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Sökning: WFRF:(Sandlund Marlene) > Doktorsavhandling

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1.
  • Bajraktari, Saranda, 1989- (författare)
  • Health promotion and fall prevention for older people : impact, relevance and economic justification for decision making in a municipality context
  • 2023
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Background: The proportion of older people is increasing and calls for a shift towards proactive approaches to support healthy ageing. The evidence base on health-promoting and preventive interventions (HPP) is promising in terms of maintaining health in older people, but for such interventions to have an impact on population health, translation of evidence to practice is crucial. To facilitate this process, factors relevant for decision makers are important to consider. One specific public health challenge is fall-related injuries in older people which cause the highest number of injury-related deaths, have many consequences for the individual (physical and psychological) as well as wide-ranging societal costs. Translation of evidence to practice faces challenges with regards to reach, limiting the public health impact of such interventions. Digital interventions have the potential to increase reach and thereby contribute as an innovative proactive approach. The aim with this thesis was twofold. First, to review the scientific literature in the field of health promotion and prevention conducted in Nordic Countries and targeting community-dwelling older people. Secondly, to evaluate reach, self-reported health outcomes and cost-effectiveness of the Safe Step digital fall preventive exercise intervention in an observational study in the municipality of Östersund-Sweden.Methods: In paper I, a scoping review design was applied to review and summarise a broad field of research focusing on seven factors important for decision-makers such as: context, population, content, feasibility aspects, experiences of participants, intervention effects, and cost-effectiveness. In Paper II, data related to reach including recruitment rate, and participant characteristics (based on self-reported health outcomes and socioeconomic status) were collected. The sample was compared with a representative sample of older people for the purpose of exploring representativeness. In paper III, self-reported health outcomes in relation to balance, leg strength, fear of falling and health-related quality of life were evaluated over the course of the one-year intervention and in relation to exercise time, reported in quarterly questionnaires. In paper IV, the cost effectiveness of the Safe Step intervention was modelled in a Markov model with five states over 12 years to evaluate the potential cost-effectiveness of the intervention in community-dwelling older people at risk of falling.Results: Paper I showed that all included studies, except one, reported a positive effect in at least one health outcome measured. Most studies did not report on cost-effectiveness, feasibility, or experiences of participants. Based on the summarised evidence, senior meetings, preventive home visits and various forms of fall preventive exercise interventions emerged as most recommendable for implementation. Results from paper II showed that the majority of participants had a better health status, were women, and were more commonly using technology in comparison to a sample population. Paper III showed that participants in the intervention self-reported positive changes in balance and leg strength at different follow-ups. Balance and leg strength indicated a small but positive association with self-reported exercise activity. Paper IV showed the potential of Safe Step being a cost-saving intervention with better health outcomes and lower costs compared to no intervention alternative. Assuming a lower estimated intervention effect and higher recruitment costs still indicated that Safe Step was cost effective.Conclusion: This thesis provides evidence to support proactive approaches in healthy ageing and recommends increased efforts in research regarding translation of such interventions to practice as to maximize impact on a population level. The Safe Step intervention shows promise in being used independently in community-dwelling older people with good overall health and familiarity with internet and digital technologies. The majority reached were women with higher education, which infers a need for other non-digital interventions or additional support to increase reach in the general population of older people at risk for falling. Preliminary effectiveness results imply that Safe Step can lead to self-rated changes in known fall-risk factors although participants reported exercise time was lower than the recommended levels. Safe Step indicates also to be a cost-effective intervention even with conservative estimates of intervention effects and higher costs.
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2.
