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- Berglund, Lars, 1986-
(författare)
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Deadlift training for patients with mechanical low back pain : a comparison of the effects of a high-load lifting exercise and individualized low-load motor control exercises
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Disability due to low back pain is common. While evidence exist that exercise is effective in reducing pain and disability, it is still largely undetermined which kind of exercises that are most effective. The overall aim of this thesis was to evaluate and compare the effects of a high-load lifting exercise and individualized low-load motor control exercises for patients with nociceptive mechanical low back pain. A secondary aim was to evaluate which patients benefit from training with a high-load lifting exercise.All four papers in this thesis were based on a randomized controlled trial including 70 participants with nociceptive mechanical low back pain as their dominating pain pattern. Participants were randomized into training with either a high-load lifting exercise (HLL), the deadlift, (n=35) or individualized low-load motor control exercises (LMC) (n=35). Both interventions included aspects of pain education. All participants were offered twelve sessions during an eight week period. The effects of the interventions were evaluated directly after and twelve months after the end of the intervention period. Outcome measures were pain intensity, activity, disability, physical performance, lumbo-pelvic alignment and lumbar multifidus muscle thickness.There was a significant between-group effect in favour of the LMC intervention regarding improvements in activity, movement control tests and some tests of trunk muscle endurance. For pain intensity there were no significant differences between groups. A majority of participants in both intervention groups showed clinically meaningful improvements from baseline to two and twelve month follow-up regarding pain intensity and activity. There were no significant differences between HLL and LMC regarding the effect on lumbo-pelvic alignment or lumbar multifidus thickness. The participants who benefit the most from the HLL intervention were those with a low pain intensity and high performance in the Biering-Sørensen test at baseline.The results of this thesis showed that the HLL intervention was not more effective than the LMC intervention. The LMC was in fact more effective in improving activity, performance in movement control tests and some tests of trunk muscle endurance, compared to the HLL intervention.The results imply that the deadlift, when combined with education, could be considered as an exercise to produce clinically relevant improvements on pain intensity in patients who prefer a high-load exercise. However, before considering deadlift training, the results suggest that pain intensity and performance in the Biering-Sørensen test should be evaluated.
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| 2. |
- Bråndal, Anna, 1966-
(författare)
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Rehabilitation after stroke with focus on early supported discharge and post-stroke fatigue
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Stroke is a major cause of disability worldwide. After treatment in a specialized stroke unit, early supported discharge (ESD) followed by home rehabilitation has shown to be an effective way to improve patient outcome and quality of care for persons with mild to moderate stroke. ESD service is recommended in the national and international guidelines for stroke care, but has only partially been implemented in Sweden. Following stroke, fatigue is a common consequence that often becomes more evident when the patient comes home. Currently, there is insufficient evidence about how to measure, treat and handle post-stroke fatigue. The overall aim of this thesis was to evaluate and implement early supported discharge (ESD) based on stroke patients experience after discharge from the stroke unit and local conditions. The aim was also to evaluate post-stroke fatigue with a potentially valid and reliable scale and finally to prepare for a study to evaluate cardiorespiratory training as a part of ESD service for patients with post-stroke fatigue.Methods In paper I, nine strategically chosen patients were interviewed of their experience of falling ill, the hospital stay, discharge, contact with health care after discharge and their request of support. Papers II-III describe and evaluate the development, content, implementation and effects of a locally adopted method for early supported discharge (Umeå Stroke Center ESD) in modern stroke care. Paper II included 153 consecutive patients and paper III, 30 232 patients with first-ever stroke registered in the Riksstroke registry in Sweden. Paper II evaluated number of patients/year, clinical and functional health status, satisfaction in relation to needs, accidental falls/other injuries and resources with the result summarized in a value compass. The implementation process was evaluated retrospectively by means of Consolidated Framework for Implementation (CFIR). Paper III evaluated patient reported outcome measurements (PROMs) at 3 months. The primary outcome in paper III was satisfaction with the rehabilitation after discharge. Secondary outcomes were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toilet hygiene and dressing). Multivariable logistic regression models for each PROM was used to analyze associations between PROMs and ESD/no ESD. In Paper IV, the Fatigue Assessment scale (FAS) was translated into Swedish and evaluated regarding psychometric properties when self-administered by persons with mild to moderate stroke. 72 consecutively patients selected from the stroke unit admission register received a letter including three questionnaires: the FAS, the Short Form Health Survey (SF-36) subscale for vitality and the Geriatric Depression Scale GDS-15. A second letter with FAS was sent within 2 weeks, for re-test evaluation. Paper V is a study protocol for a planned randomized controlled trial (RCT) of 50 consecutive stroke patients will who receive stroke unit care followed by ESD-service at Umeå Stroke Center, University Hospital, Umeå, Sweden. Paper V will investigate if a structured cardiorespiratory interval training program (CITP) added to the ESD-service may result in relieved post-stroke fatigue and increased oxygen uptake.Results The interviews in Paper I revealed three main categories with subcategories: “Responsible and implicated”, “Depersonalized object for caring measures” and “The striving for repersonalization and autonomy”. The findings indicate that coming home gave the informants’ important insights and understanding of the stroke, its consequences and was also an important factor for the recovery. Paper II-III showed that it is possible to develop and implement an adapted ESD service for stroke patients based on the patients’ experiences and requests, evidence-based recommendations and local conditions. The ESD service reduced dependence of activity, increased mobility with seemingly no increased risk of accidental falls or other injuries. The patient satisfaction in relation to needs regarding the ESD was high. Paper III showed that patients that received ESD were more satisfied with rehabilitation after discharge, had less need for assistance with ADL and less dysthymia/depression compared to patients that did not receive ESD. Study IV showed that the Swedish FAS used at home as a selfadministered questionnaire is a reliable and valid questionnaire for measuring fatigue in persons with mild to moderate stroke. The internal consistency was good, the agreement between the test and retest reliability for individual items (weighted kappa) was for the majority of items good or moderate. The relative reliability for total scores was good and the absolute reliability was 9 points. The Swedish FAS had no floor nor ceiling effects and correlated both with the SF-36, subscale for vitality and the GDS-15 indicating convergent construct validity, but not divergent construct validity.Conclusion It is possible to develop and implement ESD care for stroke patients based on patients’ experience and needs, evidence-based principles and local conditions. Early supported discharge (ESD) in the setting of modern stroke unit care appears to have positive effects on rehabilitation in the subacute phase. The Swedish FAS used at home as a self-administered questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.
