Lars-Gunnar Gunnarsson

Predicting accidental falls in people with multiple sclerosis — a longitudinal study

Objective: To investigate accidental falls and near fall incidents in people with multiple sclerosis with respect to clinical variables and the predictive values of four tests. Design: A longitudinal, multi-centred cohort study with prospectively collected falls. Procedures: Self-reported incidents during the three months following a standardized test procedure. Subjects: Seventy-six people with multiple sclerosis and an Expanded Disability Status Scale score between 3.5 and 6.0. Main outcome measures: Berg Balance Scale, Timed Up and Go cognitive, Four Square Step Test (FSST) and 12-item Multiple Sclerosis Walking Scale. Results: Forty-eight people (63%) registered 270 falls. Most falls occurred indoors during activities of daily life. We found a correlation of rs=0.57 between near falls and falls, and of rs = 0.82 between registered and retrospectively recalled falls. Fallers and non-fallers differed significantly regarding Expanded Disability Status Score (odds ratio (OR) 1.99, 95% confidence interval (CI) 1.22; 3.40), spasticity (OR 1.14, CI 1.02; 1.31), proprioception (OR 2.50, CI 1.36; 5.12) and use of walking aids (OR 2.27, CI 1.23; 4.37). Reported use of walking aids both indoors and outdoors increased the odds of falling fivefold while disturbed proprioception increased the odds 2.5—15.6 times depending on severity. The odds of falling were doubled for each degree of increased Expanded Disability Status Score and more than doubled for each degree of increased spasticity. The Berg Balance Scale, use of walking aids and Timed Up and Go cognitive best identified fallers (73—94%) and proprioception, Expanded Disability Status Score, 12-item Multiple Sclerosis Walking Scale and Four Square Step Test best identified non-fallers (75—93%). Conclusions: In clinical practice, looking at the use of walking aids, investigating proprioception and spasticity, rating Expanded Disability Status Score and using Berg Balance Scale or Timed Up and Go cognitive all contribute when identifying fallers.

Epidemiology of Neuromuscular Diseases, Including the Postpolio Sequelae, in a Swedish County

The epidemiology of neuromuscular diseases was studied in the county of Orebro, Sweden (study population 270,000). Several different sources of data were utilized, compared and validated. On the prevalence of day (January 1, 1988) 474 patients were identified. The rate per 100,000 population was 92 for the postpolio sequelae (PPS) and 84 for the other neuromuscular diseases (motor neuron disease 9, hereditary neuropathies 9, myoneural disorders 16, myotonic disorders 19, muscular dystrophies 20 and myositis 11). Of the patients with the PPS, 80% reported late-onset symptoms. On the basis of an expanded survey including all medical records in one health care district, the prevalence of the PPS was estimated to be 186/100,000 population.

Factors perceived as being related to accidental falls by persons with multiple sclerosis

Purpose. This study explores and describes factors that persons with multiple sclerosis (MS) perceive as being related to accidental falls. Method. A qualitative content analysis with primarily deductive approach was conducted using the International Classification of Functioning, Disability and Health. Twelve persons with MS, and identified as fallers, were interviewed. Results. Factors perceived to cause accidental falls that had not previously been targeted in MS populations in relation to falls were identified as divided attention, reduced muscular endurance, fatigue and heat sensitivity. Previously reported risk factors such as changed gait pattern, limited walking ability, impaired proprioception, vision and spasticity were supported. Activities involving walking, recreation and leisure, maintaining and changing body position, lifting or carrying, taking care of the home, washing the body, moving around, preparing meals and housekeeping were limited and considered to be risk activities. Supportive persons and assistive device reduced falls, and unsuitable physical environments and climate conditions induced falls. Several preventative strategies were described as partially compensating for the impairments, limitations and restrictions. Conclusions. Investigating accidental falls using the perspective of the patient gave important information about variables not earlier targeted in MS research.