  • Månsson, Linda, 1973- (författare)
  • Digital fall prevention for older adults : Feasibility of a self-managed exercise application and development of a smartphone self-test for balance and leg strength
  • 2021
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • As the numbers of older adults grow, fall prevention is vital to reduce health care needs due to falls and to increase quality of life. Balance and strength exercises have been found to be effective in fall prevention, however, long-term adherence is often poor. The growth of digital technology in society has generated opportunities for fall prevention with eHealth. The aim of this thesis was to evaluate the feasibility and use of a new digital fall prevention exercise programme, and to develop and investigate a smartphone self-test application for balance and leg strength. Three different studies included community-dwelling older adults ≥ 70 years, who were able to rise from a chair and stand without support. A feasibility study evaluated a new digital exercise programme (DP) compared to a paper booklet exercise programme (PB) for self-managed fall prevention in a four-month controlled participant preference trial (n = 67) (Paper I & II). Self-reported data on adherence, falls efficacy, and functional ability were collected and analysed, along with performance-based measures of gait speed, balance, and chair stand test. In Paper II the feasibility was explored of using the self-reported scales and performance-based outcome measures. A self-test application was also developed (Paper III) in co-creation with 10 participants, who met during five sessions to design the application’s instructions and user interface. The participants’ preference for and their contribution to the application design was analysed with qualitative content analysis with a deductive-inductive approach. A concurrent validity study (n = 31) (Paper IV) assessed the correlations between variables from the self-test prototype and outcome measures from clinical instruments. Results from the feasibility study show that 43% chose the DP and 57% PB, and the attrition rate was 17% and 37% respectively. Both groups had similar adherence, but for the subgroup that exercised most, participants in the DP group reported significantly more exercise time (Paper I). Participants in both groups reported a boost in balance after the intervention, and in the DP group also improved leg strength. Significantly more participants continued to use the DP at 12 months. The self-managed exercise intervention (Paper II) resulted in improvements in functional leg strength, which positively correlated with exercise time, but no other performance-based outcomes showed any significant improvements. Performance-based measurements of balance as well as the self- reported balance confidence and fear of falling revealed ceiling effects. Pre-assessments of self-reported outcomes and performance-based measures showed significant but low correlations, no such correlations were seen in change scores. The deductive-inductive analysis of the co-creation process resulted in 17 subcategories within the seven facets of the Optimized Honeycomb model for iii user experience (Paper III). The main results were that participants desired clear and appropriate information to understand why things were done in a certain way, and their contributions enhanced the user experience of the self-test. The concurrent validity testing of the self-test prototype (IV) showed low to moderate correlations for the strength test but limited correlations for the balance test. In conclusion the DP group showed comparable adherence to the programme as the PB group, as well as to previous studies, indicating it was feasible to use the new DP. DP participants also reported better exercise maintenance after 12 months. Positive self-reported effects were expressed in addition to leg strength improvement. Outcome measures for balance and falls efficacy revealed ceiling effects, consequently, these instruments might not be suitable for assessments in all community-dwelling older adults. In particular, for balance related outcomes there is a need for new more sensitive measurements. The co-creation of the smartphone self-test was feasible and valuable for user experience, but further validity and reliability testing are needed before it can serve as an independent assessment tool. 
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3.
  • Nedergård, Heidi, 1978- (författare)
  • “Taking the next step” : whole-body biomechanical gait analysis, and user-perspectives on robotic-assisted gait training post-stroke
  • 2021
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Background: Stroke, and its subsequent motor function impairments may result in limited gait ability characterised by compensatory movement patterns that include deviations and asymmetries. How these movement patterns should be evaluated and quantified in order to be monitored and treated in the long term is not yet standardised. Limitations in walking quality and quantity negatively affect quality of life and lead to great costs for society if independence is lost. Improved walking ability is hence highly prioritised in stroke rehabilitation. Gait-assisting robots have been developed to enable favourable controlled, high-intensive and task-specific training. Studies evaluating the effects of robotic-assisted gait training (RAGT) have, however, shown inconsistent results. Identifying responders to treatment may facilitate further development of RAGT to improve outcomes. This requires in-depth knowledge of how specific gait movement patterns should best be identified, quantified and treated in rehabilitation. There is also a need for greater insight into how individuals experience gait training in general, and RAGT in particular, as this will likely affect the performance and outcomes of training.Aim: This thesis aims to contribute to the discussion on how to quantify gait movement patterns post-stroke from a whole-body perspective. It will also evaluate the effects of RAGT on biomechanical measures of gait and explore the experience of high-intensive