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| 3. |
- Pohl, Petra, 1965-
(författare)
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Falls in older community-dwelling women and men : risk factors and safety strategies. Fall risk awareness, fear of falling, and preferred exercise properties from a gender perspective.
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Falls are the leading cause for non-fatal injuries in older community-dwelling people. Compared to men, women fall more often, experience more fall-related injuries, and report fear of falling (FoF) more often. Falls may be prevented with specific exercises, but adherence is often low in long-term. One aim of the thesis was to gain a deeper understanding of the risk factors previous falls, FoF, and gender. Another aim was to explore safety strategies in older community-dwelling people in terms of fall risk awareness and actions taken to protect from falls, and to identify motives for exercising and preferred exercise properties. A gender perspective was used throughout the thesis.Methods To determine the impact of the risk factors on future falls and injurious falls, a cross-sectional design was used combined with longitudinal data. Baseline data from 230 community-dwelling people over 75 years were collected with questionnaires and performance-based tests. FoF was measured with the single item question “Are you afraid of falling?”. Monthly fall calendars were collected for one year (monitoring year). Based on status on falls, participants were classified as those with i) no falls (n=119), ii) 1 non-injurious fall (n=51), iii) ≥2 non-injurious falls (n=40), and iv) ≥1 injurious fall (n=20). These data were linked to data from an injury database (IDB) with respect to registered injurious falls for a period of about 5 years (long term follow-up). Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of future injurious fall events. To find relationships between FoF, gender, and falls (defined as two or more falls), a general log-linear analysis was performed. Associations between FoF and the components of the International Classification of Functioning (ICF) were explored with a structural equation model. To explore fall risk awareness and safety strategies, and to identify motives and preferred exercise properties, qualitative study design was used. Multistage focus groups were held with 18 community-dwelling people (10 women and 8 men) between 70 and 80 years. Transcriptions were analysed with qualitative content analysis.Results Fourty-eight per cent of the 230 participants fell at least once during the monitoring year, and 23% experienced recurrent falls. Compared to men, women reported FoF more often, but did not experience more recurrent falls, and no more injurious falls. FoF was significantly associated with the ICF components Activity/Participation and Personal Factors in women and men both; but in opposite directions for women and men on Personal Factors. During the long-term follow-up, 91 injurious falls were registered in 70 participants (30%). Those with injurious falls during the monitoring year were at significant risk of experiencing new injurious falls in long-term (HR 2.78; 95% CI 1.40-5.50), compared to those with no falls. Women experienced a higher rate of fractures than did men. Analyses from the multistage focus groups resulted in three categories: Facing various feelings; Recognizing one’s fall risk; and Taking precautions. A comprehensive theme tied them together: Safety precautions through fall risk awareness. Analyses also resulted in six categories identifying preferred exercise properties in the context of falls prevention: Motives to start exercise; Barriers to start exercise; Exercise characteristics; Confirmation; Spirit lifters; and Maintenance tricks. All categories included sub-categories. Both studies revealed greater variations among women and among men than between women and men.Conclusion Community-dwelling people over 75 years who have experienced an injurious fall are at high risk of sustaining new injurious falls the forthcoming five years, and should be offered multifactorial fall risk assessments with targeted interventions to optimize the prevention of future falls. The single item question “Are you afraid of falling?” has no predictive value for future falls, and the answer may be strongly gendered. The questions should therefore be avoided in clinical practice and research in community settings. The participants of the qualitative studies implicity and explicitly described how they had become aware of fall risks in everyday life, and both women and men took precautionary actions. Raised fall risk awareness was achieved by several channels including the media, and by meeting with peers and professionals with expertise in falls prevention. A wide variety of preferred exercise properties in the context of falls prevention were identified among the older community-dwelling people. The variations of the requests were greater among women and among men than between women and men. The results should be taken into consideration when offering exercise-based falls prevention interventions to older people. The results from this thesis indicated that measures can be taken on a broad front in order to reduce the damage from injurious falls in older community-dwelling people. A gender perspective is warranted for in clinical practice and future research. Adopting a gender perspective may broaden the understanding of gender differences and similarities when implementing falls prevention activities.