Quality of life and impairment in patients with multiple sclerosis

Objectives: The aims of this study were to describe the quality of life in patients with multiple sclerosis (MS) given immunological treatment and in those not given immunological treatment and to investigate the relationship between impairment and quality of life. Methods: Twenty nine patients given immunological treatment were matched with the same number of patients not given such treatment. Matching variables were sex, Kurtzke’s Expanded Disability Status Scale (EDSS), years since diagnosis, and age (total n = 58). The patients were interviewed using the self-reported impairment checklist and they answered two questionnaires on quality of life, the 36-Item Short-Form Health Survey (SF-36) and the Subjective Estimation of Quality of Life (SQoL). Results: The self-reported impairment checklist captured a more differentiated picture of the patients’ symptoms of MS than the EDSS. Health related quality of life was markedly reduced, while the subjective quality of life was less affected. There was a stronger association between self-reported ratings of impairment and health related quality of life on the SF-36 than between impairment and global ratings of quality of life on the SQoL. Subjective quality of life on the SQoL was not directly dependent on impairment expressed in physical limitations. There were no statistically significant differences between the treated and untreated groups. A non-significant trend towards better health related quality of life was found in favour of the treated group with respect to emotional role, physical role, and social function on the SF-36. Conclusions: The self-reported impairment checklist and SF-36 proved to be valuable complements to the well established EDSS in describing the diverse symptoms of MS. Measuring both health related quality of life and subjective wellbeing provides valuable knowledge about the consequences of MS.

Using a novel exercise programme for patients with muscular dystrophy. Part II: a quantitative study.

Purpose: To quantitatively evaluate the effects of qigong in patients with muscular dystrophy. Methods: Thirty-six patients with muscular dystrophy were assigned to either a treatment or comparison group, by means of a stratified randomization procedure. The intervention period lasted for 3 months. Balance and respiratory function were assessed by means of Bergs Balance Scale and an electronic spirometer, respectively. Health-related quality of life was tested by means of a Swedish version of the Medical Outcome Study Short Form Health Survey (SF-36), coping levels by means of a Swedish version of the Ways of Coping Questionnaire and depression levels by means of a modified version of the Montgomery Åsberg Depression Rating Scale. Results: Perceived general health was maintained in the treatment group whereas this was not the case in the comparison group (p = 0.05). Positive reappraisal coping decreased in the treatment group but not in the comparison group (p = 0.05). There was a tendency to maintain balance function during training and performance of qigong whilst there was a decline when not training. Conclusion: Qigong may be useful as an adjunct therapy regimen in patients with muscular dystrophy in that it can bring about a decreased rate of decline in general health. The change in coping pattern in this study needs more investigation. More research is also needed in order to more fully investigate the effects of qigong on such physical variables as balance function.

Pain, disability and coping reflected in the diurnal cortisol variability in patients scheduled for lumbar disc surgery

Background: Symptoms of lumbar disc herniation can be induced by both mechanical compression of the nerve roots and by biochemical irritants from the disc tissues. Proinflammatory cytokines, as well as stress are potent stimulators of the hypothalamic–pituitary–adrenal axis, reflected in enhanced release of cortisol from the adrenal cortex. Altered cortisol production is also associated to behaviour and coping patterns.

Self-perceived limitations of gait in persons with multiple sclerosis

This study aimed to describe the self-perceived walking limitations of those with multiple sclerosis (MS) using the Swedish translation of the 12-item MS Walking Scale [MSWS-12 (S)], and to investigate it for concurrent validity and internal consistency. Eighty-one persons, recruited from five centres in Sweden, were tested using the Four Square Step Test (FSST), the Timed Up and Go cognitive (TUGcog) and the Berg Balance Scale (BBS) in randomized order, besides filling in the MSWS-12 (S). Perceived limitations were reported in 89–96% of the sample, i.e. performance of activities related to standing or walking, decreased speed and distance, and qualitative aspects; and self-perception regarding the ability to run being most extremely affected. Correlations between the MSWS-12 (S) and the objective tests were low, as were correlations between items in the MSWS-12 (S) and the BBS or time taken to complete the TUGcog or the FSST. The internal consistency was acceptable for nine of the 12 items (0.7–0.84). The majority of the sample experienced limitations in several aspects of their walking ability. Concurrent validity was not established between the MSWS-12 (S) and the other tests. There may be a discrepancy in self- perception of disability and objective measures. The use of subjective, as well as objective measures is recommended.

