Lena von Koch

Injurious Falls Among Middle Aged and Older Adults With Multiple Sclerosis

OBJECTIVE To determine the prevalence of, and risk factors for, receiving medical attention for a recent injurious fall among middle-aged and older adults who have multiple sclerosis (MS). DESIGN Survey. SETTING United States. PARTICIPANTS Seven hundred people with MS, age 55 years or older and living in the United States, were randomly selected from the North American Research Committee on Multiple Sclerosis Registry and invited by mail to participate in the study. A total of 354 people, aged 55 to 94 years, completed the survey. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participants self-report regarding receipt of medical care for a fall-related injury (received care within the past 6mo, >6mo ago, or never). RESULTS More than 50% of study participants reported injurious falls; 12%, in the 6 months before the interview. Proportional odds models were used to identify factors associated with increased odds of receiving medical attention for a fall-related injury within the past 6 months. Compared with study participants who reported receiving medical attention for a fall-related injury more than 6 months ago or never, participants who reported receiving medical attention for a fall-related injury within the past 6 months were more likely to report fear of falling (odds ratio [OR]=1.94; 95% confidence interval [CI], 1.27-2.96) and osteoporosis (OR=1.65; 95% CI, 1.03-2.62). CONCLUSIONS Injurious falls were commonly reported by survey participants. Findings suggest that management of fear of falling and osteoporosis are important components of comprehensive fall-injury prevention programs for people aging with MS.

High concurrent presence of disability in multiple sclerosis. Associations with perceived health.

Objectives(1) To explore functioning and concurrent presence of disabilities — concerning cognition, manual dexterity, walking, energy, mood, activities of daily living (ADL), and social/lifestyle activities — in persons with multiple sclerosis (PwMS) cared for at an outpatient MS clinic. 2) To describe the PwMS’ perceived physical and psychological impact and associations with the same disabilities.Material/methodsA descriptive cross-sectional study was carried out in 219 PwMS at the MS Centre, Karolinska University Hospital. Logistic regression employing proportional odds models was used to identify the associations of the disabilities with the perceived physical and psychological impact.ResultsIn this sample the distribution with regard to disease severity as per Expanded Disability Status Scale was; mild 59.5%, moderate 17% and severe 23.5%. Despite the high proportion with mild disease severity disability regarding cognition was found in 49%, manual dexterity 76%, walking 43%, energy 67%, mood 29%, ADL 44% and social/lifestyle activities in 48%. Two or more disabilities were found in 80%, 24 % had six or seven disabilities. Disability regarding energy, mood, walking, manual dexterity and ADL was significantly associated with increase in the perceived physical impact, whereas disability in energy and mood was significantly associated with increase in the perceived psychological impact.ConclusionsThe presence of several concurrent disabilities, some significantly associated with high perceived physical and psychological impact, in the majority of PwMS in outpatient clinics highlights the importance to identify disabilities, in particular fatigue and depressed mood, in order to supply health care interventions aiming to improve the life situation of PwMS.

A Randomized Controlled Trial of Early Supported Discharge and Continued Rehabilitation at Home After Stroke Five-Year Follow-Up of Patient Outcome

Background and Purpose— The optimal organization of rehabilitation services after discharge from a stroke unit has not been determined. This study sought to evaluate the effect of early supported discharge and continued rehabilitation at home (ESD), in terms of patient outcome 5 years after stroke and changes in selected data over time. Methods— Eighty-three patients from Southwest Stockholm, mildly or moderately impaired 5 to 7 days after acute stroke, were enrolled in a randomized controlled trial. The core components of the ESD service were initial treatment in a stroke unit and the involvement of an outreach team to deliver and coordinate home-based rehabilitation in partnership with the patient. At the 5-year follow-up, measures used to assess patient outcome included survival, motor capacity, dysphasia, activities of daily living (ADL), social activities, subjective dysfunction, and self-reported falls. Results— Fifty-four patients (30 in the intervention group and 24 in the control group) were evaluated 5 years after stroke, at which time a significantly larger proportion of patients in the intervention group were independent in extended ADL and active in household activities. Conclusions— This ESD service has a beneficial effect on extended ADL 5 years after stroke for mildly to moderately impaired patients.

Randomized controlled trial of rehabilitation at home after stroke: one-year follow-up of patient outcome, resource use and cost.