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| 4. |
- Stecksén, Anna, 1982-
(författare)
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Stroke thrombolysis on equal terms? : implementation and ADL outcome
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Stroke thrombolysis is a method for restoring cerebral blood flow after ischemic stroke, with high priority in the Swedish national guidelines. implementation of stroke thrombolysis in Swedish routine stroke care has shown marked differences between demographic groups, hospital types, and regions. The general aim of this thesis were to examine the implementation of ischemic stroke thrombolysis in Swedish routine stroke care with an equity perspective; to gain more insight into the factors that influence implementation, how the treatment has reached patient groups, and differences in long-term outcomes between women and men. Analysis of data from research interviews with clinicians working within stroke care displayed that the facilitators of and barriers to the implementation of stroke thrombolysis could broadly be categorized into those related to individuals, to social interactions and context, and to organizational and resource issues. Key facilitating factors expressed in interviews were work pride and motivation, good leadership, involvement of all staff members in the implementation process, and quality assurance. Major barriers concerned lack of competence and experience, outdated attitudes regarding stroke management, counterproductive power structures, lack of continuity, and insufficient human resources. National quality register data displayed that stroke thrombolysis treatment expanded to reach more patients with mild deficits. Groups with higher education were more likely to receive treatment, compared to groups with lower educational level. These education group differences have, however, decreased over time in relative terms, but not in absolute terms. Further, there were considerable between-hospitals differences in treatment rates for patients with milder deficits, associated with hospital’s overall stroke thrombolysis rates. Moreover, larger non-university hospitals displayed treatment rate differences between educational groups that were not attributable to patient characteristics. Among thrombolysis-treated women and men, that was independent in ADL before their stroke and survived the first year post-stroke, women experienced higher probability to be dependent in ADL at both 3 and 12 months post-stroke, compared to men. This difference remained significant despite comprehensive adjustments for individual characteristics, symptom severity, and acute effects from stroke thrombolysis.This thesis displays that clinicians face barriers and facilitators at several levels, suggesting implementation interventions could be targeted towards both the individual-, the social interactions and context-, and also the organisation and available resources level. Assurance of clinicians’ individual competence, peer support, and clinical leadership seem to be important areas to intervene. Stroke thrombolysis rates have expanded over time, and an increase in stroke thrombolysis delivery to patients with mild stroke symptoms has contributed to this increase. However, it seems considerable differences between hospitals inhibit equity of care delivery. Further, socioeconomically disadvantaged groups receive less often stroke thrombolysis. Type of hospital seems to play a role, yet the reasons for this difference are not fully understood. This thesis also display that stroke thrombolysis-treated women that survive 1 year after stroke, appears to face higher risk for dependency in ADL, compared to men.
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| 5. |
- Tuvemo Johnson, Susanna, 1964-
(författare)
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Falls and fall prevention in community-dwelling older adults
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Falls are the primary cause of injuries among older adults, and accidents that result from falls can lead to personal suffering and extensive societal burdens. The overall aims of this thesis were to explore and describe falls and fall prevention strategies in community-dwelling older adults and to evaluate a fall prevention home exercise program, the Otago Exercise Program (OEP), with or without motivational interviewing (MI).Methods: Qualitative and quantitative research methods were uses. The designs were as follows: a cross-sectional, descriptive and comparative study (study I); a descriptive feasibility investigation (study II) and a randomized controlled trial (RCT) with two interventions, the OEP and OEP+MI, as well as a control group, with a 12-month follow-up (study III); and a prospective and descriptive study (study IV). The four studies comprised community-dwelling individuals aged 75 years or older. Study I included 262 individuals and studies II-IV had 175 participants who needed walking aids or home support. Study II also included 12 physical therapists. Data collection was performed via self-reported questionnaires, fall calendars, exercise diaries, physical performance tests and a semi-structured questionnaire. Results and conclusions: Suggested actions to prevent falls significantly differed between high and low active older adults (study I). Support for self-directed behavioral strategies could be important for preventing falls in older adults who have low physical activity levels. The study protocol for the RCT had acceptable feasibility (study II), and only minor changes of the protocol were needed. There were no benefits for OEP or OEP+MI with personal support implemented nine times over the 12-month period. However, all groups maintained physical functioning and activity (study III). To increase physical functioning and reduce falls in this sub-group of older adults, more frequent personal support and/or an alternative delivery format may be required for efficient intensity and challenge in home exercises. Over 12 months, falls and fall-related injuries in the RCT sample were the most common when moving around within the home and transitioning from sitting to standing (study IV). Special attention to these activities might be important for preventing falls in community-dwelling older adults who need walking aids or home support.
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