A comprehensive rehabilitation programme tailored to the needs of adults with muscular dystrophy

Objective: To assess if activities of daily living (ADL), coping and quality of life could be improved in adults with muscular dystrophy through a comprehensive rehabilitation programme. Design: Quasi-experimental, controlled clinical study comparing patients with similar age and disease aspects. Setting: Two different counties in Sweden, being either study or control setting. Subjects: The study group comprised 37 adults (21 women, 16 men; mean age 50 years), while the control group comprised 39 people (25 women, 14 men; mean age 46 years). Interventions: Four rehabilitation sessions tailored to different medical, physical and psychosocial needs of the patients, comprising a total of 10 days over a period of 18 months. Main measures: ADL, the Mental Adjustment to Cancer Scale measuring coping strategies, the Sickness Impact Profile measuring health-related quality of life, the Hospital Anxiety and Depression Scale, and the Psychosocial Well-being Questionnaire. Results: No significant differences were found between groups with regard to the outcome measures. There was increased dependence on others in ADL after 18 months in both groups, but it was more pronounced in the control group. Furthermore, a clear trend was observed in the data with regard to coping patterns, the control group using more coping strategies such as ‘Helplessness/hopelessness’ (P=0.057), ‘Anxious preoccupation’ (P=0.085) and ‘Fatalistic’ (P=0.073) when being compared to the study group. Conclusions: No apparent effects on ADL were found from the rehabilitation programme, although there was a tendency of reduction of maladaptive coping patterns in the study group. This initial study may provide the rationale and basis for a randomized controlled trial.

Muscular Dystrophy in adults: A five-year follow-up.

The aim was to describe the natural history of adults with hereditary muscular dystrophies, including myotonic dystrophy, with respect to muscular function, ventilation and electrocardiogram. In a prospective study, 46 subjects were followed over a period of five years. In 1991 and 1996, their muscle function was assessed according to an observation scheme and their lung vital capacity was measured by spirometer. Electrocardiograms were obtained in 1991, 1993 and 1996. Deterioration of muscular function was seen with regard to both the functional muscle tests and the vital capacity. The proportion of pathological electrocardiograms increased from 38% in 1991 to 54% in 1996 in the 26 patients with myotonic dystrophy without an increase in clinically detected cardiac abnormalities. Timely examinations using standard methods can reveal medically important information on deterioration, which often passes clinically unnoticed because of the insidious progress of the diseases.

Lead exposure from tourist earthenware: A pilot survey

Lead from glazed earthenware used for food storage is a well-known health hazard sporadically causing lead intoxication and may be a source of disseminating lead exposure in specific population groups. To obtain a contemporary scope of the problem a pilot survey was conducted in a random sample of 2000 households with Swedish charter tourists to Greece in 2003. Response was obtained from 214 (10.7%). From these households blood samples were obtained from 33 potentially lead exposed subjects and 33 controls (participation rate among selected participants of each category was 66% and 33%, respectively). No statistically significant difference in mean blood lead was found between groups (arithmetic mean 0.13 and 0.10micromol/l for exposed and controls, respectively; p>0.05), but increased lead levels for two exposed subjects (1.0 and 0.77micromol/l) were associated with their Hellenic earthenware (tea mugs). This pilot survey, probably the first epidemiological study of the current problem, did not indicate that earthenware purchased in Greece by Swedish tourists and used for food storage is a widespread source of lead, but limitations with regard to statistical power preclude definite conclusions.