and robotic-assisted gait training in persons with impaired walking ability due to stroke.Methods: A systematic review and meta-analysis consolidated the evidence for the effects of RAGT on biomechanical measures of gait in persons post-stroke. Two descriptive, cross-sectional studies based on kinematic gait data (31 persons post-stroke and 41 non-disabled controls) investigated potential variables to quantify post-stroke gait. The size and angular velocity of the inclination angles between the Centre of Mass (CoM) and the ankle or head, respectively, was investigated with curve analyses covering the entire gait cycle. Furthermore, misclassification rates were calculated based on leave-one-out cross-validation and logistic regression to address the combinations of kinematic variables that most correctly classify a person post-stroke when compared to controls. Finally, individual interviews were performed and analysed using qualitative content analysis to explore the experiences of high-intensive gait training, including RAGT, among persons post-stroke.Results: The systematic review included 13 studies with a total of 412 individuals. The meta-analyses did generally not reveal significant differences between RAGT and comparator groups for biomechanical parameters. Risk of bias assessments raised concerns for several of the studies and the general quality of evidence for these outcomes was very low. An important finding was an inconsistency of biomechanical outcome measures. Data from the primary cross-sectional studies included in this thesis indicated a bilateral lower body adaptation likely to increase the base of support and an upper body leaning towards the affected side during walking in persons post-stroke. Furthermore, core sets of 2-3 kinematic gait variables were identified from both the upper and lower body that, when combined, were most likely to differentiate post-stroke gait from gait in non-disabled controls. Finally, qualitative analysis of participants’ perspectives on high-intensive gait training including RAGT revealed four categories which described: 1) A generally positive mindset when starting the gait training intervention; 2) That engaging in a high-intensive gait training programme was appreciated although experienced as mentally and physically exhausting. The role of the physiotherapist was perceived as crucial; 3) Potential barriers during RAGT, such as discomfort and lost control during walking with the robot, but also facilitators like concrete feedback and the possibility to walk longer distances, and; 4) The participants’ feelings of confidence or concern for the future.      Conclusions: The systematic review demonstrated a very low certainty in current evidence for employing RAGT instead of non-robotic gait training to improve gait biomechanics post-stroke. In addition, it emphasized the lack of standardised guidelines as to which outcome measures most sufficiently quantify gait post-stroke. The cross-sectional studies included in this thesis, presenting upper and lower body kinematic variables to differentiate gait patterns between individuals with stroke and those without, highlight the advantages of adopting a whole-body perspective when evaluating gait post-stroke. Finally, interviews identified valuable aspects from the user’s perspective that should be considered during further development of RAGT devices and the design of high-intensive gait rehabilitation programmes post-stroke. 
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4.
  • Pettersson, Beatrice, 1987- (författare)
  • Fall prevention exercise for older adults : self-management with support of digital technology
  • 2021
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Background: Falls are a major public health issue, which can cause physical and psychological suffering for the individual as well as large costs for the society. To increase access and adherence to evidence-based fall prevention exercise, utilisation of older adults’ own capabilities and digital health offers promising solutions. The aim of this thesis was to explore a digital programme as support for self-management of fall preventive exercises in community-dwelling older adults with a focus on participant experiences, behaviour change, and intervention reach.Methods: This thesis comprises four papers, of which Papers I and II report from a feasibility study comparing two self-managed fall prevention exercise programmes, a paper booklet and the digital Safe Step programme. Papers III and IV describes a randomised controlled trial, which evaluates the effectiveness of the Safe Step programme in combination with educational videos, to reduce falls in comparison with educational videos alone. In Paper I, individual interviews were analysed with inductive qualitative content analysis to explore older adults’ experiences of self-managing their fall prevention exercise. In Paper II, a deductive and inductive approach was utilised for the analysis of comments in questionnaires, individual, and focus group interviews to explore experiences of self-determination when using the Safe Step programme. The classification system of motivational and behaviour change strategies based on Self-determination theory was utilised as a categorisation matrix. An additional analysis of behavioural regulation for exercise according to the Self-determination theory was performed in this thesis. Paper III is a protocol for a randomised controlled trial, and Paper IV describes the recruitment strategies, and reach of this trial through comparison with another representative sample of adults 70 years or older by descriptive statistics.Results: Results from Papers I and II show that the older adults appreciated the autonomy of a self-managed exercise programme. They expressed a capability to independently select exercises and manage their progression with support from the programme. However, some wanted the support of others in their training. The behaviour change support in the Safe Step programme was voiced as motivating and supportive, and the diversity of behaviour change strategies was emphasized as important to suit many