The analysis revealed 3 subthemes concerning participants’ perceptions of highly challenging and progressive balance training: (1) movement to counter the disease, (2) dual‐task training in contrast to everyday strategies, and (3) the struggle to maintain positive effects. The first subtheme reflects how physical activity was used as a short‐term and long‐term strategy for counteracting PD symptoms and their progression. The second subtheme incorporates the described experiences of being maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants’ everyday lives. The third subtheme describes participants’ long‐term struggle to maintain program effects on cognitive and physical function in the face of disease progression. Interpretation of the underlying patterns of these subthemes resulted in one overarching theme: training at the limits of balance capacity causes a rethinking motor and cognitive resources. Limitations The findings of this study cannot be considered to reflect the beliefs of those with weaker or negative beliefs concerning physical activity or be transferred to those at more severe stages of the disease. Conclusions Findings from this study suggest that being pushed to the limits of balance capacity provoked people with mild to moderate PD to rethink their individual motor and cognitive resources, a process that was further enabled by the PD‐specific group setting.

Comparison of the Berg Balance Scale and the Mini-BESTest for Assessing Balance in Ambulatory People With Spinal Cord Injury: Validation Study

Background The Berg Balance Scale (BBS) has several constraints-ceiling effect, low responsiveness, and uncertain predictability of falls-in neurological populations. The Mini-BESTest, which has not yet been validated in spinal cord injury (SCI) populations, has shown no ceiling effect, slightly better responsiveness, and could in some neurological populations predict falls. Objective Validate and compare psychometric performances of the BBS and Mini-BESTest in individuals with chronic SCI. Design Cross-sectional validation study. Methods Forty-six individuals able to walk 10 meters (85% American Spinal Injury Association Impairment Scale grade D) with mean age of 55±17 years and median 7 years (range: 1-41) postinjury were included. Floor/ceiling effects were inspected; internal consistency, construct validity, and receiver operating characteristics were analyzed. Results The Mini-BESTest had no ceiling effect; 28% of participants achieved the maximum score on the BBS. Both scales showed excellent internal consistency (α > .93). Strong correlations between both scales (r s = 0.90, P < .001) and between both scales and Timed Up and Go (r s > .70), Spinal Cord Independence Measure-mobility items (r s > .80), and 10-Meter Walk Test (r s > .80) support high construct validity. Both scales could differentiate community walkers without walking aids from participants using aids (AUC > .86) and individuals with low/high concerns about falling (AUC > 0.79) but not recurrent (>2 falls/year) and infrequent fallers (AUC < 0.55). The BBS and Mini-BESTest separated 2 and more than 3 different levels of balance control, respectively. Limitations Small sample. Conclusions Both the BBS and Mini-BESTest were found to be valid scales for assessing balance control in individuals with chronic SCI. The Mini-BESTest may be preferable for this group primarily due to the lack of a ceiling effect.

Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study

QUESTIONS What is the 1-year incidence of falls and injurious falls in a representative cohort of community-dwelling ambulatory individuals with chronic spinal cord injury? What are the predictors of recurrent falls (more than two/year) and injurious falls in this population? DESIGN One-year longitudinal observational multi-centre study. PARTICIPANTS A representative sample of 68 (of 73 included) community-dwelling ambulatory individuals with traumatic SCI attending regular follow-up programs at rehabilitation centres. OUTCOME MEASURES Primary outcome measures were incidence and predictors of recurrent falls (more than two/year) and injurious falls reported every 2 weeks for 1year. RESULTS A total of 48% of participants reported recurrent falls. Of the 272 reported falls, 41% were injurious. Serious injuries were experienced by 4% of participants, all of whom were women. Multivariate logistic regression analysis showed that recurrent falls in the previous year (OR=111, 95% CI=8.6 to 1425), fear of falling (OR=6.1, 95% CI=1.43 to 26) and longer time taken to walk 10m (OR=1.3, 95% CI=1.0 to 1.7) were predictors of recurrent falls. Fear of falling (OR=4.3, 95% CI=1.3 to 14) and recurrent falls in the previous year (OR=4.2, 95% CI=1.2 to 14) were predictors of injurious falls. CONCLUSION Ambulatory individuals have a high risk of falling and of fall-related injuries. Fall history, fear of falling and walking speed could predict recurrent falls and injurious falls. Further studies with larger samples are needed to validate these findings. [Jørgensen V, Butler Forslund E, Opheim A, Franzén E, Wahman K, Hultling C, Seiger Å, Ståhle A, Stanghelle JK, Roaldsen KS (2017) Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study. Journal of Physiotherapy 63: 108-113].

High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: A prospective study of risk indicators.

OBJECTIVE To identify risk indicators for, and incidence of, recurrent falls and fall-related injuries in wheelchair users with traumatic spinal cord injury. DESIGN Prospective multi-centre study. SUBJECTS One hundred and forty-nine wheelchair users with spinal cord injury attending follow-up in Sweden and Norway. METHODS Inclusion criteria: wheelchair users ≥ 18 years old with traumatic spinal cord injury ≥ 1 year post-injury. EXCLUSION CRITERIA individuals with motor complete injuries above C5. Falls were prospectively reported by text message every second week for one year and were followed-up by telephone interviews. Outcomes were: fall incidence, risk indicators for recurrent (> 2) falls and fall-related injuries. Independent variables were: demographic data, quality of life, risk willingness, functional independence, and exercise habits. RESULTS Of the total sample (n = 149), 96 (64%) participants fell, 45 (32%) fell recurrently, 50 (34%) were injured, and 7 (5%) severely injured. Multivariate logistic regression analysis showed that reporting recurrent falls the previous year increased the odds ratio (OR) of recurrent falls (OR 10.2, p < 0.001). Higher quality of life reduced the OR of fall-related injuries (OR 0.86, p = 0.037). CONCLUSION Previous recurrent falls was a strong predictor of future falls. The incidence of falls, recurrent falls and fall-related injuries was high. Hence, prevention of falls and fall-related injuries is important.