Background and Purpose: This study sought to evaluate early supported discharge and continued rehabilitation at home after stroke, at a minimum of 6 months after the intervention, in terms of patient outcome, resource use and health care cost. Methods: Eighty-three patients, moderately impaired 5–7 days after acute stroke, were included in a randomized controlled trial, 42 being allocated to the intervention and 41 to routine rehabilitation. One-year follow-up of patient outcome included mortality, motor capacity, dysphasia, activities of daily living, social activities, perceived dysfunction, and self-reported falls. Resource use over 12 months included inpatient hospital care, outpatient health care, use of health-related services, informal care, and cost of health care. Results: On univariate analysis there was no difference in patient outcome. Multivariate regression analysis showed that intervention had a significant effect on independence in activities of daily living. A significant difference in inpatient hospital care, initial and recurrent, was observed, with a mean of 18 (intervention) versus 33 days (control) (p = 0.002). Further significant differences were that the control group registered more outpatient visits to hospital occupational therapists (p = 0.02), private physical therapists (p = 0.03) and day-hospital attendance (p = <0.001), while the intervention group registered more visits to nurses in primary care (p = 0.03) and home rehabilitation (p = <0.001). Other differences in outcomes or resource utilization were nonsignificant. Conclusion: In Sweden, early supported discharge with continued rehabilitation at home proved no less beneficial as a rehabilitation service, and provided care and rehabilitation for 5 moderately disabled stroke patients over 12 months after stroke onset for the cost of 4 in routine rehabilitation.

Balance exercise for persons with multiple sclerosis using Wii games: a randomised, controlled multi-centre study

Background: The use of interactive video games is expanding within rehabilitation. The evidence base is, however, limited. Objective: Our aim was to evaluate the effects of a Nintendo Wii Fit® balance exercise programme on balance function and walking ability in people with multiple sclerosis (MS). Methods: A multi-centre, randomised, controlled single-blinded trial with random allocation to exercise or no exercise. The exercise group participated in a programme of 12 supervised 30-min sessions of balance exercises using Wii games, twice a week for 6–7 weeks. Primary outcome was the Timed Up and Go test (TUG). In total, 84 participants were enrolled; four were lost to follow-up. Results: After the intervention, there were no statistically significant differences between groups but effect sizes for the TUG, TUGcognitive and, the Dynamic Gait Index (DGI) were moderate and small for all other measures. Statistically significant improvements within the exercise group were present for all measures (large to moderate effect sizes) except in walking speed and balance confidence. The non-exercise group showed statistically significant improvements for the Four Square Step Test and the DGI. Conclusion: In comparison with no intervention, a programme of supervised balance exercise using Nintendo Wii Fit® did not render statistically significant differences, but presented moderate effect sizes for several measures of balance performance.

Rehabilitation in the home versus the hospital: The importance of context

PURPOSE Stroke rehabilitation has received increased attention in the past decade. Recent trials with new alternatives such as home-based rehabilitation services are being conducted. The purpose of the study was to explore differences between a therapy session with a stroke patient in two different contexts, i.e. in the patients home and in the hospital. METHODS The research design was a qualitative case study. Three data collection methods were used; participant observations of therapy sessions in two different contexts, semi-structured interviews and documents. RESULTS The data were examined and coded for common categories. Analysis of the data looking for similarities and differences in behaviour of two therapists and their patients during therapy sessions in the hospital and in the home was performed. The observations revealed that there was clearly a difference in behaviour; a different role-set used by the two therapists when working in the patients home versus in the hospital. The major difference in patient behaviour was that the patient, observed in his home, took the initiative and expressed his goals, which was not the case with the patients observed in the hospital. The findings were confirmed in the interviews and the documents. CONCLUSION It is suggested that the context is a key component to be considered in the rehabilitation process of stroke patients.

Rehabilitation at home after stroke: a descriptive study of an individualized intervention

Objective: To describe the content of a programme involving early hospital discharge and continued rehabilitation at home after stroke. Design: Quantitative and qualitative descriptive study of an intervention within the context of a randomized controlled trial. Setting: Huddinge University Hospital, Stockholm, Sweden. Subjects: Forty-one patients, moderately impaired after stroke, rehabilitated by a team of six occupational, physical, and speech and language therapists. Results: The average duration of the programme was 14 weeks, the mean number of home visits 12, and the median total time consumption 23 hours and 20 minutes, of which face-to-face contact with the patient constituted 54%. The rehabilitation process was pursued by the patient and the therapist in partnership. Supported by the team the therapists incorporated a wider domain of activities than usual and left a considerable amount of the training to self-directed activities. The most common foci of the visits were speech and communication, ADL activities and ambulation. When planning the intervention the therapists paid attention to discrepancies between the desires and abilities of the patient on the one hand and environmental demands on the other – discrepancies detected through observation of the patient in the home environment. Conclusions: The home environment offers therapists working in a team opportunities to adopt a behaviour that enables patients with moderate neurological impairments after stroke to resume responsibility and influence over their rehabilitation process, resulting in an individualized rehabilitation programme that varies in duration, content and frequency of home visits.