older adults’ preferences. In Paper II, the behaviour change support were found supportive for the basic human psychological needs according to the Self-determination theory, although, support for autonomy and competence were more clearly stated than for relatedness. An additional category was formed and proposed as an amendment to the classification system used as an analytical matrix. In the thesis, expressions of intrinsic and extrinsic motivations for doing the exercise from participants in Paper I were triangulated with results from the Behavioural Regulations in Exercise Questionnaire-2. The results confirmed the trend found in the qualitative analysis of more intrinsically motivated expressions in the group using the Safe Step programme. A study protocol was written that described the design of the Safe Step randomised controlled trial, including the aims, methodology and overall organisation of the research (Paper III). In Paper IV, the most successful recruitment strategy to the randomised controlled trial was identified as advertisement in social media. The recruited participants were predominantly women, highly educated, and frequently used applications or internet on mobile devices.Conclusion: Finding of this thesis support implementation of fall prevention strategies through increased utilisation of older adults' self-management capabilities. Older adults’ experiences of exercising with a self-managed digital exercise program can be understood as managing pieces of a personal puzzle and was shaped more by the sum of the features and behaviour change support in the programme than by parts of the programme. The Safe step programme seems to provide support for more self-determined exercise motivation, than a paper booklet, which can support maintenance of the new exercise routines. The older adults’ experiences, as well as the characteristics of the participants reached, highlight the necessity for a variety of fall prevention strategies that reflect the diversified needs and preferences of older adults.
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5.
  • Sandlund, Marlene, 1972- (författare)
  • Motion interactive games for children with motor disorders : motivation, physical activity, and motor control
  • 2011
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • As motion interactive games have become more widespread the interest in using these games in rehabilitation of children with motor disorders has increased among both clinical professionals and the families of these children. The general aim of this thesis was to evaluate the feasibility of using interactive games in rehabilitation of children to promote motivation for practice, physical activity, and motor control. A systematic review of published intervention studies was conducted to obtain an overview of existing research and the current levels of evidence for using interactive games in motor rehabilitation of children. Sixteen studies met the inclusion criteria, out of these three were randomized controlled trials while half were case series or case reports. Thirteen studies presented positive findings, which indicated a promising potential. However, more convincing research is needed. Commercially available motion interactive games have only been used in a few studies on motor control, and in none of these home based practice was provided. Moreover, no earlier studies have evaluated if these games may increase motivation for training and daily physical activity among children with disabilities. To address these issues a feasibility intervention including 15 children in the ages 6-16 years and with mild to moderate cerebral palsy was conducted. Each child was provided with a Sony PlayStation2â and the EyeToyâ games in Play3, and was recommended to practice with the provided games for at least 20 minutes/day during four weeks. The intervention was evaluated with gaming diaries, physical activity monitors (SenseWear Armband), interviews with the parents, and the clinical motor tests Movement Assessment Battery for Children-2 (mABC-2), Bruininks-Oseretsky Test of Motor Proficiency subtest 5:6, and the 1 Minute Walk Test. In addition, 3D motion analysis was used to evaluate effects on quality of goal-directed arm movements towards virtual and real objects, respectively. Motivation for practice and compliance of training were high, although declining somewhat during the course of the four weeks. The children’s physical activity increased significantly during the intervention. However, four children were excluded from this analysis due to lack of complete data from the physical activity monitors. According to mABC-2 the children’s motor performance improved, but there were both floor and ceiling effects, indicating a low sensibility of this test. The two additional motor tests showed only non-significant progress. Results from the 3D motion analysis suggest that the children improved movement precision when playing the games, movement smoothness when reaching for real objects, and used a more economic reaching strategy with less trunk involvement. In the interviews the parents expressed the view that motion interactive games promote positive experiences of physical training and add elements of social interaction to the training. They also experienced less urge to take on a coaching role. The training provided by the games was considered unspecific and there was a desire for individualized games to better address the unique rehabilitative need of each child. In conclusion, it is feasible to use motion interactive games in home rehabilitation for children with cerebral palsy to promote short term motivation for practice and general physical training. Specific effects on motor control need to be further explored and there is also a need for reliable tests that are adequate and sensitive enough to capture changes in movement control. In future development of interactive games for rehabilitation purposes, it is a challenge to preserve the motivational and social features of games while at the same time optimizing an individualized physical training.
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