The relationship between walking, manual dexterity, cognition and activity/participation in persons with multiple sclerosis

Background: Multiple sclerosis has a vast impact on health, but the relationship between walking, manual dexterity, cognition and activity/participation is unclear. Objective: The specific aims were to explore the discriminative ability of measures of walking, manual dexterity and cognition, and to identify cut-off values in these measures, for prediction of independence in personal and instrumental activities of daily living (ADL) and activity/participation in social and lifestyle activities. Methods: Data from 164 persons with multiple sclerosis were collected during home visits with the following measures: the 2 × 5 m walk test, the Nine-hole Peg Test, the Symbol Digit Modalities Test, the Katz Personal and Instrumental ADL Indexes, and the Frenchay Activities Index (measuring frequency in social and lifestyle activities). Results: The 2 × 5 m walk test and the Nine-hole Peg Test had high and better discriminative and predictive ability than the Symbol Digit Modalities Test. Cut-off values were identified. The accuracy of predictions was increased above all by combining the 2 × 5 m walk test and the Nine-hole Peg Test. Conclusion: The proposed cut-off values in the 2 × 5 m walk test and the Nine-hole Peg Test may be used as indicators of functioning and to identify persons risking activity limitations and participation restrictions. However, further studies are needed to confirm the usefulness in clinical practice.

APPLIED RELAXATION IN THE TREATMENT OF LONG-LASTING NECK PAIN: A RANDOMIZED CONTROLLED PILOT STUDY

OBJECTIVES To evaluate the feasibility of study design and method for evaluating effects of interventions on patients with long-lasting neck pain and to compare treatment effects of: (i) a pain and stress management group intervention with applied relaxation, and (ii) individual physiotherapy treatment as usual. DESIGN Randomized controlled pilot study. SUBJECTS Thirty-seven patients with long-lasting neck pain. METHODS The patients were randomly assigned either to applied relaxation or treatment as usual. The applied relaxation group received 7 group sessions over a period of 7 weeks and the treatment as usual group an average of 11 individual sessions spread over 20 weeks following baseline. Twenty-nine participants completed the intervention and filled in a self-assessment questionnaire before treatment, and 7 and 20 weeks after baseline. The questionnaire comprised: Neck Disability Index, Coping Strategies Questionnaire, Hospital Anxiety and Depression Scale, Tampa Scale of Kinesiophobia, and questions regarding neck pain, analgesic use, sleep, sick-leave and utilization of healthcare. RESULTS The applied relaxation group had better perceived control over pain at the 20 weeks follow-up compared with the treatment as usual group. CONCLUSION The design and methods of this pilot study were feasible and will be suitable for a larger randomized controlled study.

Perceived needs and satisfaction with care in people with multiple sclerosis: A two-year prospective study

BackgroundConsidering the costs of multiple sclerosis (MS), it is crucial that the health-related services supplied are in accordance with needs as they are perceived by people with MS (PwMS). Satisfaction with care is related to quality of care and can provide health care providers with the means for improvement. The aim was to explore the perceived needs and satisfaction with care amongst PwMS over a two-year period, also taking sex and disease severity into consideration.MethodsThe sample consisted of 219 outpatients at a MS specialist clinic. Data on perceived needs and satisfaction with care were collected every six months using a questionnaire which included various dimensions of care. The data was analysed for the whole sample and on an individual level, as well as in subgroups with regard to sex and disease severity.ResultsThere were no statistically significant variations in the proportion of PwMS with perceived needs concerning different health-related services during the study period. However, individual variations were found with regard to both perceived needs and satisfaction with care. Few PwMS perceived a continuous need for a specific service. However, the majority perceived a need for rehabilitation, assistive devices, transportation service for the disabled, psychosocial support/counselling and information on social insurance/vocational rehabilitation at least sometimes. Severe MS was associated with a greater perceived need for almost all the services studied and women experienced a need for psychosocial support/counselling to a greater extent than men. In relation to the different categories of health care staff, PwMS were most satisfied with nurses with regard to all dimensions of care. They were least satisfied with the availability of psychosocial support/counselling; and information about social insurance/vocational rehabilitation.ConclusionDespite the large proportion of individuals with mild disease severity in our sample, a considerable number of needs were identified of which many, on an individual level, varied over time. Key services demanded by PwMS were identified. Also the level of satisfaction with care varied and areas with a potential for improvement were identified such as the availability of rehabilitation services including an increase in the supply of psychosocial support and counselling.